Jurupa Hills Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a copy of the notice of transfer/discharge was provided to the State Long-Term Care Ombudsman (assists with conflict resolution and protection of resident rights) prior to the planned discharge date , for two of two sampled residents (Residents 1 and 2). This failure had the potential to violate the resident's rights to appeal their discharge. Findings: On June 3, 2025, at 10:05 a.m., an unannounced visit was conducted at the facility to investigate a complaint on discharges. On June 4, 2025, at 1:50 p.m., during a concurrent interview and record review with the Social Services Director (SSD), the SSD stated the following information for Residents 1 and 2: 1. Resident 1 was admitted to the facility on [DATE], with diagnoses which included pneumonia (lung infection) and sepsis (a systemic infection that triggers a dysregulated host response, leading to life-threatening organ dysfunction). Resident 1 was planned for discharge to home on April 30,…

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 pain management was provided according to the physician's order and plan of care, for one of ten (Resident A). This failure had the potential to result in Residents A's pain to not be managed. Findings: On May 9, 2025, at 10:45 a.m., an unannounced visit was made to the facility for the investigation of a complaint regarding quality of care. On May 9, 2025, a review of Resident A ' s medical record was conducted. Resident A was admitted to the facility on [DATE], with diagnoses which included morbid obesity (a body mass index [BMI] of 40 or higher, or a BMI of 35 or higher with obesity-related health problems). Resident A's Order Summary Report, included the following orders for pain medication and management: - .MONITOR PAIN EVERY SHIFT: DOCUMENT PAIN LEVEL: 0= no pain, 1-3=mild pain, 4-5= moderate pain, 6-9= severe pain 10=excruciating pain ., date ordered January 3, 2022; - .Percocet (a pain medication) 10-325mg (milligram-a 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 observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. For Residents 57 and 48, the nursing staff failed to properly clean and disinfect the shared blood pressure (BP-pressure of blood in blood vessels) cuffs and stethoscope according to the disposable wipe manufacturer's specified contact time (the time the resident equipment was to be in contact with the disposable wipes to kill micro-organisms), for two of four residents observed during medication administration observation; and 2. For Resident 65, Certified Nursing Assistant (CNA) 2 failed to use the disposable gown while providing high contact resident care activities, for one of 51 residents requiring Enhanced Barrier Precautions (EBP - an infection prevention practices using gowns and gloves during high-contact resident care activities to reduce the spread of multidrug-resistant organism). This failure had the potential for vulnerable residents to be exposed 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 an assessment and evaluation for self-administration (taking medication or substance by oneself, rather than by a healthcare professional) of medication albuterol inhaler (used to prevent and treat wheezing, difficulty breathing, chest tightness, and coughing caused by lung disease such as asthma) was completed, for one of 27 residents reviewed (Resident 180). In addition, the facility failed to ensure the medication was stored safely and securely. This failure increased the potential for unsafe self-administration and duplication of administered medication for Resident 180, and potential for visitors, and other residents to have access to the medication at bedside. Findings: On March 25, 2025, at 4:30 p.m a concurrent observation and interview was conducted with Resident 180. Resident 180 was observed awake, alert, sitting up on his bed and was able to verbalize his needs. Resident 180 was observed to reach into his pant's pocket…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accommodate the needs, for one of two residents reviewed (Resident 56), when Resident 56 was not provided appropriate bed for the resident's height. This failure resulted in Resident 56 not to have his preference to use a bed tall enough to accommodate his height and had discomfort when lying in bed. Findings: On March 23, 2025, at 4:18 p.m., a concurrent observation and interview was conducted with Resident 56. Resident 56 was observed in bed, awake and alert. Resident 56 was observed with a bed footrest made out of cardboard from a carton box. In a concurrent interview, Resident 56 stated he was about 6'7 - 6'8 tall (79 to 80 inches), and his current bed was too small. Resident 56 stated he asked a few months ago for a tall bed to accommodate his height, but it was not provided to him. On March 26, 2025, at 9:26 a.m., a concurrent observation and interview was conducted with Resident 56. Resident 56 was observed again, lying in bed,…

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 the necessary care and services to maintain cleanliness and proper hygiene of resident's fingernails, for one of 27 residents reviewed (Resident 115). This failure had the potential to negatively impact the physiological and psychological well-being of Resident 115. In addition this failure had the potential to result in cross contamination of bacteria underneath the dirty fingernails to Resident 115's food during meals. Findings: On March 23, 2025, at 11:04 a.m., Resident 115 was observed sitting at the edge of the bed alert, oriented, and able to verbalize his needs. Resident 115 was observed with blackish materials underneath all his long fingernails. Resident 115 stated it had been a month since his nails were cleaned. Resident 115 stated he would not mind if staff would clean his nails. On March 23, 2025, at 12:06 p.m., Certified Nursing Assistant (CNA) 3 was interviewed. CNA 3 stated she took care of Resident 115 on March…

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 care and treatment according to the professional standards of practice and physician's order was provided, for one of 24 residents (Resident 105) when Insulin Lispro (a type of insulin medication) was administered to Resident 105 when the blood sugar level was below below the hold parameter). This failure had the potential for Resident 105 to experience hypoglycemia (a condition in which the body's blood sugar level goes below the standard range). Findings: On March 23, 2025, at 12:54 p.m., during a concurrent observation and interview with Resident 105, Resident 105 was observed lying in bed, awake and alert. Resident 105 stated a nurse gave him insulin when his blood sugar was low. Resident 105 stated he was half asleep when his blood sugar was taken and when he was given the insulin, he did not feel good and knew his blood sugar was low. Resident 105 stated he asked the nurse to check his blood sugar, and it was 32. Resident 105 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 a resident who is fed by enteral means (directly to the gastrointestinal system or stomach) receives the appropriate care to prevent complications of enteral feeding when, one of one resident reviewed for tube feeding (Resident 122), was positioned with the head of the bed (HOB) not elevated 30-45 degrees while receiving tube feeding (nutrition provided through a tube inserted into the stomach). This failure had the potential for Resident 122 to experience complications from tube feeding, such as aspiration (when food or liquid or other materials enters the airway and lungs instead of being swallowed) , nausea, vomiting, or abdominal pain. Findings: On March 24, 2025, at 8:57 a.m., Resident 122 was observed laying flat on the bed and was receiving tube feeding nutrition. On March 25, 2025, at 9:11 a.m., during a concurrent observation of Resident 122 and interview with Licensed Vocational Nurse (LVN) 3, Resident 122 was observed…

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 respiratory care and treatment, for one of two residents reviewed for oxygen administration (Resident 101), when the physician's order for oxygen administration was not followed. This failure had the potential to result in ineffective oxygen therapy, respiratory distress, and decline in the resident's health condition. Findings: On March 23, 2025, at 3:53 p.m., Resident 101 was observed in bed with oxygen (O2) via nasal cannula (NC - a tube used to deliver oxygen through the nose). Resident 101's oxygen administration was observed at 3.5 liters per minute (LPM). On March 26, 2025, at 10:50 a.m., Resident 101 was observed in bed with O2 via NC at 4 LPM. On March 26, 2025, at 10:52 a.m., a concurrent observation of Resident 101, interview, and record review was conducted with Licensed Vocational Nurse (LVN) 3. LVN 3 confirmed Resident 101 was receiving 4 LPM of oxygen. LVN 3 verified Resident 101's physician order for oxygen should…

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 request a medication regimen review (MRR) following changes in condition (worsening of an existing problem or the emergence of new signs or symptoms, such as falls), and failed to ensure the consultant pharmacist (CP) identified potential medications contributing to falls and make recommendations to the facility for reduction or discontinuation of the medications during the monthly MRRs for one out of five sampled residents (Resident 35). This failure had the potential for medications not being optimized for best possible health outcome, and unnecessary or prolonged use of medications which could lead to medication adverse effects (such as falls) for the resident. Findings: A review of Resident 35's admission Record, indicated Resident 35 was admitted to the facility on [DATE], with diagnoses including contracture (a permanent shortening or tightening of muscles that restricts movement) of right upper arm muscle, spastic (uncontrolled muscle movements)…

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 five sampled residents (Resident 74) was free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications when administered buspirone (used to treat anxiety) without behavioral monitoring. This failure had the potential to result in unnecessary use of medications for Resident 74 which increased the potential for medication interactions, adverse reactions, and unidentified risks associated with the use of psychotropic medications that included but not limited to dizziness, nausea, headache, and nervousness. Findings: On March 26, 2025, at 2:32 p.m., during an interview with the Director of Nursing (DON), the DON described the facility's psychotropic medication management process as follows: - All residents admitted with or started on psychotropic medication were assessed for the diagnosis and the corresponding behavioral manifestation; - Nursing staff verified 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 one (Resident A) of four sampled residents' wheelchair was maintained in a safe and operable condition. This failure had the potential to cause injury to Resident A when he is using a wheelchair with two broken wheel brakes. Findings: On November 15, 2024, at 5:30 p.m., an unannounced visit to the facility was conducted to investigate three complaints. On November 18, 2024, at 12:30 p.m., a review of Resident A's medical record was conducted. Resident A was admitted to the facility on [DATE], with diagnoses which included Hemiplegia and Hemiparesis (muscle weakness or partial paralysis on one side of the body). Resident A's care plan, dated July 9, 2024, indicated Resident A had .decreased functional mobility . On November 18, 2024, at 1:37 p.m., an observation and concurrent interview was conducted with Resident A. Resident A stated he was admitted to the facility after he had a stroke. Resident A stated the locks on his…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their grievance policy and procedure for one resident, (Resident 1) when the family representative (FR) expressed concerns about Resident 1 ' s care. This failure may have contributed to a delay in response to verbal concerns submitted on behalf of Resident 1. Findings: On October 9, 2024, a review of Resident 1 ' s Electronic Records (ER-systematized collection of patient and population electronically stored health information in digital format) was conducted. Resident 1 was admitted on [DATE], with diagnoses including major depressive disorder (common mental health condition that impacts how a person feels and thinks), Parkinsonism (general term for a group of brain conditions, causes stiffness and slowed movement), and dementia (a group of disease characterized by memory loss). Resident 1 ' s history and physical, dated August 27, 2024, indicated Resident 1 did not have capacity to make decisions. A review of Resident 1's Order Summary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure two of seven sampled residents' (Resident D and Resident E) pain were managed consistent with professional standards of practice, and the residents' comprehensive person-centered care plans, when the residents did not receive pain medications in accordance with the physician orders. This failure has the potential to negatively affect the health status of Residents D and E. Findings: On June 20, 2024, at 8:35 a.m., an unannounced visit to the facility was conducted to investigate quality of care issues. On June 20, 2024, at 4:50 p.m., an interview was conducted with Resident D. Resident D stated she was having pain, her lesions on her arms were painful, and her tongue hurts, because her mouth was sore it was difficult for her to eat her food. A review of Resident D's medical record indicated the resident was admitted to the facility on [DATE], with diagnoses which included pemphigus vulgaris (a rare skin disease in which blisters develop). A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one of seven sampled residents (Resident D) received treatment and care in accordance with professional standards of practice, when the new physician orders from a consulting physician ' s office were not initiated as soon as the resident came back to the facility. This failure has the potential to result in worsening of Resident D ' s autoimmune disease (when the body ' s immune system attacks itself). Findings: On June 20, 2024, at 8:35 a.m., an unannounced visit to the facility was conducted to investigate issues on quality care. On June 20, 2024, at 9:00 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated the Social Services Department or case management was responsible in arranging appointments for the residents in the facility, and if transportation is needed, they would take care of that as well. The DON stated a resident is allowed to attend an appointment without a staff member if the resident is alert,…

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 one of seven sampled residents (Resident E) was assessed properly for bladder and bowel control. This failure had the potential for Resident E to not be identified, assessed, and provided appropriate treatment and services to achieve as much bladder and bowel function as possible. Findings: On June 25, 2024, at 9:30 a.m., an unannounced visit to the facility was conducted to investigate a complaint for quality of care. Resident E's medical record was reviewed on June 25, 2024, at 10:50 a.m. Resident E was admitted tot the facility on May 22, 2024, with diagnoses which included heart failure. Resident E's Nursing-Bowel and Bladder Observation/Assessment, dated May 22, 2024, indicated new admission, resident has bladder incontinence-yes, resident has bowel incontinence-yes, type of toileting program-check and change every 2 hours. Resident E's Minimum Data Set (MDS-a clinical assessment of a resident), on admission, dated June 4, 2024, indicated in Section H Bladder and Bowel, resident is always continent…

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 their policy and procedure on abuse, for one of three residents, (Resident 1) when the facility failed to develop a plan of care to ensure safety of the resident including notifying the staff of the incident and interventions to prevent further abuse on Resident 1. This failure resulted in the facility staff to not be informed of necessary information to ensure safety and protection for Resident 1 and further place Resident 1 at risk for further abuse. Findings: On May 16, 2024, 9 a.m., an unannounced visit was conducted at the facility to investigate an allegation of financial abuse. On May 16, 2024, a review of Resident 1's medical record was conducted. Resident 1 was admitted to the facility on [DATE], with diagnoses which included anxiety (a feeling of worry, nervousness, or unease about something with an uncertain outcome), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an allegation of financial abuse was reported to the California of Department of Public Health (CDPH) immediately, or not later than two hours, when the facility received a report of the abuse allegation from the General Acute Hospital (GACH) staff, for one of three residents reviewed (Resident 1). This failure had the potential to result in a delay of the implementation of appropriate action and the provision of protection for Resident 1 and placed other residents at risk for further abuse. Findings: On May 16, 2024, at 9 a.m., an unannounced visit was conducted at the facility to investigate an allegation of financial abuse. On May 16, 2024, a review of Resident 1's medical record was conducted. Resident 1 was admitted to the facility on [DATE], with diagnoses which included anxiety (a feeling of worry, nervousness, or unease about something with an uncertain outcome), major depressive disorder (a mental health disorder characterized by…

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 observations, interviews, and facility policy review, the facility failed to ensure food was prepared and served in a manner to prevent potential cross contamination. Specifically, staff failed to utilize a beard restraint while preparing drinks for meal service, and another staff member failed to wash their hands and change gloves when leaving the meal service line to prepare a quesadilla. These failures had the potential to affect 125 of 125 residents who received meals from the dietary department. Findings included: A review of a facility policy titled, Dress Code, dated 2023, revealed PROPER DRESS included, 8. If applicable, beards and mustaches (any facial hair) must wear beard restraint. On 03/26/2024 at 11:19 AM, [NAME] #6 was observed working in the kitchen with a full beard. [NAME] #6 did not wear a beard restraint. [NAME] #6 was observed preparing drinks for the lunch meal service. He completed the lunch meal service without wearing a beard restraint. During an interview on 03/26/2024 at 1:44 PM, [NAME] #6 stated it was the expectation of the facility that dietary…

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 observations, interviews, record reviews, and facility document and policy review, the facility failed to test staff identified via contact tracing as having a high-risk COVID-19 exposure. This had the potential to affect all residents who resided in the facility. Additionally, the facility failed to ensure that perineal care was performed in a sanitary manner for 1 (Resident #51) of 1 resident observed during perineal care. Findings included: 1. A review of a facility policy titled Coronavirus Disease (COVID-19) Policy on Surveillance, Testing, Reporting, Management and Staffing Guidance, revised in December 2023, revealed, Screening and Monitoring: 1. The Infection Preventionist is responsible for establishing and overseeing the active screening and monitoring efforts. The policy revealed, Surveillance and Reporting: 1. All surveillance findings are collected and reviewed daily by the Infection Preventionist. Further review revealed, Response Driven Testing or Post-Exposure Testing: a) All staff and…

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

Based on interviews, record review, facility policy review, and review of the California Department of Health Care Services Preadmission Screening and Resident Review (PASRR) Level 1 Assessment Guide, the facility failed to ensure the accuracy of Level I PASRR screenings completed for 2 (Resident #12 and Resident #110) of 5 sampled residents reviewed for PASRR requirements. Findings included: A review of a facility policy titled, admission Criteria PASARR, revised in March 2019, revealed, 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. a. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID, or RD. A review of the California Department of Health Care Services Preadmission Screening and Resident Review (PASRR) Level 1 Assessment Guide, dated 01/12/2023, revealed, Section III-Serious Mental Illness Questions…

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 interviews, record review, facility policy review, and review of the California Department of Health Care Services Preadmission Screening and Resident Review (PASRR) Level 1 Assessment Guide, the facility failed to submit a status change to a level I PASRR following a new mental health diagnosis for 1 (Resident #58) of 5 sampled residents reviewed for PASRR requirements. Specifically, Resident #58 had a prior positive level 1 PASRR but was later diagnosed with a new mental health diagnosis, and the facility failed to submit a status change to the resident's level 1 PASRR evaluation. Findings included: A review of a facility policy titled, admission Criteria PASARR, revised in March 2019, revealed, 9. All new admissions and readmissions are screened for mental disorders [MD], intellectual disabilities [ID] or related disorders [RD] per the Medicaid PASARR process. a. The facility conducts a level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID, or RD. A review of the California…

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 interviews, record review, and facility policy review, the facility failed to ensure the resident's medication regimen was free from unnecessary medications for 1 (Resident #58) of 5 sampled residents reviewed for unnecessary medications. Specifically, Resident #58 had an order for lorazepam (a benzodiazepine that may be used to treat anxiety) that was started on 02/08/2024 with no stop date or re-evaluation for continued use. Findings included: A review of a facility policy titled Psychotropic Medication Use, revised in July 2022, revealed, Psychotropic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review. The policy revealed 14. PRN [pro re nata; as needed] orders for psychotropic medications will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of that medication and documented the rationale for continued use. The duration of the PRN order will be indicated in the order. A review of Resident #58's admission…

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

Based on interviews, record review, and facility policy review, the facility failed to follow vital sign parameters when administering medications for 1 (Resident #58) of 5 sampled residents reviewed for unnecessary medications. Specifically, facility staff failed to hold medications when Resident #58's Systolic Blood Pressure (SBP) was less than (<) 110 millimeters of mercury (mmHg) as outlined in the physician's order. Findings included: A review of a facility policy titled Administering Medications, revised in April 2019, revealed, Medications are administered in a safe and timely manner, and as prescribed. The policy revealed, 4. Medications are administered in accordance with prescriber orders. Further review revealed, 11. The following information is checked/verified for each resident prior to administering medications: b. vital signs, if necessary. A review of Resident #58's admission Record revealed the facility admitted the resident on 06/18/2021. According to the admission Record, the resident had a medical history that included diagnoses of hypertension and heart failure.…

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 interviews, record review, and facility policy review, the facility failed to maintain medical records that were accurately documented for 1 (Resident #31) of 5 sampled residents reviewed for unnecessary medications. Findings included: A review of a facility policy titled Psychotropic Medication Use, revised in July 2022, revealed, 6. Diagnosis of a specific condition for which psychotropic medications are necessary to treat will be based on a comprehensive assessment of the resident. The policy revealed, 8. Resident diagnosis is based on a comprehensive assessment and evidence-based criteria and is consistent with professional standards. A review of Resident #31's admission Record revealed the facility admitted the resident on 07/07/2023. According to the admission Record, Resident # 31 was diagnosed with schizophrenia on 10/23/2023. A review of Resident #31's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/20/2024, revealed Resident #31 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate…

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 the survey agency (CDPH - California Department of Public Health) a written result of the abuse investigation within five (5) calendar days, for one of three sample residents (Resident A). This facility failure had the potential in a delay in the implementation of the intervention to ensure Resident A's safety and may place the residents at risk for further abuse. Findings: On September 15, 2023, at 1:35 p.m., an unannounced visit to the facility was conducted to investigate an allegation of abuse. On September 15, 2023, at 2:53 p.m., Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated Resident A ' s Family Member (FM) reported that Resident A was touched inappropriately on her private part by a black staff. On September 15, 2023, at 4 p.m., Resident A was interviewed. Resident A stated she saw a black man inside her room looking at her, and the man then touched her private part, then left when she asked him, What are you doing?…

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 demonstrate a rationale for a one of three sampled residents' (Resident 1) transfer to a board and care. In addition, the facility failed to complete a thorough discharge summary to reflect post-care provider relevant for the continuity of care for Resident 1. These failures had the potential to jeopardize the health and safety of Resident 1. Findings: A review of Resident 1's admission record indicated the resident was admitted to the facility on [DATE], with diagnoses which included brain cancer, lung cancer, diabetes, and anxiety disorder. The record further indicated the resident was her own representative. A review of Resident 1's Brief Interview for Mental Status (BIMS) dated August 4, 2023, indicated the resident had a score of 9 (moderate cognitive impairment). A review of Resident 1's Notice of Proposed Transfer/Discharge dated July 27, 2023, signed by Resident 1, indicated the resident was anticipated to be discharge on [DATE], because 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 reasonable care for the protection of personal property for one of four sampled residents (Resident 1). This failure resulted in the loss or theft of Resident 1's personal property. Findings: A review of Resident 1s face sheet (a document with clinical and demographic data) indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis of hemiparesis (weakness on one side of the body), cerebral infarction (stroke), and thrombosis (a blood clot within blood vessels that limits the flow of blood) of the left extremity. During an interview with Resident 1 on September 20, 2023, at 3:36 p.m., Resident 1 stated he was admitted to the facility with a computer tablet, charger and one water bottle. Resident 1 stated the tablet computer was missing upon his discharge on [DATE]. Resident 1 stated on November 30, 2022, he notified the Social Services Director (SSD) of the missing tablet computer. Resident 1 stated that 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. On June 9, 2021, Resident 22's record was reviewed. Resident 22 was readmitted to the facility on [DATE], with diagnoses including sepsis (a life-threatening complication of an infection). The Social History Assessment, dated March 10, 2021, indicated Resident 22's family member was contacted but there was no documented evidence a written information or assistance was offered to the family member regarding formulating an advance directive. On June 9, 2021, at 3:25 p.m., a concurrent interview and record review was conducted with SSD 2. SSD 2 stated there was no documentation a written information regarding formulating an AD was provided to Resident 22's RR. 2. On June 9, 2021, Resident 87's record was reviewed. Resident 87 was admitted to the facility on [DATE], with diagnoses which included cervical disc disorder with myelopathy (compression of the spinal cord in the neck) and diabetes mellitus (abnormal blood sugar). The facility document titled, POLST (Physician Order for Life-Sustaining Treatment), dated…

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 care and treatment were provided for three of 26 residents reviewed (Residents 172, 423, and 14) when: 1. For Resident 172, proper bowel management was not provided to address constipation (difficult bowel movement [BM]). This failure resulted in Resident 172 to experience discomfort and had the potential to result in complications related to constipation. 2. For Resident 423, the intravenous medication (IV - administration of fluids or medication through the vein) vancomycin (an antibiotic to treat infection) was not administered in a timely manner. In addition the physician was not notified when the IV medication was not administered timely. This failure had the potential for a delay of treatment for Resident 423. 3. For Resident 14, the physician's order to discontinue the fluid restriction was not carried out since July 21, 2020. This failure had the potential for Resident 14 to be at risk for dehydration and develop…

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 nutritional needs of the residents (Residents 20, 110, 39, 2, 70, 81, 16, 12, and 47) were met when: 1. The large portion diet was observed not in accordance with the production/dietary spreadsheet (used to determine the amount of food to serve for menu production), potentially affecting all residents on large portion diet; 2. The renal diet (diet for individuals with kidney disease) for Resident 39 was not served in accordance with the production/dietary spreadsheet; and 3. Multiple residents did not receive the designated vegetables on their food tray when the facility ran out of vegetables. These failures resulted in residents not being served their meals in accordance with the physician's orders and/or the production/dietary spreadsheet, which could potentially lead to health complications related to nutrition. Findings: On June 10, 2021, at 12:30 p.m., the diet menu spreadsheet was reviewed and indicated the following food to be served for lunch: oven baked pork chop with cream gravy, buttered…

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 sanitary conditions were maintained in the food and nutrition services and food were stored in accordance with professional standards for food service safety when: 1. One can of tapioca pudding was observed with a dent on the side of the can; 2. An open box of 25 pounds (lbs) of rice was not placed in a closed container; and 3. Food items were stored past the use-by-date. These failures had the potential for the growth of harmful microorganisms which may result in food-borne illnesses in a medically vulnerable population. Findings: On June 7, 2021, at 9:14 a.m., an initial kitchen tour was conducted with the Dietary Supervisor (DS). One big can of tapioca pudding (six pounds and 12 ounces) was observed in the dry goods storage area. The can of tapioca pudding was observed to have a dent on the side. In a concurrent interview with the DS, she stated dented cans should be discarded and not readily available for use. One open box of 25 lbs of rice was observed with an open date label of June 1, 2021. 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 accommodate the resident's request for the use of a denture adhesive for one week, for one of one resident reviewed (Resident 173). This failure resulted in Resident 173's frustration of constantly cutting the food served during meals and not using his dentures to chew his food. In addition, this failure had the potential for Resident 173 to not to consume his food and may result in weight loss. Findings: On June 9, 2021, at 2:40 p.m., a concurrent observation and interview was conducted with Resident 173. Resident 173 was observed awake, alert, and sitting on his bed talking to his roommate. Resident 173 was asked about his lunch meal. He stated he ate his lunch without his dentures. Resident stated he ran out of denture adhesive for a week. He stated he told the nursing staff about the need for the adhesive paste for his dentures for a week. Resident 173 stated he had to chop up his food during meals, and further stated, Got tired 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 conduct a thorough investigation for an allegation of abuse against a staff member for one of two residents reviewed for abuse (Resident 91). This failure had the potential to put Resident 91 and other vulnerable residents at risk for abuse. Findings: On June 8, 2021, at 3:04 p.m., Resident 91 was observed sitting in bed. In a concurrent interview with Resident 91, she stated there was an incident last week between her and Licensed Vocational Nurse (LVN) 3. She stated while she was sitting in the wheelchair praying for another resident inside the other resident's room, LVN 3 yanked (a sudden hard pull) her wheelchair, she slipped off the wheelchair, and landed on her bottom and hands. She stated LVN 3 told her You did that on purpose, and she walked away. She stated three staff members picked her up from the floor. She stated one of her hands hurt and an x-ray (radiologic procedure) was done. She stated she reported the incident to the Administrator 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 ensure accurate screening for PASARR (Preadmission Screening and Resident Review - a federal program to prevent individuals with mental illness, intellectual disability or related conditions from being inappropriately placed in a nursing facility), was conducted for one of one resident reviewed for PASARR. This failure had the potential for Resident 34 to not be properly evaluated and not receive appropriate care and services. Findings: On June 9, 2021, Resident 34's record was reviewed. Resident 34 was admitted to the facility on [DATE], with diagnoses which included schizophrenia (mental illness) and depression (mood disorder). The Preadmission Screening and Resident Review (PASRR) Level I Screening Document, dated September 23, 2020, indicated, .Diagnosed Mental Illness .No . The Minimum Data Set (MDS - an assessment tool), dated October 1, 2020, indicated Resident 34 had an active diagnoses of schizophrenia and depression. On June 14, 2021, at 8:59…

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 discharge (D/C) plan was discussed with the resident, for one of one resident (Resident 32) reviewed for discharge. This failure had the potential for Resident 32 to not be aware and/or participate with the D/C plan. Findings: On June 8, 2021, at 11:10 a.m., Resident 32 was observed lying in bed, alert and awake. In a concurrent interview with Resident 32, she stated, Nobody came to talk about anything. Resident 32 stated she did not know how long she was going to stay in the facility and that the facility staff did not discuss with her about the D/C plan. She further stated she did not want to stay longer in the facility. On June 14, 2021, the record of Resident 32 was reviewed. Resident 32 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (lung disease). The IDT (Interdisciplinary Team) Conference Summary), dated March 25, 2021, was reviewed. There was no documented…

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 assistance during meals was provided, for one of one resident reviewed (Resident 13), when the resident was eating the pureed food using her hands. This failure had the potential for Resident 13 to not be able to consume the food served and could place the resident at risk for nutritional problems. Findings: On June 7, 2021, at 12:45 p.m., during the lunch meal observation, Resident 13 was observed sitting in bed and her lunch tray was placed on an over bed table in front of her. Resident 13's tray was observed to have pureed food on a plate, a cup of pureed dessert, and four ounces (oz - unit of measurement) of milk. She was observed holding a spoon with her left thumb and pointer finger. She was observed getting the pureed food off the plate and the cup using her fingers from her left hand. Certified Nursing Assistant (CNA) 1 was observed feeding Resident 13's roommate. Resident 13 was not within sight of CNA 1 as the curtain 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 provide bilateral floor mats, as ordered and as indicated in the care plan to address the resident's fall risk, for one of three residents reviewed (Resident 22). This failure had the potential for Resident 22 to be at risk for injury and accidents. Findings: On June 8, 2021, Resident 22's record was reviewed. Resident 22 was readmitted to the facility on [DATE], with diagnoses including sepsis (a life-threatening complication of an infection) due to bladder infection, and history of thigh bone fracture. The physician's order, dated May 27, 2021, indicated, bilateral floor mat (mattress) for safety . every shift monitoring . Resident 22's care plan, dated March 17, 2021, indicated, AT RISK FOR FALL . Interventions . bilateral fall mat for poor safety awareness . Floor mats were not observed at Resident 22's bedside on the following dates and times: - June 8, 2021, at 2:45 p.m.; - June 9, 2021, at 10 a.m.; - June 10, 2021, at 5 p.m.; and -…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure nutritional care and services were provided, for two of four residents reviewed for nutrition (Residents 34 and 15), when: 1. For Resident 34, the physician was not notified in a timely manner of the IDT (Interdisciplinary Team - a group of healthcare professionals who work together for the common goal of the resident) recommendations to address the resident's significant weight loss. Weekly weights were not obtained when Resident 34 had significant weight losses in March, April, and May 2021. In addition, the physician was not notified of Resident 34's refusal for laboratory tests; and 2. For Resident 15, the facility did not provide the resident's meal preference to add soup with lunch and dinner to address the resident's significant weight loss. These failures had the potential for Residents 34 and 15 to have further weight loss and/or compromised nutritional status. Findings: 1. On June 7, 2021, at 12:38 p.m., Resident 34 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 a physician's order was obtained for the use of oxygen, for one of two residents reviewed for oxygen use (Resident 110). This failure resulted in Resident 110's continuous oxygen use without a specific physician's order. This failure had the potential for Resident 110 to receive unnecessary oxygen treatment without proper physician's evaluation. Findings: On June 8, 2021, at 11:33 a.m., Resident 110 was observed sleeping in bed. He was observed to be using oxygen through a nasal cannula (NC - a device used to deliver oxygen using a plastic tubing placed in the nostrils) at four liters per minute (LPM - unit of measurement). The oxygen tubing was observed to have a label dated June 7, 2021. On June 8, 2021, at 4:29 p.m., a concurrent observation and interview was conducted with Resident 110. He was observed sitting in bed and was using oxygen through a nasal cannula at four LPM. In a concurrent interview, Resident 110 stated he had…

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 carry out the physician's order for fluid restriction for one of two residents (Resident 79) reviewed for dialysis (process of removing excess water, solutes and toxins from the blood in people whose kidneys can no longer perform these functions naturally). This failure also had the potential for Resident 79 to have fluid overload (the condition of having too much water in the body) and further compromise his physical health. Findings: On June 7, 2021, at 11:38 a.m., a gray pitcher full of water was observed on the bedside table of Resident 79. In a concurrent interview with Resident 79, he stated he drank water from the pitcher. On June 7, 2021, at 1:04 p.m., certified nursing assistant (CNA) 4 was interviewed. She stated Resident 79 would get a pitcher of water at bedside and was not on any fluid restriction that she knew of. She stated the staff did not document the fluid intake of Resident 79. On June 8, 2021, at 10:11 a.m., 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure drinks were provided according to the residents' needs, for four of four residents reviewed (Residents 13, 113, 4, and 39), when: 1. Residents 13 and 113, who had fortified diet orders, were not provided eight ounces (oz - unit of measurement) of milk as specified in the menu; and 2. Residents 4 and 39, who had renal diet (diet provided to residents with kidney disease) orders, were not provided pineapple juice as specified in the menu. These failures had the potential for Residents 13, 113, 4, and 39 to not receive the appropriate nutrients needed to address their health conditions. Findings: On June 7, 2021, at 12:45 p.m., during the lunch meal observation, Resident 13 was observed sitting up in bed eating her lunch. She was observed to have pureed food, dessert, and four oz of milk on her lunch tray. Resident 13's diet meal ticket indicated .Fortified .8 (eight) fl (fluid) oz Milk 2% . On June 7, 2021, at 1:16 p.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 ensure: 1. The urinal of Resident 2 was labeled with his name. This failure had the potential for cross contamination to occur when used by other residents, which could result for Resident 2 and other residents to develop bladder infection. 2. The medication nebulizer mask with dispenser (medication dispenser attached to a machine used to administer breathing treatment) for Resident 44 was stored inside a bag when not in use; and 3. The oral suction catheter of Resident 96 was stored inside a bag when not in use. These failures had the potential for bacterial growth and increased the risk for Residents 44 and 96 to develop respiratory infection. Findings: 1. On June 7, 2021, at 11:40 a.m., an uncovered and used urinal was observed on top of Resident 2's night stand without a label. Attempted to interview Resident 2 but was unable to answer. On June 7, 2021, at 11:45 a.m., Licensed Vocational Nurse (LVN) 3 was interviewed. 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.