Riverside Postacute Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure, 10 of 39 residents reviewed for Advance Directive (AD - written statement of a person's wishes regarding medical treatment) (Residents 1, 10, 14, 15, 30, 57, 89, 106, 156, and 176) the resident or their resident representative (RP) had been provided follow up information regarding the formulation of an AD.These failures had the potential to result in the ADs for Residents 1, 10, 14, 15, 30, 57, 89, 106, 156, and 176, not being readily accessible to staff and physicians, which could lead to the residents' wishes regarding medical treatment being unknown and ultimately not honored.Findings:1. On February 24, 2026, at 8:39 a.m., an interview was conducted with Resident 14. Resident 14 stated that she was unsure of having been asked by the facility about formulating an AD and that she would like to know more. Resident 14's record was reviewed. Resident 14 was admitted to the facility on [DATE]. The History and Physical Examination, (H&P) 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 provide sufficient nursing staff to be able to provide for care and services for the residents of the facility. This failure caused delays in the response to multiple residents' (Residents 19, 39, 43, 62, 108, 121, 124, 128, 183, 148, 150, 97, 13, 87, 108, and 162) call lights which had the potential to put residents at risk for falls, accidents, late provision of care or care not being rendered at all.Findings: On February 24, 2026, Resident council meetings (independent, resident-led groups that typically meet monthly to discuss concerns, improve quality of life, and influence care) minutes for December 2025, January 2026, and February 2026 were reviewed. The minutes indicated residents complained to the facility that call lights were not being answered in a timely manner. On February 24, 2026, at 3:10 p.m., an interview was conducted with the residents who attended the residents' council. All residents who attended the residents'…

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 pharmacy services were provided in a timely manner, for 14 of 39 residents reviewed (Residents 118, 106, 8, 153, 13, 163, 108, 69, 182, 185, 184,186, 176, and 167) for pharmacy services, when:1. For Resident 118, 106, 8, 153, 13, 163, 108, and 69, medications were not administered as ordered by the physician on multiple occasions between December 2025, January 2026, and February 2026, due to medication unavailability. (Cross Reference F760).2. Residents 182, 185, 184, and 186, did not receive the PPD skin test (test to detect Tuberculosis {contagious lung infection}) as scheduled due to unavailability of the PPD solution;3. For Residents 176 and 167, the facility did not establish a system for receiving and ensuring Over-The Counter (OTC) medications are readily available for residents' use; and4. For Resident 106, the medication Albuterol Sulfate Inhalation (drug used for treat shortness of breath by relaxing airway muscles) was…

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

Based on observation, interview, and record review, the Pharmacy Consultant (PC) failed, for eight of 39 residents reviewed for pharmacy services (Residents 118,106, 8, 153, 63,108, and 69), to identify drug irregularities when multiple licensed nurses were documenting in the electronic medication Administration Record (eMAR) prescribed medications were not administered on multiple occasions between December 2025, January 2026, and February 2026, due to medication unavailability. (Cross Reference F760).This failure resulted in these residents not receiving medications as ordered by the physician to manage and treat medical conditions. Findings:On February 24, 2026, Resident 118's medical record was reviewed. The licensed nurses documented in the eMAR that Resident 118 did not receive her medication Lacosamide (anticonvulsant medication used to treat seizures) from December 17, 2025, to January 15, 2026.(Cross Reference F760 Finding #1).On February 25, 2026, Resident 106's medical record was reviewed. The licensed nurses documented in the eMAR that Resident 106 did not receive five…

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 proper infection control measures were implemented when:1.For Resident 66, there was no EBP (Enhanced Barrier Precaution - an infection control strategy in nursing homes requiring staff to wear gowns and gloves during high-contact resident care, such as bathing, dressing, or device care) signage posted at the door outside Resident 66's room who had a urinary catheter (a flexible tube used to drain urine); 2. A kitchen staff was observed to touch the kitchen floor and continued with food handling without washing hands and changing gloves; 3. For Resident 106, the CNA attempted to reapply resident 106's nasal cannula after it had been on the floor; 4. The staff failed to hand sanitize in between meal tray pass; and 5. For Resident 30, the facility did not label his suction machine and discard the contents inside the canister in accordance with the facility policy. These failures had the potential to result in cross-contamination,…

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 residents to call for staff assistance) was fully functional when the call light system panel did not have an audible sound. This failure had the potential for the residents in the facility not to receive assistance from the staff in a timely manner. Findings: On February 25, 2026, at 12:48 p.m., while standing in the hallway at Station 3, between rooms [ROOM NUMBERS], the Maintenance Director (MND)was observed to approach room [ROOM NUMBER] and asked the resident if he needed help. The call light for room [ROOM NUMBER]A was observed on, without an audible sound. The call light panel located on the wall in Station 3 was observed with the light on for room [ROOM NUMBER] with no audible sound. There was no staff member present at the nurse's station. On February 25, 2026, at 12:50 p.m., the Maintenance Director (MND) was interviewed. He stated he worked at the facility 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 an allegation of physical abuse was reported within two hours to the California Department of Public Health (CDPH - State Agency Licensing and Certification Program) for one of 39 residents reviewed (Resident 20).This failure had the potential to result in a delay in the investigation and reporting further allegations of abuse for Resident 20.Findings:On February 25, 2026, at 12:31 p.m., Resident 20 was observed lying in bed, awake and alert. In a concurrent interview with Resident 20, he stated he had a urinal hanging at the foot of his bed. Resident 20 stated his previous roommate, was in his wheelchair and asked him if the urinal was his and answered, yes. He stated his previous roommate took the urinal that was hanging at the foot of his bed and threw it at him. Resident 20 stated he got wet with urine, and did not report the incident to the nurse until the next day. He stated he could not recall the date of the incident. Resident 20 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 for two of 39 residents reviewed for quality of care (Residents 47, and 108) the following:1. For Resident 47, the medications Equate (brand name) Multivitamins and Over-The-Counter (OTC) throat lozenges found at the bedside had a physician's order for use.This failure had the potential for Resident 47 to not be monitored for safe self-administration of medication and medication side effects; and2. For Resident 108, the facility did not ensure a laboratory order to monitor the effectiveness of the thyroid medication was in place.This failure had the potential for Resident 108 to not be monitored for complications related to hyperthyroidism (overactive thyroid). Findings: 1. On February 24, 2026, at 1:19 p.m., a concurrent observation and interview was conducted with Resident 47. Resident 47 was observed sitting in the wheelchair, in his room. A bottle of Equate Complete Multivitamins and a pack of throat lozenges were observed 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 for three of 39 residents reviewed for oxygen administration (Residents 29, 206, and 181) when:1.For Residents 29 and 106, respiratory care and treatment were not provided 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 residents' health condition; and2. For Resident 181, the facility did not ensure the resident's oxygen tubing was labeled in accordance with the facility practice.This failure had the potential to result in cross-contamination, increasing the spread of infection to an already vulnerable population of residents in the facility. Findings: 1a.On February 24, 2026, at 9:28 a.m., a concurrent observation and interview was conducted with Resident 29. Resident 29 was observed in bed with oxygen (O2) via nasal cannula (NC - a tube used to deliver oxygen through the nose). Resident 29's oxygen…

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 food preference was honored for one of three residents (Resident 108). This failure had the potential to result in the resident refusing meals and experiencing decreased nutritional intake.Findings:On February 23, 2026, at 1:34 p.m., an observation and interview were conducted with Resident 108 in her room as she was eating her lunch. Resident 108 was observed to have a lettuce salad on her plate. Resident 108 stated, I told them I don't want lettuce, and they still keep bringing me lettuce, I don't have teeth; I can't chew the lettuce, they don't listen. Resident 108's meal ticket was observed on the resident's table that read, .Notes: No lettuce.Dislikes: Vegetables (lettuce). Resident 108's meal ticket was observed to list the following: .Diet Order: Regular Texture, Regular Diet- Thin liquids.Notes: No lettuce.Dislikes. Vegetables (Lettuce). On February 24, 2026, Resident 108's record was reviewed. Resident 108…

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 policy and procedure for Self-Administration of Medications was followed for one of six residents, (Resident 4).This failure had the potential for Resident 4 to overdose, have medications in an unsecured location, and staff to be unaware of the medications Resident 4 was taking. Findings:A review of Resident 4's medical records indicated Resident 4 was admitted on [DATE], with diagnoses of acute, (a serious condition that develops quickly without warning when the lungs can't get enough oxygen into the blood), and chronic, (a long-term condition in which the respiratory system is unable to adequately exchange oxygen and carbon dioxide in the body), respiratory failure, radiculopathy, (a pinched nerve, is the injury or damage to nerve roots in the spine where they exit the spinal column), lumbar region, chronic pain syndrome, acetonuria, (the presence of excessive amounts of ketone bodies in the urine indicating the body is…

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 call lights were answered in a timely manner when one of six residents (Resident 1), waited for 31 minutes for his call light to be answered when he wanted his briefs changed.This failure had the potential for Resident 1's needs to be unmet and experience possible skin breakdown due to wearing a wet brief for an extended period of time.Findings:A review of Resident 1's medical records indicated resident was admitted on [DATE], with diagnoses of cerebral infarction, (also known as a stroke, refers to damage to tissues in the brain due to a loss of oxygen to the area), hemiplegia, (paralysis of one side of the body), and hemiparesis, (weakness of one side of the body), following cerebral infarction affecting right dominant side, muscle wasting and atrophy, (wasting, thinning, or loss of muscle tissue, resulting in decreased size, strength, and movement capability), major depressive disorder, (a mood disorder that causes a persistent…

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 four of four sampled residents, Residents 2, 3, 4, 5, the residents and/or their responsible party were notified of payor changes when the residents were changed from Medi-cal to private pay. This failure is a violation of Residents 2, 3, 4, 5 and/or their responsible parties of resident's rights.Findings:A review of Resident 2's medical record indicated the resident was admitted to the facility on [DATE], with diagnoses which included history of transient ischemic attack (a temporary blockage of blood flow to the brain) and that he is self-responsible.A review of Resident 2's Minimum Data Set (MDS- an assessment tool) dated January 1, 2025, indicated the resident's cognitive function is intact.A review of Resident 2's Census tab in PointClickCare (PCC - an electronic record software) indicated the resident's primary payer is Private Pay (paying out-of-pocket with personal money rather than insurance) effective January 1,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide copies of financial records upon request within two business days after receiving the request from the Long-Term Care Ombudsman (LCTO- an advocate who assists residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences) on behalf of the resident, for one of six sampled residents, Resident 2.This failure is a violation of Resident 2 and the resident's representative's rights.Findings: A review of Resident 2's medical record indicated the resident was admitted to the facility on [DATE], with diagnoses which included history of transient ischemic attack (temporary blockage of blood flow to the brain causing stroke-like symptoms) and vascular dementia (decline in thinking skills caused by restricted blood flow to the brain). Resident 2 is self-responsible.A review of the Resident 2's Minimum Data Set (an assessment tool) dated January 1, 2026, indicated he has the capacity to understand…

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, and record reviews, the facility failed to protect the residents' rights to be free from sexual abuse by another resident and verbal abuse by a staff member for two of the ten residents reviewed (Resident 1 and Resident 7) when: 1.For Resident 1, staff witnessed a male resident (Resident 2) touching Resident 1's breast with one hand and trying to raise Resident 1's shirt up with the other hand; and This failure has the substantial probability of causing Resident 1 to experience anxiety, emotional distress, or fear of recurrence of the sexual abuse which could subsequently lead to decreased engagement in social activities by Resident 1. 2. For Resident 7, another resident (Resident 9) witnessed the CNA (certified nurse assistant) verbally abused Resident 7, by telling Resident 7 to shut up when the resident was crying. This failure has the substantial probability of causing Resident 7 to experience anger, feeling of worthlessness, and inability to trust staff which could…

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 safe environment and adequate supervision were provided for two of four sampled residents (Residents 2 and 3), when Residents 2 and 3 were observed to have smoking paraphernalia kept at bedside. In addition, the facility failed to ensure Resident 2's capability and deficit was assessed to determine the need for assistance and supervision for smoking.These failures had the potential for environmental risk, hazards and accidents resulting in serious burn injuries and/or fire for Residents 2 and 3 and other residents at the facility.Findings:On January 22, 2026, at 1:30 p.m., a concurrent observation and interview was conducted with Resident 2. Resident 2 was observed sitting in bed alert, oriented, and well-groomed, accompanied by a sitter. Resident 2 stated he is a smoker and he keeps his smoking materials in his jacket by the bedside. Resident 2 was observed pulling a red and white pack of cigarettes and a purple lighter from his…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure bedside water pitchers were filled or that fresh water was offered daily to maintain proper hydration for two of seven sampled residents (Residents 1 and 7).This failure has the potential to adversely impact the residents' hydration status.Findings:On January 21, 2026, at 9:08 a.m., a concurrent observation and interview was conducted with Resident 1. Resident 1 was observed alert and oriented, seated in his wheelchair beside the bed. Resident 1's bedside table contained a teal water pitcher which was one-quarter full of water. Resident 1 stated the CNAs would usually refill his water, but this had not been done this morning.On January 22, 2026, at 8:32 a.m., a concurrent observation and interview were conducted with Resident 1. It was noted that Resident 1's water pitcher remained at the same level as observed on January 21, 2026. Resident 1 reported that his water pitcher had not been refilled either yesterday or today.On January…

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 Licensed Vocational Nurse (LVN) 1 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 (SARS-CoV-2-a highly contagious respiratory disease) positive resident.This failure had the potential to spread COVID-19 to other residents.Findings:On January 8, 2026, at 5:48 a.m., during an observation outside Resident 1'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…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect the residents' right to be free from physical abuse by a staff member for one of three residents reviewed (Resident 1) when a Certified Nursing Assistant (CNA) placed a towel over Resident 1's mouth.This failure had the potential to obstruct Resident 1's breathing causing suffocation and the risk of aspiration (inhaling food, liquid, or foreign material into the lungs), and emotional distress.Findings:A review of Resident 1's admission Record indicated he was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (disrupted blood flow to the brain).A review of Resident 1's Minimum Data Set (MDS- a standardized assessment) dated November 3, 2025, indicated he has severely impaired (never/rarely made decisions) capacity to make decisions and dependent with activities of daily living.A review of Resident 1's SBAR (Situation, Background, Assessment, and Recommendation - a structure communication form…

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 physical abuse involving one of three residents reviewed, Resident 1, was reported to the California Department of Public Health (CDPH), not later than two hours after the allegation was made.This failure resulted in a delay in an investigation being started and had the potential to place Resident 1 and other residents at risk of harm from further abuse.Findings:On December 8, 2025, CDPH received a report from the facility of an allegation of abuse by a staff member involving Resident 1 which occurred on December 6, 2025. The allegation indicated that a Certified Nursing Assistant (CNA) placed a towel over the resident's head and mouth.A review of Resident 1's admission Record indicated he was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (disrupted blood flow to the brain).A review of Resident 1's H&P (history and physical) Note dated November 21, 2024, indicated the resident's…

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

Based on interview and record review, the facility failed to develop and revise a comprehensive, person-centered care plan to address transportation needs for one of three sampled residents (Resident 1) reviewed for dialysis. The facility did not complete an interdisciplinary assessment or care plan update when it changed the resident's transportation method for dialysis from a wheelchair-accessible van to a standard vehicle (Uber). As a result, the resident was transported in an inappropriate vehicle that did not accommodate her functional limitations, leading to missed dialysis treatments, hospitalization, and physical injury.Findings:On October 3, 2025, at 1:08 p.m., during an interview, the SSD stated dialysis residents are admitted to the facility with transportation and dialysis appointments already arranged and that she arranged transportation for any make up dialysis days. The SSD stated Resident 1's insurance is accepted by very few transportation companies. The SSD stated they were using a private wheelchair van transportation for Resident 1, but the facility stopped…

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 safe and sanitary food preparation and storage practices in the kitchen when: 1. One jar of minced garlic in the walk- in refrigerator was found to be past its used by date and was readily available for use; 2. Several Romaine lettuces were observed in the walk-in refrigerator not properly stored within their designated bags and exposed to open air; 3. One brown cutting board was found with multiple deep indentations; 4. Two hot water thermos water spurs were found with calcium build up and brown grime above the spurs; 5. Two dietary staff did not follow the manufacturer's guidelines for testing QUAT sanitizer concentration with a test strip; and 6. Two dietary staff did not know the correct concentration of the dishwasher sanitizer. These failures can create unsafe conditions and lead to foodborne illness (stomach illness acquired from ingesting contaminated food) in a vulnerable population of 152 of the 159 residents who received food prepared in the kitchen.Findings:1. On September 8, 2025, at 10:19…

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, 10 of 38 residents reviewed for Advance Directive (AD - written statement of a person's wishes regarding medical treatment) (Residents 1, 9, 13, 28, 36, 123, 126, 155, 157, and 168) the resident or their resident representative (RP) had been provided follow up information regarding the formulation of an AD.These failures had the potential to result in the ADs for Residents 1, 9, 13, 28, 36, 123, 126, 155, 157, and 168, not being readily accessible to staff and physicians, which could lead to the residents' wishes regarding medical treatment being unknown and ultimately not honored.Findings:1. On April 14, 2025, at 3:58 p.m., an interview was conducted with Resident 1. Resident 1 stated that he was unsure of having an AD and unsure if he was asked if he would like to formulate one.Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE].A review of the History and Physical Examination, (H&P) dated March 6, 2025,…

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 for four of five certified nurse assistants (CNAs 1, 2, 4, and 5) performance evaluations were completed. This failure had the potential for staff performance needs not to be identified and addressed in a timely manner. Findings:On September 10, 2025, five CNAs personnel files were reviewed. The review indicated the following:1.CNA 1 was hired on February 1, 2016. The most recent annual performance evaluation was dated April 27, 2020.2. CNA 2 was hired on August 13, 2024. No annual performance evaluation found.3. CNA 4 was hired on June 4, 2024. No annual performance evaluation found; and4. CNA 5 was hired on June 4, 2024. No annual performance evaluation found.On September 10, 2025, at 8:33 a.m., a concurrent interview and record review of performance evaluation records was conducted with the Director of Staff Development (DSD). The DSD stated for four of five CNAs (CNA 1, 2, 4, and 5), the annual performance evaluation was not found in the respective personnel file. The DSD stated each CNA is required to have an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure proper infection control measures were implemented when:1. For Resident 86, Licensed Vocational Nurse (LVN) 4 did not wear personal protective equipment (PPE - equipment, such as gloves and gown, used to protect against infection or illness) when providing care to Resident 86, who was on enhanced barrier precaution (EBP-an infection control intervention to reduce transmission of multidrug-resistant organisms [MDRO- bacteria that have become resistant to multiple antibiotics).2. For Resident 116, Certified Nursing Assistant (CNA 1) did not wear personal protective equipment when providing care.3. For Resident 64, LVN 5 did not use the proper disinfecting wipes to clean the blood pressure machine between residents' use.4. For Resident 157, CNA 8 did not wear proper PPE when providing care and changing Resident' 157's gown.These failures had the potential to result in cross-contamination, increasing the risk of infection spread among…

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 written Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN- a notice to provide information to residents/beneficiaries if they wish to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility) for one of three residents reviewed for SNF ABN (Resident 92).This failure resulted in Resident 92 not being informed in writing about potential liability for payment of non-covered Medicare Part A services, placing the resident at risk of unexpected financial burden.Findings:A review of Resident 92's admission Record was conducted. Resident 92 was admitted to the facility on [DATE], with a diagnosis which included asthma (respiratory condition characterized by difficulty in breathing). Resident 92's Medicare Part A coverage began on April 17, 2025, and ended on July 1, 2025. Resident 92 remained in the facility for long term care after Medicare coverage ended.A review of Resident 92'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 ensure reasonable care for the protection of resident's property for two of three residents (Residents 120 and 147) when: 1. The personal inventory list was not available for Resident 120 and2. The inventory of personal belongings list was incomplete for Resident 147.These failures resulted in the inability to verify and account for residents' belongings which had the potential to result in psychosocial harm for Residents 120 and 147.Findings: 1. On September 8, 2025, at 9:37 a.m. an interview was conducted with Resident 120 in her room. Resident 120 stated she had her partial dentures upon admission. Resident 120 stated she does not have her partial dentures and feels shy without it. A review of Resident 120's admission Record dated September 12, 2025, indicated an admission date of March 19, 2024, which included a diagnosis of schizoaffective disorder (mental disorder). A review of Resident 120's History and Physical dated March 21, 2024, indicated…

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 all residents were free from abuse when one of five residents (Resident 168) reviewed for abuse was verbally abused by another resident (Resident 10), after Resident 168 asked Resident 10 to lower the volume of his music. Resident 10 verbally threatened Resident 168 and called him derogatory names.The facility failure resulted in Resident 168 feeling threatened by Resident 10, which could negatively impact the resident's psychosocial well-being. Findings:On September 8, 2025, at 11:11 am, a concurrent observation and interview was conducted with Resident 10 in his room. It was noted that loud music could be heard from the hallway. Resident 10 stated there was an incident with Resident 168 and acknowledged that he continues to play his music loud and does not care if it bothers anyone.A review of Resident 10's admission Record dated September 10, 2025, indicated the resident was admitted on [DATE], with diagnoses which included…

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 incorporate the recommendations from the PASARR level II determination and evaluation into the care plan for one (Resident 123) of two residents reviewed for PASRR (Pre-admission Screening & Resident Review- a federal requirement to determine whether or not an individual who has an active diagnosis of mental illness or intellectual disability meets the criteria for admission to a nursing facility and identify what specialized services an individual needs). This failure had the potential for Resident 123's special needs not to be met while in the facility. Findings:A review of Resident 123's admission record indicated Resident 123's was admitted to the facility on [DATE], with diagnoses which included schizoaffective disorder (a mental disorder).A review of Resident 123's PASRR report indicated, Your (Resident 123) Level I screening conducted at (name of facility) followed by a Level II Evaluation on March 27, 2024 .The facility staff will receive a copy…

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 two residents reviewed (Resident 174).This failure had the potential for Resident 174 to be at risk for infection due to the unsanitary condition of his fingernails.Findings:A review of Resident 174's medical records was conducted. Resident 174 was admitted to the facility on [DATE], with diagnoses which included acquired absence of right eye and glaucoma (cloudy vision) on left eye.A review of Resident 174's care plan titled, .Activities of Daily Living (ADL) Self-Care Performance Deficit r/t (related to) impaired balance, limited mobility and muscle weakness, included the interventions, Bathing/showering: check nail length and trim and clean on bath day and as necessary.report changes to the nurse.On September 9, 2025, at 11:47 a.m., a concurrent observation and interview were conducted with Resident 174, Resident 174…

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 and record reviews, the facility failed to complete monitoring for a skin related change of condition for one of one resident (Resident 12) reviewed for quality of care.This failure resulted in inconsistent evaluation of the wound and placed Resident 12, who had diabetes (abnormal blood sugar) and peripheral vascular disease (a problem with blood flow), at risk for infection, delayed wound treatment, and worsening of the condition of the left second toe.Findings:A review of Resident 12's admission Record dated September 10, 2025, indicated an admission date of July 20, 2025 with a diagnoses which included peripheral vascular disease and diabetes mellitus.A review of Resident 12's History and Physical dated August 25, 2025, indicated resident can make needs known but cannot make medical decisions.A review of Resident 12's Minimum Data Set (MDS - an assessment tool) dated September 2, 2025, indicated a Brief Interview for Mental Status (BIMS - a tool to assess cognitive function) score was 05 (severe cognitive impairment).A review of Resident 12's Podiatric…

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 and record review, the facility failed to adequately monitor nutritional status for one of two residents (Resident 126) when meal intakes were not consistently documented.This failure had the potential to result in inability to track intake trends, identify weight loss risk, and delay in corrective action subsequently resulting in nutritional decline.Findings:On September 9, 2025, at 10 a.m., an interview was conducted with Resident 126. Resident 126 stated she has lost weight and eats less than half of the meals served.A review of Resident 126's admission Record dated September 12, 2025, indicated an admission date of May 7, 2025, with a diagnosis which included moderate protein-calorie malnutrition (poor protein and calorie intake).A review of Resident 126's History and Physical dated May 8, 2025, indicated resident had the capacity to understand and make decisions.A review of Resident 126's Minimum Data Set (MDS an assessment tool) dated August 12, 2025, indicated a Brief Interview for Mental Status (BIMS - a tool to assess cognitive function) score of 14…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow dental recommendations for one of two residents (Resident 138) reviewed for dental services. This failure had the potential for nutrition problems, discomfort, and decreased quality of life. Findings:A review of Resident 138's records was conducted. Resident 138 was admitted to the facility on [DATE], with diagnoses which included oropharyngeal dysphagia (difficulty swallowing). A review of Resident 138's Minimum Data Set (MDS - an assessment tool) dated August 11, 2025, indicated a Brief Interview of Mental Status (BIMS - a tool to assess cognitive function of an individual) score of 13 (moderate cognitive intact). A review of Resident 138's Nutritional Assessment, dated November 26, 2024, indicated, .Oral Condition.oral condition issues.edentulous (missing teeth). A review of Resident 138's Psychosocial Note, dated August 18, 2025, indicated, .Resident was seeing (sic) by (name of dental company) on 08/15/25. A review of Resident 138's Dental…

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 call light system was working properly for one of twelve resident call lights (Resident 5). This failure had the potential to delay medical care needed for Resident 5.Findings:On September 8, 2025, at 9:36 a.m., an interview with Resident 5 was conducted. Resident 5 stated his call light was not working because the staff did not come to help when it was pressed. Resident 5 further stated they just walked by, and he needed to scream to get their attention. On September 8, 2025, at 9:37 a.m., a concurrent observation and interview with Certified Nursing Assistant 2 (CNA 2) was conducted. CNA 2 pressed Resident 5's call light button and stated the call light was not working.On September 8, 2025, at 9:39 a.m., a concurrent observation and interview with the Licensed Vocational Nurse 3 (LVN3) was conducted. LVN 3 stated the call light was not working. LVN 3 stated it should be working, in order to properly respond to resident needs.On September 12, 2025, at 3:36 p.m., an interview with Resident 173…

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 sufficient staffing to be able to provide care and services to the residents of the facility.This failure caused the delay in response to the resident's call lights being answered and had the potential for late provision of care or the care not being rendered at all.Findings:On July 31, 2025, at 10:03 a.m., Resident 1 was observed lying in bed, awake and alert. In a concurrent interview with Resident 1, she stated she received showers every Thursday. She stated she wanted to receive more showers, but the staff told her they were so busy. On July 31, 2025, at 11:30 a.m., Residents 2 and Resident 3 were observed in their room. Resident 2 was sitting in the wheelchair, with unkempt hair, awake and alert.Resident 2 stated, They do not have enough staff. He stated there were some nights when there were no (Certified Nursing Assistants) CNAs to answer the call lights. He stated, It took forever for the staff to come and answer the call…

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

Based on observation, interview and record review, the facility failed to provide care and treatment according to professional standards of practice when one of three residents (Resident 8) was administered Midodrine (a medication used to treat orthostatic hypotension - low blood pressure that occurs upon standing) when Resident 8's blood pressure (BP) was above the physician's ordered parameters.This failure had the potential for Resident 8 to experience hypertension (high blood pressure).Findings:On August 1, 2025, Resident 8's medical record was reviewed. Resident 8 was admitted to the facility on April18, 2025, with diagnoses which included orthostatic hypotension. The physician's order dated May 9, 2025, indicated, .Midodrine HCL (hydrochloride - a chemical compound) Oral Tablet 5 MG (Midodrine HCL) Give 1 tablet by mouth two times a day for HYPOTENSION HOLD FOR SBP (systolic blood pressure - top number) > (greater than) 110. The Medication Administration Record (MAR) indicated the medication Midodrine was administered on the following dates:- June 1, 2025, at 9 a.m., BP =…

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 inform one of three residents (Resident 7) of a change in her insurance that occurred while she was at the facility.This failure resulted in Resident 7 not receiving the planned care and services upon her discharge from the facility. Findings:On July 31, 2025, at 8:24 a.m., during a telephone interview with Resident 7, she stated the facility changed her insurance without her knowledge. Resident 7 stated she did not receive the home health visits ordered when she was discharged from the facility. She stated the Home Health Agency called and informed her the insurance (Name of Insurance) was terminated as of June 1, 2025. Resident 7 stated the facility changed her insurance without her knowledge.Resident 7's record was reviewed. Resident 7 was admitted to the facility on [DATE], with diagnoses which included a fracture of shaft of humerus (long bone of the upper arm) of the right arm. The Minimum Data Set (an assessment tool), dated June 20, 2025,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a comfortable and sanitary environment for two of two residents (Residents 2 and 3) when:1. Resident 2's sheets were not changed, and Resident 3's urinals (a portable device used for urination) with urine were left hanging on the bed and on the bedside table, and2. A bag of soiled linen was left on the floor of another room.This failure resulted in Resident 2 and 3 not to have a sanitary and comfortable environment.Findings:On July 31, 2025, at 11:30 a.m., during an observation from the hallway, a strong urine odor was smelled coming from room [ROOM NUMBER]. Resident 2 was observed sitting in the wheelchair by bed 35-C, awake and alert, with unkempt hair. Resident 2's bed was not made and the mid section area of the fitted sheet was observed brownish in color. A urinal was observed hanging on the side rails of Resident 2's bed. Resident 3 was observed lying in bed, awake and alert, and well groomed. Three urinals (one empty and 2…

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 implement their policy and procedure when the facility failed to ensure an allegation of physical abuse was reported within two hours to the California Department of Public Health (CDPH - State Agency Licensing and Certification Program) for one resident (Resident 9) of three residents reviewed for abuse. The facility's abuse policy, dated June 2022, documented that the facility would report all alleged incidents of abuse to CDPH within two hours. On July 31, 2025, it was alleged that a facility staff member forcibly transferred Resident 9 to her wheelchair. The facility failed to report the allegation until over four hours after the incident, at 6:31 a.m. This failure had the potential to result in delaying resident protection and delaying the start of an investigation. Findings:On August 1, 2025, at 2:25 p.m., a telephone interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated on July 31, 2025, at around 2:30 a.m., she 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 routine Norco (narcotic pain medication) was available for one of two residents (Resident 1), when Resident 1 did not receive four doses in June 2025, and nine doses in July 2025.This failure had the potential for Resident 1 to experience psychological distress and unmanaged pain.Findings:On July 14, 2025, at 9:40 a.m., an interview was conducted with Resident 1 in her room. Resident 1 was well-groomed and interviewable. Resident 1 stated she has been at the facility for three years. Stated she has been using Norco for three years, which has been effective for managing her arthritic pain and it is a routine medication for her. Resident 1 stated the Norco is to be ordered 4 days before it runs out and when it is delayed she was always told it's either an issue with the pharmacist, or the doctor did not sign for it. She stated in the past, Norco was pulled from the emergency kit, but it wasn't done because the doctor needed to sign…

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 wound treatment for one of two residents' (Resident 4) left lower extremity open wound for three days since admission to the facility. This failure of delayed provision of wound treatment can lead to serious complications like sepsis, infection and even amputation. Findings: A review of Resident 1's admission Record, indicated the resident was re-admitted to the facility on [DATE], with diagnoses which included non-pressure ulcer of other part of the left foot and ankle and peripheral vascular disease (reduced circulation of blood to a body part). A review of Resident 4's general acute care hospital (GACH) document titled Discharge Summary, dated May 1, 2025, indicated Resident 5 was admitted on [DATE], with open wound to her lower extremity and was discharged to nursing home (skilled nursing facility) on May 1, 2025. A review of Resident 4's general acute care hospital notes (GACH) titled PATIENT PROGRESS NOTES, dated May 1, 2025, indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident was free from physical abuse, when two facility staff witnessed one Certified Nursing Assistant (CNA 1) roughly pushed one of three sampled residents (Resident 1) multiple times, to prevent resident from getting up from bed. Resident 1 has severe cognitive impairment. This failure could very likely result in Resident 1 experiencing increased anxiety and distress which negatively impact Resident 1's psychosocial, and mental well-being. Findings: On May 1, 2025, at 8:55 a.m., an unannounced visit was made to the facility to investigate an allegation of abuse. A review of Resident 1's record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), anxiety, Parkinson ' s disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise…

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 physical abuse involving one of three sampled resident (Resident 1) and a facility staff was reported to California Department of Public Health (CDPH - State Agency-Licensing and Certification Program) immediately or not later than two hours. The facility was made aware of the alleged physical abuse on March 5, 2025. This failure has the potential for delayed investigation which placed Resident 1 at risk for further abuse while at the facility. Findings: A review of Resident 1's admission Record, indicated the resident was admitted to the facility on [DATE], with diagnoses which included dementia (a group of symptoms affecting memory, thinking and social abilities). A review of Resident's Minimum Data Set (an assessment tool), dated December 12, 2024, indicated he had moderate cognitive impairment. A review of Resident 1's Nurses' Notes indicated the following: a. March 5, 2025, at 5:49 p.m., Resident states she kept punching me…

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 the proper procedure in removing blockage of the gastronomy tube (G-tube a tube placed through the abdominal wall directly into the stomach, typically for feeding purposes), in accordance with the policy and procedure for one of three sampled residents (Resident 2). This failure had the potential to negatively impact the resident's ability to receive nutrition, hydration and medication. Findings: A review of Resident 2's medical record indicated he was admitted to the facility on [DATE], with diagnoses which included dysphagia (difficulty swallowing) with G-tube. A review of Resident 2's Nurses Note, dated April 12, 2025, at 5:03 a.m. written by Licensed Vocational Nurse (LVN) 1, indicated .Charge nurse went in to try and flush G-tube with water and when charge nurse noticed that the tubing was clogged she then attempted to unclog the tube and in the process of trying to get the tube unclogged a small bubble popped about halfway down the tubing…

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 written notice of bed hold policy (reserving a resident's bed while resident is out of the facility for therapeutic leave or hospitalization) was provided for two of three residents reviewed for hospitalization (Residents 1 and 2) when they were transferred to the general acute care hospital (GACH). This failure had the potential for Residents 1 and 2 to not be informed of their rights to hold the bed while out of the facility and the right to be readmitted back to the facility. Findings: On April 2, 2025, at 9:30 a.m., an unannounced visit was conducted at the facility to investigate an admission, transfer, and discharge rights concern. 1. On April 2, 2025, at 10:30 a.m., during a concurrent observation and interview with Resident 1 in his room, he was lying in bed, alert and conversant. Resident 1 stated he was transferred out to the hospital because of a lung problem. Resident 1 stated he could not remember discussing the 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 ensure sufficient staff were provided to meet the needs of the residents when: 1. For 9 of 161 residents, (Residents 42, 56, 66, 91, 103, 107, 132, 267, and 417) complained that staff failed to assist with activities of daily living (ADL- daily care activities) in a timely manner; and 2. Three (3) of nine (9) confidentially interviewed residents from the Resident Council meeting complained that call lights were not being answered timely, food was being served late, and residents were left sitting in their urine and bowel for long periods of time. These deficient practices caused feelings of frustrations and anger, among the residents, and negatively affected the quality of care for the residents. Findings: 1a. On March 17, 2025, at 10:10 a.m., during an interview with Resident 417, Resident 417 stated the facility was short of nursing staff. Resident 417 stated there were long waits for the call bell to be answered and the Certified…

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 bedtime snacks were offered and were sufficient, for 153 of 153 residents who received food from the kitchen. This failure had the potential to affect the nutritional and psychosocial wellbeing of residents. Findings: On March 18, 2025, at 9:59 a.m., during the confidential resident council meeting, five out of 10 residents stated bedtime snacks were not offered and sufficient for them. On March 18, 2025, at 10:06 a.m., an interview was conducted with Resident 120. Resident 120 stated she is diabetic, and the facility did not have sugar free or diabetic evening snacks available for her. On March 18, 2025, at 7:09 p.m., a concurrent observation and interview was conducted with Dietary Aide (DA) 3 at the kitchen. There were three plastic containers observed in the walk in refrigerator. Each container stored two (2) sandwiches, 12 individual single serving package graham crackers; 10 individual single serving package saltine crackers, six (6) bananas; three (3) oranges, two (2) Jello, two (2) apple sauce…

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 and used gloves were found on the floor surrounding the dumpsters. This failure had the potential to attract pests and cause infection control issue. Findings: On March 17, 2025, at 9:23 a.m., a concurrent observation and interview was conducted with the Food and Nutrition Services Director (FNS) outside the back kitchen at the dumpsters area. Food residual were observed on the grass near the entrance door of the kitchen. Trash and used gloves were found on the floor surrounding the dumpster area and gate area. The FNS stated the back kitchen area's floor need to be kept clean otherwise it would promote bacterial growth, attract pests, and it is infection control issue. On March 20, 2025, at 9:33 a.m., a phone interview was conducted with the Registered Dietician (RD). The RD stated the outside back kitchen floor should be kept clean. The RD explained trash, used gloves and food residual could attract pests and had potential to cause infection control issue.…

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 safe, comfortable, and home like environment for the residents was provided when: 1. Comfortable temperature levels were not maintained for multiple resident rooms (Rooms 41B, 47C, and, 49B). This resulted in multiple residents feeling cold, especially at night (Residents 95, 102, and 119)and had the potential to have effect on resident's medical condition; and 2. There was no documented evidence weekly checks of laundry equipment were performed by the Maintenance Director (MD). In addition, additional laundry staff was not maintained to assist in washing and distributing personal clothing timely. This resulted in the residents' personal belongings to not be distributed timely and had the potential to affect the residents psychosocial well being; and Findings: 1. On March 17, 2025, at 11:01 a.m., a concurrent observation and interview was conducted with Resident 95 in his room. Resident 95 was in bed with multiple blankets, he…

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 provision of pharmacy services met the needs of four of four residents when: 1. The licensed nurse discarded Resident 159's non-scheduled medication waste into a regular trash bin during the preparation for the medication administration. This failure had the potential for the misuse of the medications and environmental harm; 2. The licensed nurse left Resident 159's medications unattended on the resident's bedside table during the medication administration. This failure had the potential for misuse of the medications by the residents, facility staff and/or visitors; 3. Random controlled medication audit for Residents 12 and 128 did not reconcile. The medications were signed out of the Count Sheet (a controlled drug record, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the electronic Medication Administration Records (eMAR) to indicate they were administered to the residents.…

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 four of five residents reviewed for unnecessary medications (Residents 23, 38, 42, and 126) were free from unnecessary psychotropic (drug that affects brain activities associated with mental processes and behaviors) medications when there was no documented evidence of monitoring for the followings: 1. For Resident 38, Seroquel (antipsychotic medication to treat hallucinations and thought disorder), Buspirone (anti-anxiety drug, used to treat anxiety), and Depakote were ordered without a specific quantifiable monitoring for non-pharmacological interventions; 2. For Resident 126, Wellbutrin (anti-depressant, medication for depression) SR (sustained release, drug designed to release medication slowly over a period) was ordered without a specific quantifiable monitoring for target behaviors for which the medication was ordered. In addition, Wellbutrin SR, Sertraline (anti-depressant drug, used to treat depression), Buspirone, and Seroquel were…

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 proper labeling and storage of medications in accordance with the facility policy and procedures and/or manufacturer's instructions when: 1. IV (intravenous) Mini-bag plus containers removed from or in an opened manufacturer's overwrap without beyond use dates were stored in IV Cart, Medication Cart 2, and Medication Cart 4; 2. Total of three expired medications were stored in Treatment Cart, Medication Cart 1, and Medication Cart 2; and 3. One discontinued medication was kept in stock in Medication Cart 2 along with other active medications. These failures had the potential for the residents to receive medications beyond their effective dates, receive expired medications and had the potential for residents to have access to the discontinued medications and administer it unsafely. Findings: 1a. On March 17, 2025, at 9:13 a.m., during a medication administration observation with Licensed Vocational Nurse (LVN) 4, LVN 4 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.

Based on observation, interview, and record review, the facility failed to ensure the dietary staff safely and effectively carried out the functions of food and nutrition services when (Cross Reference F812): 1. The food service workers did not follow the manufacturer's guideline regarding the length of time for testing the red bucket Quaternary (Quat) sanitizer (sanitizing solution used for sanitizing food contact surfaces); 2. The food service workers did not know the appropriate concentration of the Quat sanitizer; 3. Diet Aides (DA) 1 and 3 were unable to demonstrate the proper steps to clean the dirty meal carts; 4. [NAME] (CK) 2 and Diet Aide 2 did not know how to calibrate the food thermometer; and 5. Diet Aides 3 and 4 did not know how long they need to submerge washed kitchen ware in the sanitizer sink. These failures had the potential to cause foodborne illness (illness caused by food contaminated with bacteria, viruses, parasites or toxins) for 153 out of 153 sampled residents who received foods from the kitchen. Findings: 1. On March 17, 2025, a review of the test strip…

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 record reviews, the facility failed to ensure food were prepared according to the prescribed recipe, when: 1. [NAME] 1 did not add margarine to a fortified diet during the noon meal on March 17, 2025; 2. Food service workers did not have a system to distinguish a diet Jello for Controlled Carbohydrate Diet during the noon meal on March 17, 2025; 3. [NAME] 2 did not use the right scoop to portion salad for dinner on March 18, 2025; 4. [NAME] 2 did not use the right scoop to portion meat for dinner on March 18, 2025; and 5. Diet Aide 5 did not measure the amount of shredded cheese to be placed in cheese quesadilla on March 18, 2025. These failures had the potential to negatively impact the residents' nutritional status and further compromising the resident's medical status. Findings: 1. On March 17, 2025, a review of the facility's document titled Fortified Menu Plan (diet with added extra nutrients to increase the calories and/or protein density to promote improvement residents' nutrition status) posted next to the trayline (a system of food…

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 were served at appropriate temperatures, were palatable (the taste and/or flavor of the food) and with variety of foods, according to the residents' preferences and the facility's policy and procedure, for nine residents (Resident 23, 35, 52, 66, 91, 103,107, 132, and 146) out of 153 residents who receive food from the kitchen. This failure placed residents at potential risk to decrease nutritional intake and affect the resident's nutritional status. Findings: (Cross reference 805) On March 17, 2025, at 10:02 a.m., during an interview with Resident 52, Resident 52 stated, Served food is warm not hot; cold food not cold; like ice cream sometimes is melty. On March 17, 2025, at 10:20 a.m., during an interview with Resident 66, Resident 66 stated, The food mostly does not have much taste; 80 percent of the time. On March 17, 2025, at 11:30 a.m., during an interview with Resident 91, Resident 91 stated, Food served same thing day after day. The food is cold. On March 17, 2025, at 11:59 a.m., during an…

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

Based on observation, interview, and record review, the facility failed to ensure the appropriate food texture was provided when: 1. For 13 of 13 residents who received pureed diet (is a diet with food texture need to blend until smooth for residents who have difficulty chewing and/or swallowing) received pureed meat that were not smooth with meat fiber still intact for dinner on March 18, 2025; 2. For Resident 39 who had a physician order for nectar thick liquid received lumpy milk and a regular shake during lunch on March 18, 2025; 3. For Resident 85 who had physician ordered for nectar thick liquid received pudding consistency milk and Jello during lunch on March 18, 2025; and These failures had the potential to place the residents at risk of choking, aspiration (when food is breathed into the lungs), coughing and decreased meal or fluid intake. Findings: 1. On March 18, 2025, at 4:38 p.m., a concurrent observation and interview was conducted with [NAME] (CK) 2. CK 2 was observed preparing pureed meat. CK 2 stated he was preparing 18 servings of pureed meat for residents on…

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

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and distributed in accordance with professional standards for food service safety when: 1. Dust was observed on several areas (dry storage room and back door frame) in the kitchen; 2. Dietary Aide (DA 4) and Engineering Plant Director (EPD) had facial hair and were not wearing a hair restraint; 3. Two opened food items were exposed to the air in the walk-in freezer; 4. The walk in refrigerator gasket was found to have black grime buildup; 5. Three baking pans of pizza were stored underneath the steam table which was near a sanitizer bucket, and with air gap; 6. Wilting produce (three cucumbers and 2 green bell peppers) were found in the walk in refrigerator; 7. The cabinet used to store kitchen ware had chipped wood; 8. Two hot waterspouts had calcium buildup; 9. Unsanitary ice bags were placed on the floor of the facility lobby; 10. Eight expired boxes of English muffins were found in dry storage pantry; 11. A dirty rag was placed on the clean coffee cart; 12. The food…

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 facility record review, the facility failed to ensure a written Quality Assurance Performance Improvement (QAPI - a systematic, interdisciplinary, comprehensive, and data-driven approach to maintain and improve safety, quality of care, and quality of life of the residents) plan in place to address the facility's systemic process issues related to staffing, dietary, and laundry services. These failures resulted in multiple residents to not receive appropriate services from Certified Nursing Assistant (CNA) staffing, dietary, and laundry services. In addition, these failures had the potential to place other residents residing at the facility to be at risk for not achieving their highest physical, mental, psychosocial well-being. Findings: On March 17, 2025 to March 21, 2025, during the facility's recertification survey, systemic issues were identified with sufficient nursing staff (see findings under F725), food services (see findings under F804), laundry services (see findings under F584). On March 21, 2025, at 11:30 a.m., an interview and a concurrent record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure infection prevention and control practices were upheld when: 1. During lunch meal observation on March 17, 2025, Resident 36's IV (intravenous- into the vein) tubing was observed touching the food on her plate; 2. Two laundry staff stated they did not routinely check the washer and dryer temperatures. In addition, they were not able to state what the temperature requirements were for washing and drying linen and clothes; and 3. One laundry staff was observed placing linen that was touched by a resident, back into an uncovered linen cart. In addition, the laundry staff covered the clean linen in a large linen bin, with a linen cover that came in contact with the floor. These failures had the potential to spread infection among the vulnerable residents of the facility. Findings: 1. On March 17, 2025, at 12:08 p.m., an observation of the lunch meal service at the dining room was conducted. Resident 36 was observed seated at a dining…

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 an effective pest control program to ensure the facility remained free of pests when four bugs, one (1) spider, and one (1) house fly were found in the kitchen. This failure had the potential to place 153 out of 153 residents who received food from the kitchen at risk for food borne illnesses (illness caused by food contaminated with bacteria, viruses, parasites or toxins). Findings: On March 17, 2025, at 10:30 a.m., a concurrent observation and interview with the Food and Nutrition Services Director (FNS) was conducted at the dry storage room inside the kitchen. Four bugs (brown color with wings) and one spider were observed on the ceiling. The FNS stated the kitchen should not have any pests as it could cause cross contamination (bacteria are unintentionally transferred from one substance or object to another with harmful effect) of the foods stored in dry storage and lead to food borne illnesses. On March 18, 2025, at 5:30 p.m., an observation was conducted in front of steamtable inside 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 meals were served at the same time, for two of three residents (Residents 101 and 127) when: 1. Resident 101 was not served his lunch meal on March 17, 2025, at the same time as the other residents at the same table; and 2. Resident 127 was not served his lunch meal on March 17, 2025, and dinner meal on March 18, 2025, at the same time as the other residents at the same table. These failures increased the potential to negatively affect Resident 101 and 127's psychosocial well-being and could place the residents at risk to not consume the food served. Findings: 1. On March 17, 2025, at 12:10 p.m., during a concurrent meal observation and interview with Resident 101 in the dining room, Resident 101 was observed sitting on a wheelchair together with three other residents in the same table. The staff were observed to serve the food to the other three residents and did not provide the meal to Resident 101. Resident 101 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 interview and record review, the facility failed to ensure informed consents (process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention in order to obtain agreement or permission for care, treatment, or services) were obtained prior to the initiation and administration of psychotropic medications according to the facility's policy and procedure, for two of five residents reviewed for unnecessary medications (Residents 23 and 38). This deficient practice had the potential for the residents or the responsible party (RP) not to be informed of the risk and benefits of the psychotropic medications, and to make an informed decision, before receiving the medications. Findings: 1. On March 20, 2025, Resident 23's medical record was reviewed. A review of Resident 23's admission Record, indicated the resident was admitted to the facility on [DATE], with diagnoses including insomnia (difficulty sleeping), depression, anxiety,…

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 grievance were addressed, for one of three residents (Resident 55), when Resident 55 notified the facility staff of missing leg prosthesis. This failure had the potential for Resident 55 to have a decline in Activities of Daily Living (ADL) and could affect psychosocial and physical well being. Findings: On March 19, 2025, Resident 55's medical record was reviewed. Resident 55 was admitted to the facility on [DATE], with diagnoses which included respiratory failure with hypoxia (lungs fail to adequately oxygenate the blood, leading to low oxygen levels), absence of left leg below the knee, blindness in both eyes. A review of the History and Physical, dated May 25, 2022, indicated the resident had a fluctuating capacity to understand and make decisions. A review of Resident 55's Minimum Data Set (MDS - a resident assessment tool), dated October 14, 2024, indicated Resident 55's Brief Interview for Mental Status (BIMS) score of 12…

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 issue a written notice of discharge to the resident (or resident representative) and to the Office of the Ombudsman, for one of one resident reviewed for hospitalization (Resident 10), when the resident was discharged from the facility while still at the general acute care hospital (GACH). This failure had the potential to result in the lack of coordination of support for Resident 10 during discharge planning or after discharge to the community and had the potential for Resident 10 to be not informed of his appeal rights. Findings: On March 20, 2025, Resident 10's record was reviewed. A review of Resident 10's admission Record, indicated Resident 10 was admitted to the facility on [DATE], with diagnoses which included schizophrenia (mental disorder with disruption in thought processes), bipolar (disorder with episodes of mood swings from depression to manic highs), dementia (group of conditions that interfere with daily functioning), depression…

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 medications were administered according to the physician orders, for one of 37 residents reviewed, (Resident 148). This failure had the potential to inadequately control Resident 148's blood pressure, pulse rate, and blood sugars, which could affect Resident 148's overall health condition. Findings: On March 19, 2025, Resident 148's record was reviewed. A review of Resident 148's admission Record, indicated Resident 148 was admitted to the facility on [DATE], with diagnoses which included hypertensive heart disease (heart issue that develops due to a long term high blood pressure), diabetes mellitus (abnormal blood sugar), and bradycardia (slow heart rate). A review of Resdient 148's Physician Order, dated December 12, 2024, indicated the following orders: - Clonidine HCL (a medication used to decrease blood pressure) Oral Tablet 0.1 milligrams (mg - unit measurement), Give 1 (one) tablet via PEG tube (tube inserted into stomach that brings…

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 facility's Consultant Pharmacist (CP) identified irregularities with medication therapy and made recommendations to the prescribing physicians during the monthly Medication Regimen Review (MRR), for three of five residents reviewed for unnecessary medications (Residents 38, 42, and 126) when: 1. Resident 38 was on duplicate Vitamin D (supplement) orders and received twice each day; 2. Resident 126 was on duplicate Omeprazole (medication for indigestion and heartburn) orders and received four times each day; and 3. Resident 42 was on routine opioid (medication for moderate to severe pain) therapy without bowel regimen. These failures resulted in Resident 38 and 126 to receive a wrong dose of medications and had the potential for Resident 42 to receive unsafe medication use and/or residents not achieving highest therapeutic outcomes. Findings: 1. On March 19, 2025, a review of Resident 38's admission Record, indicated Resident 38 was admitted…

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 residents were free from unnecessary medications when same medications were ordered for the same strength, frequency and indication and not reviewed and clarified to prevent duplication of therapy, for two of five unnecessary medications sampled residents (Residents 38 and 126): 1. Resident 38 was on duplicate Vitamin D (supplement) orders and received twice each day; and 2. Resident 126 was on duplicate Omeprazole (medication for indigestion and heartburn) orders and received four times each day. These failures resulted in Resident 38 and 126 receiving excessive dose of medications and had a potential to result in accumulation of medication in the residents' body and adverse effects. Findings: 1. On March 19, 2025, a review of Resident 38's clinical record indicated Resident 38 had the following physician's orders: - Vitamin D (Cholecalciferol) (a type of Vitamin D), Give 2000 IU by mouth in the morning for supplement, ordered on February 21, 2025 for start date of February 22, 2025; and - Vitamin D 50 mcg…

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 medication error rate during the medication administration observation was less than 5% when, the facility had a cumulative medication error rate of 13.79%. Four medication errors occurred out of 29 opportunities during the medication administration, for one of three residents (Resident 154). This failure resulted in medications not given in accordance with the physician's orders and the facility's policy and procedures, which had the potential for residents not receiving the full therapeutic effects of the medications and worsening of the residents' medical conditions Findings: On March 17, 2025 at 9:13 a.m., a medication administration observation was conducted with LVN 4. LVN 4 was observed preparing and administering total of 14 medications to Resident 154. Included in the medications were one nasal spray of fluticasone propionate 50 mcg (micrograms - unit of measurement), 1 tablet of Vitamin D3 50 mcg (2000 IU [International Units]), with 11 more oral pills, and 1 unit-dose vial of inhalation…

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 five residents reviewed for unnecessary medications (Resident 119), was free from a significant medication error, when phenobarbital (medication used to treat seizure) was not administered to Resident 119, as evidenced by missing documentation of administration of the medication. This failure had the potential to result in seizure for the resident due to not receiving the full therapeutic effect of the medication. Findings: On March 18, 2025, a review of Resident 119's admission Record, indicated Resident 119 was admitted to the facility on [DATE] with diagnoses which included epilepsy (seizure). A review of Resident 119's Order Summary Report, included a physician's order for Phenobarbital 32.4 mg, Give 7 (seven) tablet by mouth at bedtime for seizures, give 7 (seven) tablets for a total of 226.8 mg (milligrams - unit of measurement, ordered date January 30, 2025. A review of Resident 119's Medication Administration…

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 dental consultation was provided, for one of two residents reviewed for dental (Resident 38). This failure has the potential to place the resident at high risk for complications related to dental needs due to the possible delay in providing dental devices. Findings: On March 20, 2025, at 9:01 a.m., during a concurrent observation and interview with Resident 38 in her room, Resident 38 was observed touching her lower right gums while talking to a staff. Resident 38 stated she felt something in her gums and was painful to touched. Resident 38 further stated there was a bump and it hurts when she bites hard food. On March 20, 2025, Resident 38's record was reviewed. Resident 38 was admitted to the facility on [DATE], with diagnoses that included protein-calorie malnutrition (reduce protein and calories needed by the body). A review of Resident 38's Minimum Data Set (MDS - an assessment tool), dated December 21, 2024, indicated…

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 dietetic services supervisor had received at least six hours of dietary service in-service training as required by Title 22 of the California Code of Regulations (State Agency regulations) prior to assuming full time duties as dietetic services supervisor. This failure resulted in the lack of required in-service training hours by the dietary service supervisor and could potentially affect the operations in the dietary services. Findings: On March 18, 2025, at 9:30 a.m., an interview was conducted with the Food and Nutrition Services Director (FNS) and Registered Dietitian (RD). The FSN stated she is a Certified Dietary Manager and was not aware she needed to complete six hours of in-service training specific to the California dietary service requirements contained in Title 22 of the California Code of Regulations (CCR) prior to assuming full time duties as a dietetic services supervisor at the healthcare facility. The RD stated she was aware all Certified Dietary Managers needed to have six hours of in-service…

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 equipment in the kitchen was maintained in a safe operating condition when condensation ice buildup was found on the fans in the reach in freezer. This failure had the potential to place 153 out of 153 residents who received food from the kitchen at risk for not receiving quality of foods. Findings: On March 17, 2025, at 10:11 a.m., an observation of the reach in freezer at kitchen was conducted. Condensation ice buildup was observed on the two fans in the reach in freezer. Puddle of ice buildup was observed on the surface of a box of cut corn located at the second shelf. On March 17, 2025, at 10:43 a.m., an interview was conducted the Food and Nutrition Services Director (FNS) and [NAME] (CK)1 in front of the reach in freezer at the kitchen. The FNS acknowledged the reach in freezer was not working properly with condensation ice buildup. CK 1 stated condensation ice buildup at the reach in freezer randomly happened in the past two (2) weeks. On March 18, 2025, at 11:27 a.m., an interview was conducted…

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 two residents, Resident 2, was provided timely access to her personal funds. This failure resulted in Resident 2 being upset and had the potential to result in anxiety (feeling of uneasiness) or a feeling of loss of control impacting her overall well-being. Findings: On February 14, 2025, at 9:14 a.m., during an interview, Resident 2 stated she had a trust account (fund that holds a resident's money for their use in the nursing home) with the facility. Resident 2 stated she requested funds from her account through the Business Office Manager Assistant (BOMA) on February 13, 2025, but was given the runaround. Resident 2 stated she had still not received the money she requested. A review of Resident 2's medical record indicated she was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (COPD - a group of lung diseases that cause ongoing breathing difficulties). 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 treatments ordered by the physician were administered for two of two residents, Residents 2 and 5. This failure had the potential to result in worsening of Residents 2 and 5 ' s skin conditions. Findings: On February 14, 19, and 20, 2025, unannounced visits were conducted at the facility. 1. On February 14, 2025, at 12:35 p.m., during a concurrent observation and interview, Resident 2 was in her room, lying in bed, alert and conversant. Resident 2 stated she had tinea corporis (a fungal infection of the skin that causes circular, itchy, and scaly rashes) on her right breast and right leg, but she did not receive treatment for five days. A review of Resident 2's medical record indicated she was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (COPD - a group of lung diseases that cause ongoing breathing difficulties). A review of Resident 2's Minimum Data Assessment (MDS-an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the call light was functioning for one of three residents, Resident 1. This failure had the potential to result in Resident 1 not being able to call for help. Findings: On February 14, 19, and 20, 2025, unannounced visits were conducted at the facility. On February 14, 2024, at 12:20 p.m., during an observation inside room [ROOM NUMBER], bed A, the call light was plugged into the wall but did not activate when it was pressed. On February 19, 2025, at 5:48 p.m., during a concurrent observation and interview with Resident 1 in his room, Resident 1 was sitting in bed, and eating dinner. His call light was plugged into the wall, wrapped on the bed rail by his left-hand side. Resident 1 stated it was okay to turn on the call light. The call light did not activate. Resident 1 stated nobody would know if he was dying if the call light was not functioning. On February 19, 2025, at 5:51 p.m., during a concurrent observation of Resident 1 and interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the room was safe for two of two residents, Residents 3 and 4, when the floor tile was broken inside their room. This failure had the potential for Residents 3 and 4 to have a fall. Findings: On February 14, 19, and 20, 2025, unannounced visits were conducted at the facility. On February 14, 2025, at 10:44 a.m., during an observation in room [ROOM NUMBER], there was a broken floor tile by the restroom door. The damaged portion of the tile measured approximately three inches long and two inches wide, with black debris present in and around the area. A review of Resident 3's medical record indicated he was admitted to the facility on [DATE],with diagnoses which included chronic obstructive pulmonary disease (COPD - a group of lung diseases that cause airflow obstruction and breathing difficulties). A review of Resident 3's Mimimum Data Set (MDS - an assessment tool) dated January 15, 2025, indicated he did not have cognitive…

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 Registered Nurse (RN) coverage in the facility for 24 hours as indicated in their facility assessment (the foundation for the facility to assess its resident population and determine the direct care staffing and other resources to provide the required care to their residents). This failure had the potential to endanger the health and safety of all residents being cared for. In addition, this failure resulted in Resident 2 missing a scheduled IV (intravenous- giving medicines or fluids through a needle or tube inserted into a vein) on January 12, 2025. Findings: On January 28, February 3, 4, and 5, 2025, unannounced visits were conducted at the facility to investigate complaint allegations. On January 28, 2025, at 5:24 a.m., during an interview, Certified Nurse Assistant (CNA) 1 stated they do not always have an RN for 11-7 (night) shift. CNA 1 stated RN 1 arrived at the facility today between 2:00 a.m. and 3:00 a.m. CNA 1 stated the Staffing…

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 protect the confidentiality of the residents ' protected health information (PHI) when two licensed nurses used their personal laptops (portable computers) for med pass (administration of medications). This failure had the potential to compromise the PHI of 59 residents. Findings: On January 28, February 3, 4, and 5, 2025, unannounced visits were conducted at the facility to investigate complaint allegations. On January 28, 2025, at 11:04 a.m., during an interview, Licensed Vocational Nurse (LVN) 1 stated the laptops they used for med pass were issued by the facility. LVN 1 stated in the beginning of her employment at the facility in November 2024, she used her personal laptop for med pass because the screen was bigger. LVN 1 stated she was never told to not use her personal laptop. LVN 1 stated the Director of Nursing (DON), and the Administrator (ADM) were not aware she used her personal laptop. LVN 1 stated the facility policy was they cannot use their personal devices while they are working on the floor.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure for two of three residents, Resident 3 and 4, the overbed light had pull cords that were within their reach. This failure resulted in Residents 3 and 4 not having access to use the overbed lights. Findings: On February 3, 2025, at 12:11 p.m., during a concurrent observation and interview, Resident 3 was in her room, awake, lying in bed, with left sided weakness. The overbed light had a short pull cord, which was not within Resident 3 ' s reach. Resident 3 ' s responses to the interview were unclear. A review of Resident 3 ' s medical record indicated she was admitted to the facility on [DATE], with diagnoses which included stroke (a condition when blood flow to the brain is disrupted). On February 4, 2025, at 10:18 a.m., during an observation of Resident 3, Resident 3 was lying in bed, the overbed light had a short pull cord that is not within her reach. On February 5, 2025, at 10:25 a.m., during a concurrent observation 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 provide and document sufficient preparation and orientation to ensure a safe and orderly discharge from the facility for one of two residents, Resident 5, when: 1. Resident 5 was discharged to (name of recuperative care center – a short-term residential program that helps people recover form an illness or injury) without a referral; 2. The facility did not arrange home health for Resident 5; and 3. There was no documented evidence that Resident 5 was assessed for needed durable medical equipment (DME) such as a wheelchair and a walker. This failure had the potential to result in an unsafe discharge of Resident 5 back into the community. Findings: On February 3, 4, and 5, 2025, unannounced visits were conducted at the facility to investigate complaint allegations. A review of Resident 5 ' s electronic health record indicated he was admitted to the facility on [DATE], with diagnoses which included status post right knee replacement. A review of 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 for one of two residents, Resident 3, her cup and water pitcher was within her reach. This failure had the potential to further increase Resident 3 ' s risk for dehydration. Findings: On February 3, 4, and 5, 2025, unannounced visits were conducted at the facility to investigate complaint allegations. On February 3, 2024, at 8:30 a.m., a telephone interview was conducted with Resident 3's family member (FM). The FM stated he provided a hydration bladder (a flexible, watertight container consisting of a pouch designed to transport water while also making drinking more convenient and efficient) to Resident 3 so she could sip from it without any issues. On February 3, 2025, at 12:11 p.m., during a concurrent observation and interview, Resident 3 was awake, lying in bed, with a hydration bladder with a drinking spout, and a flat call light placed by her right-hand side. A water pitcher was on top of an overbed table that was against…

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 two residents, Resident 1, received his IV (intravenous-giving medicines or fluids through a needle or tube inserted into a vein) medication doses as ordered by the physician. This failure resulted in Resident 1 missing two doses of daptomycin (treatment for bacterial infections) and had the potential for Resident 1 to acquire further infection. Findings: On January 28, February 3, 4, and 5, 2025, unannounced visits were conducted at the facility to investigate complaint allegations. On January 28, 2025, at 7:50 a.m., during a concurrent observation and interview with Resident 1, Resident 1 was in his room, lying in bed with a PICC (peripherally inserted central catheter - a thin, flexible tube inserted into a vein in the upper arm and threaded into a large vein above the heart used to deliver medications) line in his right upper arm. Resident 1 stated he had the PICC line because he was on IV antibiotic therapy, and it…

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 the laundry equipment in good working condition, when one washing machine and two clothes dryers were not functioning. One resident out of 15 residents reviewed (Resident 1) stated some of his personal clothes were missing. This failure had the potential to result in residents ' personal clothes not being washed, cleaned and returned timely, affecting the use of those personal belongings that support a homelike environment. Findings: On January 2, 2025, January 3, 2025, and January 7, 2025, unannounced visits to the facility were conducted to investigate complaints related to residents ' rights, quality of care and physical environment. On January 2, 2025, at 11:33 am, a concurrent observation and interview was conducted with Resident 1. Resident 1 was alert and oriented. Resident 1 was observed in bed, wearing his personal clothes. Resident 1 stated he preferred to wear his personal clothes during the day. Resident 1 stated he…

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 review and interview, the facility failed to ensure the resident's representative (RR) was invited and included in the interdisciplinary team (IDT) care planning meeting for one of three sampled residents (Resident 2). This failure resulted in the RR being uninformed and not being given the opportunity to participate in making decisions for Resident 2's plan of care, treatment, and healthcare goals that could affect Resident 2's care and quality of life. Findings: On December 4, 2024, at 9:22 a.m., an unannounced visit was conducted at the facility to investigate a complaint related to Resident 2's quality of care. A review of Resident 2's admission record was conducted on December 4, 2024. Resident 2 was admitted to the facility on [DATE], with diagnosis that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), dementia (a group of thinking and social symptoms that interferes with daily functioning), encephalopathy (a group of conditions…

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 physical abuse was reported within two hours to the California Department of Public Health (CDPH-State Agency-Licensing and Certification Program) for one resident reviewed (Resident 1). This failure had the potential to result in a delay of investigation and reporting of further allegations of abuse. Findings: On October 25, 2024, at 9:20 a.m., an unannounced visit to the facility was conducted to investigate a facility reported allegation of abuse that was reported to CDPH on October 22, 2024, at 9:47 a.m. On October 25, 2024, at 12:58 p.m., during an interview and record review with the Director of Nursing (DON), the DON stated Resident 1 alleged two Certified Nursing Assistants (CNAs 1 and 2) slapped her. On October 25, 2024, at 2:08 p.m., a telephone interview was conducted with CNA 1. CNA 1 stated on October 22, 2024, approximately 1 a.m., Resident 1 accused her and CNA 2 of slapping her while changer her diaper. CNA 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the resident ' s rights to the confidentiality of medical records, for six of six residents, Residents 4, 5, 6, 7, 8 and 9, when the Licensed Nurses communicated residents ' information using non-HIPAA (Health Insurance Portability and Accountability Act - a federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient's consent or knowledge) compliant messaging applications and Registered Nurses used their personal mobile phones and phone numbers to communicate end of shift reports. This failure had the potential to compromise Residents 4, 5, 6, 7, 8 and 9 ' s protected health information. Findings: On September 3 and 4, 2024, unannounced visits were conducted at the facility to investigate complaint allegations. On September 3, 2024, at 12:58 p.m., during an interview with Registered Nurse (RN) 2, RN 2 stated she notified Medical Doctor (MD) 1 via text…

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 safe environment for three of three residents reviewed when: 1. Resident 1, who had an order for a Wanderguard (bracelet that trigger alarms on doors to alert staff if a resident leaves a safe area), eloped (when a resident leaves a healthcare facility without permission or when they are unable to make safe decisions on their own) from the facility. This failure had the potential to result in Resident 1 to sustain serious injury such as being struck by a vehicle or death; and 2. Residents 2 and 3 did not have their Wanderguard bracelets on them as ordered by the physician. This failure had the potential to result in Residents 2 and 3 to elope from the facility and have lack of access to needed health care. Findings: On September 3 and 4, 2024, unannounced visits were conducted at the facility to investigate complaint allegations. 1. A review of Resident 1 ' s medical record indicated he was admitted to the facility on [DATE],…

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, for one of two residents reviewed (Resident 3), the facility failed to ensure the resident ' s funds were conveyed to Resident 3 within 30 days of her discharge from the facility. This failure resulted in delayed conveyance of funds and financial resources that may be necessary for the delivery of health care needs after Resident 3 was discharged from the facility. Findings: On August 20, 21, and 22, 2024, unannounced visits were conducted at the facility for an investigation of a complaint. A review of Resident 3's admission Record indicated that she was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (lung disease) and Guillain-Barre Syndrome (a condition in which the body ' s immune system attacks the nerves) and dementia (loss of cognitive functioning). Resident 3 was self-responsible. Resident 3's family member was also listed as a responsible party. A review of Resident 3's History and Physical, dated March 1,…

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

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 two residents (Resident 4), a one-to-one sitter (1:1 sitter - a person who can provide continuous observation) was provided as ordered by the physician. As a result, Resident 4 was left unsupervised during which time Resident 4 had two fall incidents in June 2024, and sustained skin tears during both incidents. In addition, this failure had the potential for Resident 4 to sustain major injury such as a fracture (break in the bone). Findings: On August 20, 21, and 22, 2024, unannounced visits were conducted at the facility for an investigation of a complaint. A review of Resident 4 ' s admission Record indicated he was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (high blood sugar level) and cerebrovascular disease (conditions that affect blood flow to the brain). A review of Resident 4 ' s undated History and Physical Exam indicated .patient has intermittent capacity to make…

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 for managing Resident ' s personal funds and contact the resident family first after the physician certified the resident was no longer able to handle financial matters, for four of seven residents (Resident 7, Resident 8, Resident 9, and Resident 10), reviewed for the representative payee program (a representative payee manages Social Security funds). This failure resulted in the residents ' and the residents ' representative ' s rights regarding their financial matters not to be recognized. Findings: On August 14, 2024, at 10:00 a.m., an unannounced abbreviated survey was conducted for the investigation of a complaint. During a concurrent interview and financial record review on August 14, 2024, at 10:00 a.m., with the Business Office Manager (BOM), for Resident 7, Resident 8, Resident 9, and Resident 10. The BOM stated the facility recently received approval from the Social Security Administration (SSA) to be the representative…

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 safe standard of nursing practice was followed for one of three residents reviewed (Resident 1) when the licensed nursing staff did not document the resident's vital signs (blood pressure, pulse, and respiratory rate) and update the plan of care after Resident 1 was found unresponsive and had left side body twitching. This failure had the potential to jeopardize the health and safety of Resident 1, and had the potential for the development of complications. Findings: On August 7, 2024, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included congestive heart failure (a condition when the heart does not pump blood as well as it should) and epilepsy (a brain disorder that causes seizures which are brief episodes of involuntary movement). Resident 1 was discharged to the general acute care facility on August 5, 2024. Resident 1's Minimum Data Set (MDS - an assessment tool) dated May 9, 2024,…

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 appropriate fluid texture was provided for one of three residents (Resident 12) when kitchen staff did not have instructions for mixing thickener, and Resident 12 received nectar thick liquids instead of pudding thick liquids. This failure had the potential to place Resident 12 at risk of choking. Findings: A review of the Resident Diet List, dated August 13, 2024, indicated, Resident 12 was on a Puree texture diet (modified food for those who can not handle solid food due to chewing or swallowing difficulties), with pudding thick liquid consistency. A review of Resident 12 ' s medical record indicated he was admitted to the facility May 9, 2023, with medical diagnoses which included: multiple sclerosis (a chronic autoimmune disease of the central nervous system), schizoaffective disorder (a chronic mental illness that causes a person to experience dramatic changes in thoughts, moods, and behaviors), and dysphagia (difficulty swallowing). During an interview on August 13, 2024, at 8:05 a.m., with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement a system and follow the facility policy and procedure to ensure Preadmission Screening and Resident Review (PASRR; PASARR) Level I screenings were updated for three of four residents reviewed for PASRR (Residents 13, 14, and 15) when: 1. Resident 13 did not receive a new Level I screen after spending 30 days in the facility based on the recommendations of the initial Level I screen; 2. Resident 14 did not receive a new Level I screen when there was a significant change in condition; and 3. Resident 15 did not receive a new Level I screen after admission to the facility upon the recommendation of the Level II screener, prior to admission. These failures had the potential to result in the residents not receiving the care and services required to maintain their psychosocial well being. Findings: 1. A review of Resident 13's medical record indicated the facility admitted Resident 13 on June 24, 2024. A review of Resident 13's…

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

Based on interview and record review, the facility failed to document the changes in the resident's mental health status which required transfers to the hospital, and failed to notify the responsible party of each transfer for one of three resident reviewed (Resident 13). This failure had the potential to result in emotional distress for Resident 13 and Resident 13's responsible party. Findings: A review of Resident 13's medical record indicated Resident 13 was admitted to the facility June 24, 2024, with diagnoses which included aphasia (inability to speak) and schizophrenia (a chronic mental illness affecting behavior, thinking, and emotion). During a concurrent interview and record review on August 1, 2024, at 1:10 p.m., with the Social Services Director (SSD), the SSD clarified the timeline of events surrounding Resident 13's transfer to Hospital 1 on July 7 and Hospital 2 on July 8, 2024, based on the progress notes entered by the Registered Nurse's (RN) and the SSD. 1. On July 7, 2024, at 5:21 p.m., the RN documented Resident 13 left through the front doors and sat on a bench.…

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

Based on interview, and record review, the facility failed to provide a notice of bed-hold for one of three residents reviewed (Resident 13) and/or the resident representative, upon transfer to the acute care hospital when Resident 13 was transferred to the acute care hospital on July 7, 2024, and on July 8, 2024. This failure resulted in Resident 13 and Resident 13's respresentative not being aware of the bed-hold policy of the facility. In addition, this failure resulted in the resident not to be aware of his rights to be allowed to go back to the facility. Findings: On July 22, 2024, at 5:40 a.m., an unannounced visit to the facility was conducted to investigate an admission, transfer, and discharge issue. A review of Resident 13 ' s Physician Orders, dated July 7, 2024, indicated, .Transfer out to (Hospital 1) with police . There was no physician order documented to provide a bed-hold and no documented evidence Resident 13 or Resident 13's representative was provided a written notice of bed-hold upon transfer. A review of Resident 13's Physician Orders, dated July 8, 2024,…

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

Based on observation, interview, and record review, the facility failed to provide a safe environment when a side exit door was propped open and the alarm turned off. This failure had the potential to result in residents assessed to be at risk for elopement leaving the facility without staff being aware. Findings: During an observation on July 22, 2024, at 6:12 a.m., Resident 1 was observed in a wheelchair looking out into the facility parking lot through a side door which was propped open with a washcloth and the alarm was not on. Resident 1 turned around and went to the nurse ' s station to ask for coffee. During an observation on July 22, 2024, at 6:26 a.m., a staff member approached the open side door and walked outside. During an interview on July 22, 2024, at 6:32 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was not sure if the side doors were supposed to be propped open and the alarms turned off, because night shift always does it. During an observation on July 22, 2024, at 6:40 a.m., the side door remained propped open by the washcloth. During an interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the resident or representative a copy of medical records following a written request in an acceptable timeframe, for one of three residents reviewed (Resident 2). This failure had the potential to cause undue concern and anxiety on behalf of the resident and his family member. Findings: On July 26, 29, and 30, 2024, unannounced visits were conducted at the facility. On July 26, 2024, at 9:33 a.m., during a concurrent observation and interview with Resident 2, Resident 2 was in his room, sitting on his bed, alert and conversant. Resident 2 stated his family member (FM) was having issues with requesting his medical records. Resident 2 stated he and his FM both signed the request form. Resident 2 further stated, his FM had a copy of the request form, and he allowed his FM to handle his affairs. On July 26, 2024, at 1:44 p.m., during an interview with Licensed Vocational Nurse (LVN) 1, LVN 1 stated residents or their representative were directed to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure, for one of two residents, Resident 3 was accepted by the assisted living facility (ALF–a housing for people with disabilities or adults who cannot live independently) before he was discharged . This failure had the potential to result in Resident 3 to be rejected by the ALF and not receive the care he needed. In addition, this failure had the potential to result in unnecessary hospitalization. Findings: On July 26, 29, and 30, 2024, unannounced visits were conducted at the facility. A review of Resident 4 ' s medical record was conducted. Resident 4 was admitted to the facility on [DATE], with diagnoses which included osteoarthritis (inflammation of joints) of both hips, left fracture of upper arm and repeated falls. Resident 4 ' s History and Physical, indicated his decision-making capacity was intact. Resident 4 ' s Social Service Assessment, dated December 13, 2023, indicated the plan was to discharge to an assisted living when he was ready.…

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 two of five residents, Residents 4 and 5, plans of care were inititated when they were both involved in a resident-to-resident altercation. This failure had the potential to result in Resident 4 and 5's needs to be unmet and the potential for further altercations. Findings: On July 26, 29 and 30, 2024, unannounced visits were conducted at the facility. On July 26, 2024, at 10:35 a.m., during a concurrent observation and interview with Resident 5, Resident 5 was in his room, sitting in his wheelchair, alert and conversant. Resident 5 stated, through an interpreter, that Resident 4 was passing by when he was sitting outside of his room. Resident 5 stated Resident 4 dropped a piece of paper, and he told him to pick it up. Resident 5 stated Resident 4 kicked him in his right leg. On July 30, 2024, at 9:26 a.m., during an interview with Resident 4, Resident 4 was sitting in his wheelchair and agreed to be interviewed. Resident 4 stated he did…

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 reviewed, Resident 2, received his anti-seizure (seizure- a sudden, uncontrolled electrical activity of the brain) medications for two days. This failure had the potential to reduce the effectiveness of Resident 2 ' s anti-seizure medication. In addition, this failure potentially caused Resident 2 to have a seizure. Findings: On July 26, 29, and 30, 2024, unannounced visits were conducted at the facility. On July 26, 2024, at 9:33 a.m., during a concurrent observation and interview with Resident 2, Resident 2 was in his room, sitting on his bed, alert and conversant. Resident 2 stated he did not receive his phenobarbital (anti-seizure medication) either in April, or May 2024. Resident 2 stated he had a seizure in the facility and was not transferred out to the hospital. A review of Resident 2 ' s medical record indicated he was admitted to the facility on [DATE], with diagnoses which included seizure. 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 for, one of two residents, Resident 1, that interventions to reduce falls were evaluated for effectiveness. This failure resulted for Resident 1 to have repeated falls during his stay at the facility which could have resulted in serious injury to the resident. Findings: On July 26, 29, and 30, 2024, unannounced visits were conducted at the facility. On July 26, 2024, at 1:01 p.m., during an interview with Certified Nurse Assistant (CNA) 1, CNA 1 stated he was familiar with Resident 1 ' s care. CNA 1 stated Resident 1 moved a lot and fell out of his bed. On July 26, 2024, at 1:44 p.m. during an interview with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was familiar with Resident 1 ' s care. LVN 1 stated Resident 1 had been agitated and had behaviors of putting himself on the floor. LVN 1 stated a CNA told her that listening to music with headphones helped him calm down. LVN 1 stated Resident 1 had a fall during one of her shifts and he…

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 sufficient nursing staff to be able to provide for care and services for the residents of the facility. This failure had the potential to cause delay in the response to residents ' call lights being answered and put residents at risk for falls and accidents. This failure also had the potential for late provision of care or care not being rendered at all. Findings: On June 27, 2024, July 1 and July 2, 2024, unannounced visits were made to the facility to investigate three complaints and two facility reported incidents. On July 2, 2024, at 2:29 p.m., an interview was conducted with CNA 4, who stated she worked the 7am - 3:30 pm shift at the facility on June 22, 2024. CNA 4 stated she felt there was not enough time to complete her assignment for that day. CNA 4 further stated she felt rushed to provide care for residents and that at times, weekends .are very short. CNA 4 also stated the facility does have monthly meetings 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 one of three residents reviewed (Resident 5) was treated with respect and dignity when a Certified Nursing Assistant (CNA) told Resident 5 callate in Spanish, which meant shut up in English. This failure had the potential for Resident 5 not to feel respected and dignified which could negatively impact the resident's emotional well-being. Findings: On June 13, 2024, Resident 5's record was reviewed. Resident 5 was admitted to the facility on [DATE], with diagnoses which included Parkinson's disease (a disorder that affects movement with tremor in one hand). Resident 5's Brief Interview for Mental Status (BIMS - an assessment tool for cognition) dated May 15, 2024, was not completed. Resident 5 was rarely or was never understood. A review of Resident 5's SBAR (Situation, Background, Assessment, Recommendation - a verbal or written communication tool), dated June 12, 2024, indicated, .the assigned CNA entered the room. This is when…

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 plan of care for two of five residents reviewed (Residents 1 and 4) were updated and revised when: 1. Resident 1 had an elopement (a situation when a resident leaves the facility without authorization) incident on June 3, 2024; and 2. Resident 4 had an elopement incident on June 9, 2024. This failure had the potential to result in harm and injury to Residents 1 and 4, when their person centered care plans had no specific goals, measurable interventions and timeframes to prevent the incidents of elopement. Findings: 1. A review of Resident 1's record indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included Schizophrenia (a type of mental illness) and anxiety disorder (a type of mental health disorder with symptoms of nervousness, panic and fear). The psychiatric note dated March 15, 2024, indicated Resident 1 had episodes of .verbalizing that people do not like her. Constantly stating that some…

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 reviewed (Resident 4) was assessed, monitored, and supervised to prevent elopement (leaving the facility without permission). This failure resulted in Resident 4's eloping from the facility and had the potential to cause injury and harm to the resident. Findings: On June 11, 13, and 17, 2024, onsite visits were made to the facility to investigate a facility-reported incident regarding the elopement of Resident 4. On June 11 and 13, 2024, Resident 4's record was reviewed. Resident 4 was admitted to the facility on [DATE], with diagnoses which included psychosis (a mental disorder) and metabolic encephalopathy (brain dysfunction). A review of Resident 4's annual History and Physical (H&P), dated January 3, 2024, indicated, Resident 4 was awake and alert with confusion. A review of Resident 4's Brief Interview of Mental Status (BIMS - an assessment tool), dated May 29, 2024, indicated Resident 4 had a score of 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a comfortable and homelike environment was provided for one of seven residents reviewed (Resident 3), when Resident 3's personal belongings were placed in boxes and stored in a closet and were inaccessible to Resident 3. This failure prevented Resident 3 to enjoy her personal belongings and preferred clothing when out for an appointment, and while conducting activities at the facility. Findings: During a concurrent observation and interview on May 28, 2024, at 8:32 a.m., with Resident 3, Resident 3 was observed dressed in a hospital gown. Resident 3 stated she was not able to access her personal belongings in the closet because everything was in boxes. The resident stated she was unable to get to the closet because she is wheelchair bound and would require staff assistance to get around. She stated she relied on staff to hang the clothes, but they have not done it. The closet was observed opened, and boxes stuffed full of 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 interview, and record review, the facility failed to ensure the physician and the responsible party (RP) were notified when one of eleven sampled residents (Resident 10) alleged physical abuse against a facility staff (Certified Nursing Assistant). This failure resulted in the physician not being aware of the alleged physical abuse which delayed the provision of needed medical evaluation and treatment. In addition, the facility's failed to notify the responsible party for Resident 10, has the potential to negatively affect the psychosocial well-being of the resident. Findings: On May 30, 2024, at 11:23 a.m., an unannounced visit was conducted at the facility to investigate quality care issues. A review of Resident 10's medical records indicated the resident was admitted to the facility on [DATE], with diagnoses which included anxiety disorder (a chronic condition characterized by an excessive and persistent sense of apprehension), dementia (a chronic or persistent disorder of the mental processes caused…

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. For Resident 1, an allegation of misappropriation of funds was reported to the State Survey Agency at the mandated time frame (immediately but not later than two hours), when Resident 1 reported money was stolen from his room while he slept. The facility staff was made aware of the alleged theft on May 24, 2024. This failure had the potential to place Resident 1 and other residents at risk from harm and delayed the investigation of an allegation of misappropriation of funds. 2. An allegation of verbal abuse involving two residents (Residents 1 and 8) were reported to the State Survey Agency not later than two hours after the allegation was made. This failure had the potential to result in delayed protection of the residents, investigation of the incident, and implementation of corrective actions. Findings: 1. On May 24, 2024, at 8:30 a.m., during an interview with Resident 1, Resident 1 stated he went to the bank and withdrew…

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 grooming care, when one of eleven sampled residents' (Resident 9) fingernails and toenails were not kept trimmed. Resident 9 has hemiplegia (paralysis of one side of the body), and hemiparesis (weakness of one side of the body). This failure had the potential to lead to a low self-esteem which could negatively affect the psychosocial well-being of Resident 9. Findings: On May 30, 2024, at 11:23 a.m., an unannounced visit was conducted at the facility to investigate quality care issues. A review of Resident 9's medical records indicated the resident was admitted [DATE], with diagnoses of hemiplegia, and hemiparesis, following cerebral infarction, (stroke), affecting right dominant side, mild protein-calorie malnutrition, vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to various regions of the brain), epilepsy (seizure disorder), contracture (a condition of shortening 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 one of five residents, (Resident 5), was treated with dignity, when Resident 5's gown was not changed when he was observed with scrambled eggs down the front of his gown. This failure had the potential for Resident 5 to feel dehumanized, (deprived of positive human qualities), and live comfortably. Findings: On May 13, 2024, at 5:39 a.m., an unannounced visit to the facility on four complaints and four facility Reported Incidents were initiated. On May 13, 2024, at 7:42 a.m., Resident 5 was observed lying in bed with the head of bed elevated at 45 degrees. His breakfast tray was on the over bed table in front of Resident 5. Resident 5 was observed feeding himself, and scrambled eggs were observed spilling onto the front of his gown. On May 13, 2024, at 11:12 a.m., Resident 5 was observed in his bed with scrambled eggs on the front of his gown and in his bed. On May 13, 2024, at 11:12 a.m., an interview was attempted with 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 report an allegation of abuse on April 29, 2024, was reported in a timely manner to the State Agency (SA) as required, for two of five residents reviewed (Residents 9 and 10). This is failure to report abuse within 2 hours of incident may result in a delay in starting an investigation and securing resident safety. Findings: On May 13, 2024, at 5:30 p.m., an onsite visit to the facility was conducted to investigate a facility reported incident. On May 13, 2024, at 8:13 a.m., an observation with a concurrent interview was conducted with Resident 10. Resident 10 was observed outside his room and sitting on his wheelchair. Resident 10 was alert and interviewable. Resident 10 was asked about the physical altercation that happened between him and Resident 9. Resident stated, I tapped her on the shoulder to ask how long she's going to be on the phone. She was on it for a while, then I am on the floor. I don't want to talk about it anymore I…

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

Based on observation, interview, record review, the facility failed to ensure an updated staffing information of the total number and actual hours worked by the licensed and unlicensed nursing staff was posted in a prominent place readily accessible to residents and visitors. This failure had the potential for facility to be unable to provide and determine the actual sufficient nursing hours required in the provision of care and services for the residents in the facility. Findings: On May 13, 2024, at 6:45 a.m., an observation with a concurrent interview was conducted with the Assistant Director of Nursing (ADON). The facility's bulletin board, located in front of the Family Room/Dining Room by nurse station one was observed. On a bulletin board was a document posted and titled, Daily Nurses Shift Staffing . The document was dated May 8 and 9, 2024. In a concurrent interview, the ADON stated Daily Nurses Shift Staffing posted in the bulletin board was not current and updated. The ADON further stated the facility was required to post daily for each shift the numbers of licensed and…

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

Based on observation, interview, and record review the facility failed to provide sufficient nursing staff to be able to provide for care and services for the residents of the facility. This failure had resulted in multiple residents (Resident's 77, 18, 21, 132, 663, 97, 142, and 24) not receiving wound care treatments on multiple days (refer to F686). In addition, this failure caused delays in the response to multiple residents' call lights which had the potential to put residents at risk for falls, accidents, late provision of care or care not being rendered at all. Findings: On April 8, 2024, at 9:51 a.m., an interview was conducted with Resident 146, who stated that the nurses are hard to get a hold of, the Certified Nurse Assistants (CNAs) have no coverage on the weekends and are very short staffed. On April 8, 2024, at 10:33 a.m., during an interview Resident 71stated the facility is short staffed at night and weekends for CNAs and that it takes a long time for staff to respond to the call light. On April 8, 2024, at 11:18 a.m., an interview was conducted with Resident 53, who…

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 initiate a care plan for weight loss, poor oral intake and use of antidepressant for one of two residents, Resident 1. This failure had the potential for Resident 1 not to receive appropriate interventions tailored to her needs. Findings: On March 12, 2024, an unannounced visit was conducted at the facility for an investigation of a complaint. A review of Resident 1's records was conducted. Resident 1 was admitted to the facility on [DATE] with diagnoses which included cerebrovascular accident (stroke), type 2 diabetes mellitus (high blood sugar level), anxiety (mental illness), depression (mental illness) and failure to thrive (a state of decline in overall health). Resident 1 was transferred to (name of hospital) on March 8, 2024, for hypoglycemia (low blood sugar level). A review of Resident 1's Weights and Vital Summary, indicated she weighed as follows: 1/27/2024 . 174 Lbs (lbs. -pounds) 2/5/2024 . 168 lbs. (weight loss of 6 lbs. for one week)…

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 proper infection prevention and control practices when: a. Appropriate State department was not contacted regarding the positive cases, b. Masking was not mandated to control the spread of Covid, and c. Follow up testing was not performed per CDC (Center for Disease Control and Prevention) and CDPH (California Department of Public Health) guidelines. These failures resulted in inadequate source control and monitoring of the facility ' s vulnerable population it cared for. Findings: On January 30, 2024, at 1:00 p.m., an unannounced visit was conducted for the investigation of quality of care issues. An observation and concurrent interview on February 1, 2024, at 11:20a.m., was conducted with Housekeeper (HK) 1. HK 1 was observed cleaning isolation room [ROOM NUMBER], a Covid positive room, wearing a gown, a N-95 mask, gloves, but no face shield. HK 1 stated she did not use a face shield while cleaning the Covid positive isolation…

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 five of five sampled residents (A, B, C, D, F) received treatment and care in accordance with professional standards of practice. This failure has the potential to result in negative outcome for these five residents ' physical, mental, or psychosocial well-being. Findings: On January 30, 2024, at 1:00 p.m., an unannounced visit was conducted at the facility to investigate a quality of care issue. On January 30, 2024, at 1:45 p.m., an interview were conducted with Resident A. Resident A stated, she was wondering why there were not enough Certified Nursing Assistants (CNAs) over the weekend to help. Resident A stated breakfast was very late one of the mornings, and they did not receive their breakfast trays. Resident A stated she is able to move around on her own without assistance, so she went to the meal tray cart in the hallway and got her meal tray and of her roommate ' s (Resident D). Resident A stated the food was cold, she 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 ensure there was a sufficient number of nursing staff to provide care for five (Resident A, B, C, D, F) out of six residents reviewed. This resulted in a delay of care to meet the needs of Residents A, B, C, D, and F, which could negatively affect the Residents ' rights, physical, mental, and psychosocial well-being. Findings: On January 30, 2024, at 1:00 p.m., an unannounced visit was conducted at the facility to investigate a quality of care and staffing issues. On January 30, 2024, at 1:45 p.m., an interview were conducted with Resident A. Resident A stated, she was wondering why there were not enough Certified Nursing Assistants (CNAs) over the weekend to help. Resident A stated breakfast was very late one of the mornings, and they did not receive their breakfast trays. Resident A stated she is able to move around on her own without assistance, so she went to the meal tray cart in the hallway and got her meal tray and of her 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 interview, and record review, the facility failed to ensure pharmaceutical services were provided to meet the needs of a resident when the physician ordered medications were not acquired by the facility timely and available for use, for one of four residents reviewed (Resident 1). This failure had the potential to result in the delay of treatment and care for the resident. Findings: On February 14, 2024, at 10:40 a.m., an unannounced visit was conducted at the facility. On February 14, 2024, Resident 1 ' s record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included carotid artery syndrome (narrowing of the blood vessels in the neck restricting blood flow to the brain), peripheral vascular disease (narrowed blood vessels restricting blood flow to the limbs), and chronic obstructive pulmonary disease (COPD-lung condition that makes breathing difficult. Review of Resident 1 ' s Physician Order Summary indicated the following medications ordered January 31, 2024:…

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 resident representative's rights were respected, for one of four residents reviewed (Resident 4), when Resident 4's resident representative (RR) requested the facility to manage Resident 4 ' s benefit payments (representative (rep)-payee). This failure caused Resident 4 ' s facility payments to go unpaid and had the potential to cause Resident 4 ' s resident representative (RR) to experience undue financial stress. Findings: On February 12, 2024, the department received a letter indicating Resident 4 ' s RR was billed over $20,000 by the facility for unpaid services from [DATE]-[DATE]. On February 14, 2024, at 10:40 a.m., an unannounced visit was conducted at the facility. On February 14, 2024, Resident 4 ' s record was reviewed. Resident 4 was admitted to the facility on [DATE], with diagnoses which included Parkinson ' s disease (a disorder of the central nervous system that affects movement), dementia (impairment of the brain which causes…

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 inform the resident of the share of cost (SOC) and the amount of charges for the items and services not covered by Medicare (federal health insurance for anyone aged 65 and older)/Medicaid (federal and state program that gives health coverage to some people with limited income and resources), for one of four residents reviewed (Resident 3). This failure had the potential to result in the resident to not be informed about the potential liability for payment. Findings: On February 14, 2024, at 10:50 a.m., an unannounced visit was conducted at the facility. On February 14, 2023, at 11:20 a.m., Resident 3 was observed sitting on her bed, watching TV. During a concurrent interview, Resident 3 stated she had been at the facility for about four years. Resident 3 stated someone from the facility came into her room recently and informed her that she owed the facility $5,000-$7,000. Resident 3 stated this was the first time she received notice 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, for one of four residents reviewed (Resident 1), professional standards of practice were followed when the physician was not contacted for orders for a lung biopsy when requested by Resident 1 ' s Representative (RR) on February 8, 2024. This failure had the potential for care and services for Resident 1 to be delayed. Findings: On February 14, 2024, at 10:40 a.m., an unannounced visit was conducted at the facility. On February 14, 2024, Resident 1 ' s record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included carotid artery syndrome (narrowing of the blood vessels in the neck restricting blood flow to the brain), peripheral vascular disease (narrowed blood vessels restricting blood flow to the limbs), and chronic obstructive pulmonary disease (COPD-lung condition that makes breathing difficult. Review of Resident 1 ' s General Acute Care Records Pulmonary Consult Note dated January 19, 2024, at 6:57…

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 safe environment for one of three sampled residents (Resident 2) when Resident 2 left the facility without the staff ' s knowledge. This failure resulted in Resident 2 eloping (leaving a facility without notice) from the facility and had the potential to cause injury and harm to the resident. Findings: A review of Resident 2's record indicated, Resident 2 was admitted to the facility on [DATE], with a diagnosis of encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain), diabetes mellitus (a metabolic disease, involving inappropriately elevated blood glucose levels). The Minimum Data Set (MDS - an assessment tool) dated December 7, 2023, indicated, a Brief Interview for Mental Status (BIMS) score of 10, which indicates moderate cognitive…

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 appropriate pain management was provided for one of three sampled residents'(Resident 1) complaint of pain to right knee and leg after an altercation with another resident on December 13, 2023. This failure increased the risk for having continuous pain which could impair mobility and function for Resident 1. Findings: On December 26, 2023, at 8:13 a.m., an unannounced visit was made for the investigation of an alleged abuse. A review of Resident 1's facility medical record was conducted. Resident 1 was originally admitted to the facility on [DATE], and was readmitted on [DATE], with diagnoses which included metabolic encephalopathy (problem in the brain caused by imbalance in the blood), Parkinson's disease (disorder that affects movement), paranoid schizophrenia (pattern of behavior where a person feels distrustful and suspicious of other people) and anxiety disorder (mental disorder with a feeling of worry or fear that are strong enough to…

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

Based on observation, interview, and record review, the facility failed to ensure the call light (devices that produce a tone and light up indicating the location of the call, used by the residents to signal a need for assistance from facility staff) were answered promptly for one of three sampled residents, (Resident 1). This failure increased the potential for delayed nursing and medical management as well as actual unmet care needs. Findings: On December 7, 2023, an unannounced visit to the facility was conducted to investigate a complaint. On December 7, 2023, at 9:39 a.m., an observation with a concurrent interview was conducted with Resident 1. Resident 1 was in her room, alert and conversant. Resident 1 ' s call light button was turned on because she wanted to ask the staff who was the Certified Nursing Assistant (CNA) assigned to her. The following were observed: At 9:45 a.m., Restorative Nursing Assistant (RNA) 1 entered the room, turned off Resident 1 ' s call light button and informed Resident 1 she will find out who was the CNA assigned to her that morning; At 9:49 a.m.,…

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 services provided met professional standards for one of three sampled residents (Resident 1) when Resident 1 ' s medications were not given on time as ordered by the physician. This failure had the potential to place Resident 1 at risk for delay in treatment medical complications and further decline in their overall physical well-being. Findings: On December 7, 2023, an unannounced visit to the facility was conducted to investigate a complaint. On December 7, 2023, at 9:39 a.m., an observation with a concurrent interview was conducted with Resident 1. Resident 1 was observed in her room, alert and oriented. At 10: 50 a.m. Resident 1 stated I have not had my morning medication and I am almost an hour late. On December 7, 2023, at 11:04 a.m. an interview was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 was the licensed nurse assigned to Resident 1 in the morning shift of December 7, 2023. LVN 1 stated she was not done passing the residents' morning medications because she had an emergency that morning. On…

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

Based on interview and record review, for one (Resident 3) of eight residents, the facility failed to ensure weight loss (13 pounds/lbs.) recorded on November 20, 2023, was referred to the physician when it was identified during IDT weight variance meeting on November 24, 2023. The facility failure had resulted for an additional 4 lbs. weight loss a week later on November 27, 2023, when the physician was not notified and interventions were not put in place to prevent and halt further weight loss. Findings: On November 28, 2023, at 8:10 a.m., an unannounced visit was conducted to investigate a complaint made on behalf of the facility residents that weight variance monitoring was not being conducted. On November 28, 2023, the IDT Weekly Weight Variance record was inspected. The record indicated that Resident 3 had been identified with a 13 lbs. weight loss. Further review of Resident 3 ' s record indicated weight losses as follows: * November 27, 2023, 185 lbs.; * November 20, 2023, 189 lbs.; * November 13, 2023, 202 lbs.; and * November 6, 2023, admission weigh of 204 lbs. 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 interview and record review the facility failed to ensure for one of three Residents, Resident 1 ' s phenobarbital medication (medication to control and prevent seizure- a sudden, uncontrolled burst of electrical activity in the brain that can cause changes in behavior, movements, feelings and levels of consciousness) was made readily available for administration. The facility's failure to make the medication readily available had resulted for Resident 1 to miss one day of Phenobarbital medication. Findings: On December 5, 2023, at 7:56 a.m., an unannounced visit was conducted to investigate a complaint on behalf of Resident 1 for an allegation of Quality of Care/Treatment for issues with medications that had not been administered because they were not delivered by pharmacy. On December 5, 2023, Resident 1's record was reviewed. The record indicated Resident 1 was [AGE] year-old gentleman, admitted to the facility on [DATE], for Arthritis (Inflammation of one or more joints, causing pain and stiffness)…

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 residents reviewed (Resident 1) was free from verbal abuse when the Activities Assistant (AA) called Resident 1 an inappropriate name. This failure had the potential for Resident 1 to experience emotional distress. Findings: On December 12, 2023, at 9:55 a.m., an unannounced visit was made to the facility to investigate an allegation of verbal abuse. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 1's History and Physical (H&P), dated December 19, 2022, the H&P indicated Resident 1 had the capacity to make decisions. During a review of Resident 1's Brief Interview of Mental Status (BIMS - an assessment tool), dated September 25, 2023, the BIMS indicated Resident 1 had a score of 15 (cognitively…

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 admission agreement was honored, for one of three sampled residents (Resident 1). The facility failed to allow Resident 1 readmission to the facility while Resident 1 was on a 7 day bedhold. Findings: On October 25, 2023, at 11:05 a.m., an unannounced visit was conducted to investigate an allegation on behalf of Resident 1 for issues of Admission, Transfer and Discharge Rights. Review of the medical record on October 25, 2023, indicated Resident 1 was sent to the hospital for an infected wound on September 2, 2023. The medical record indicated there was a physicians order to tranfer Resident 1 for treatment of the wound on September 2, 2023. The medical record also indicated there was a physician's order for a 7 day bed hold in place. On October 25, 2023, Resident 1 ' s record was reviewed. The document titled, admission AGREEMENT signed for by Resident 1 on August 30, 2022, indicated, V11. Bed Holds and readmission: If you must be…

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 residents with the proper size of briefs (adult diaper-a disposable garment used to absorb urine, usually worn under clothes), for two of five residents reviewed (Resident 1 and Resident 5) when Resident 1 and 5 complained the facility briefs caused irritation to the resident's thighs due to being too small. This failure caused Resident 1 and 5 to purchase their own proper sized adults briefs causing unnecessary expenses to the residents and/or their families. Findings: On October 10, 2023, at 9:52 a.m., an unannounced visit was conducted at the facility for a complaint investigation. On October 10, 2023, at 10:52 a.m., Resident 1 was observed lying in her bed. During a concurrent interview Resident 1 stated she used an adult brief. Resident 1 stated the facility brief cut into her thighs, causing irritation. Resident 1 stated her family had to purchase adult briefs for her use, so she would not get skin irritation. Resident 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to document a change of condition, for one of five residents reviewed (Resident 1) when Resident 1 had an X-ray (picture of the inside of the body), CT scan (computerized tomography-series of x-rays taken from different angles around the body), and stool sample (laboratory [lab] test used to determine if bacteria and/or virus are detected in the stool) ordered by the physician with no documented indication. This failure had the potential for confusion of care to occur for Resident 1. Findings: On October 10, 2023, at 9:52 a.m., an unannounced visit was conducted at the facility for a complaint investigation. On October 10, 2023, at 10:52 a.m., Resident 1 was observed lying in her bed. During a concurrent interview Resident 1 stated she been having abdominal pain and gas for over a month. Resident 1 stated she had had x-rays, a CT scan and a stool sample done recently. On October 10, 2023, Resident 1's record was reviewed. Resident 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 interview, and record review, the facility failed to ensure a physician ' s order for stool sample (laboratory [lab] test used to determine if bacteria and/or virus are detected in the stool) was completed timely, for one of five residents reviewed (Resident 1). This failure had the potential to result in the delay of diagnoses and necessary treatments for Resident 1. Findings: On October 10, 2023, at 9:52 a.m., an unannounced visit was conducted at the facility for a complaint investigation. On October 10, 2023, at 10:52 a.m., Resident 1 was observed lying in her bed. During a concurrent interview Resident 1 stated she been having abdominal pain and gas for over a month. Resident 1 stated she had done a stool sample recently to rule out an infection. On October 10, 2023, Resident 1 ' s record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (COPD-lung disease that makes breathing difficult), morbid obesity, and spinal…

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 environment was free of accident hazards for two residents reviewed for accidents, when Resident 1 hit Resident 2 with a broom left out by housekeeping staff. This failure resulted in Resident 2 being physically hit and could potentially result in serious injuries. Findings: On October 5, 2023, at 11:15 a.m., an interview and observation with Resident 1 was conducted. Resident 1 stated she hit Resident 2 with a broom she found nearby on the outdoor patio of the facility. On October 5, 2023, at 11:30 a.m., an interview and observation with Resident 2 was conducted. Resident 2 was deaf and not able to talk, and through sign language and written communication indicated he was hit by Resident 1 on his left arm. On October 5, 2023, at 12 p.m., an interview with the Housekeeping Director (HD) was conducted. The HD stated housekeepers should not leave housekeeping supplies out, where residents can reach them, because it 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, for four of six residents reviewed (Resident 1, 2, 4 and 5), to maintain accurate medical records in accordance with accepted professional standards and practice when the residents' discharge was not documented clearly. This failure could increase the potential for confusion to occur in the safe and orderly discharge of the residents. Findings: On September 18, 2023, at 12:10 p.m., an unannounced visit was conducted at the facility for an unsafe discharge. Review of the discharge list of residents indicated Resident 1 and Resident 2 were discharged home on September 13, 2023. Resident 4 discharged [DATE], and Resident 5 discharged [DATE]. 2023. Review of Resident 1's record indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (abnormal sugar in the blood), and hypertension (elevated blood pressure). Review of Resident 1's Physician Order Summary indicated, .May go home with meds (medication) .…

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 six residents (Resident 1), an effective training and education regarding insulin (medication to control high blood sugar levels) administration and durable medical equipment needed to perform fingerstick blood sugars to monitor Resident 1's diabetes (abnormal sugar in the blood) were provided prior to discharge. This failure had the potential for Resident 1 to experience hyper and/or hypoglycemic (blood sugar levels are too high or low for the body to function) episodes which could be life threatening. Findings: On September 18, 2023, at 12:10 p.m., an unannounced visit was conducted at the facility for an unsafe discharge. Review of the discharge list of residents indicated Resident 1 was discharged home on September 13, 2023. Review of Resident 1's record indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus and hypertension (elevated blood pressure). Resident 1's physician…

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 was treated with dignity and respect, when a Restorative Nursing Assistant (RNA) forcefully fed Resident 1. This failure resulted in not ensuring residents' rights to be treated with dignity and respect and could potentially result in negative physical or psychosocial outcomes, such as choking, or changes in mood and/or behavior. Findings: On October 5, 2023, at 10:28 a.m., an interview with the Registered Nurse (RN) was conducted. The RN stated Resident 1 was on an RNA feeding program, she was assisted by the RNA with meals. The RN stated nurses and staff at the facility were not allowed to force feed a resident who does not want to eat. On October 5, 2023, at 10:40 a.m., an interview with Certified Nursing Assistant (CNA) 1 was conducted. CNA 1 stated on September 25, 2023, she witnessed the Restorative Nursing Assistant (RNA) force feeding Resident 1. CNA 1 stated Resident 1 told the RNA no indicating she did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, functional and sanitary environment for the residents, staff and public, when one of 15 residents' (Resident 15) room had a leak on the ceiling. In addition, there was an opened ceiling adjacent to room [ROOM NUMBER]. This failure could result for water from the rain to actively drip down and could leave puddles causing accidents to residents and staff, and a potential for fungal spores to be dispersed in the environment. Findings: On August 21, 2023, at 12 p.m., an unannounced visit to the facility was conducted to investigate physical environment issues. A review of Resident 15's medical record indicated she was admitted to the facility on [DATE], with diagnoses of encephalopathy, (any diffuse disease of the brain that alters brain function or structure), schizoaffective disorder, (a chronic mental health condition that involves symptoms of disturbances in thought and mood swings), hypothyroidism, (a condition resulting…

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, to provide phenobarbital medication (to control and prevent seizure- a sudden, uncontrolled burst of electrical activity in the brain that can cause changes in behavior, movements, feelings, and levels of consciousness) on August 11, 12, and 13, 2023, in accordance with the physician order for one of three sampled residents (Resident 1). The facility failure to administer Resident 1's Phenobarbital medication had the potential for the resident to experience a seizure and complication. Findings: On August 15, 2023, at 9:00 a.m., an unannounced visit was conducted to investigate a complaint on quality-of-care issue. On August 15, 2023, Resident 1's record was reviewed. The record indicated Resident 1 admitted to the facility on [DATE], with diagnoses which included epilepsy (two or more seizures that occurs at least 24 hours apart), deep vein thrombosis (DVT-blood clot in the legs) and pulmonary embolism (PE-blood clot in the lungs). On August 15, 2023, at 10:00…

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 routine phenobarbital medication (medication to control and prevent seizure- a sudden, uncontrolled burst of electrical activity in the brain that can cause changes in behavior, movements, feelings and levels of consciousness) was made readily available for administration, for one (Resident 1) of three residents. The facility failure to make the medication readily available had resulted for Resident 1 to missed three days of Phenobarbital medication. Findings: On August 15, 2023, at 9:00 a.m., an unannounced visit was conducted to investigate a complaint on quality-of-care issue. On August 15, 2023, Resident 1's record was reviewed. The record indicated Resident 1 admitted to the facility on [DATE], with diagnoses which included epilepsy (two or more seizures that occurs at least 24 hours apart), deep vein thrombosis (DVT-blood clot in the legs) and pulmonary embolism (PE-blood clot in the lungs). On August 15, 2023, at 10:00 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 the call lights (devices that emit a tone and light up indicating the location of the call, used by the residents to signal a need for assistance from facility staff), were plugged in and operational, when three out of five residents (Residents 1, 2, and 4), who required assistance from staff with activities of daily living (ADLs), verbalized their concerns of facility staff not answering their call lights and/or attending to their needs in a timely manner. This failure had the potential for delayed medical management and unmet care needs. Findings: On August 17, 2023, at 10:35 a.m., an unannounced visit was conducted at the facility for a quality-of-care complaint. On August 17, 2023, at 10:55 a.m., Resident 1 was observed lying in her bed. A family member (FM) was seated at her bedside. During a concurrent interview, Resident 1 stated her call light occasionally did not work. At 11:04 a.m., Resident 1 was observed to push 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 skin redness was identified and accurately documented, water was offered and at bedside, and the residents were offered get out of bed, for one of five residents reviewed, (Resident 1), when: 1. Resident 1 had redness and irritation to her left neck that was not identified or assessed; 2. There was no water pitcher or water observed at Resident 1's bedside; and 3. Resident 1 stated she would like to go to activities and/or the dining room for meals but was not assisted up. This failure had the potential to result in the delay of the necessary care and treatment needed for Resident 1 and had the potential for Resident 1 to experience dehydration, and a diminished quality of life. Findings: On August 17, 2023, at 10:35 a.m., an unannounced visit was conducted at the facility for a quality-of-care complaint. On August 17, 2023, at 10:55 a.m., Resident 1 was observed lying in her bed, redness was noted to the left side of her neck. 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 exercise reasonable care for the protection of the resident's property from theft or loss to occur, when: 1. Resident belongings were not inventoried and accurate for 3 out of 14 residents (Residents 1, 3, and 7), and; 2. Resident 7 left the facility against medical advice (AMA) and his belongings were disposed of before Resident 7 could retrieve them. This failure resulted in the violation of the resident's rights of having a safe environment, ensuring the protection of personal property and/or belongings and had the potential to cause emotional distress for the residents and/or family. Findings: On August 30, 2023, at 10:10 a.m., an unannounced visit was conducted at the facility. On August 30, 2023, at 11:15 a.m., Resident 1's room was observed empty, Resident 1 was not in his room. Resident 1's room was observed with multiple personal belongings on the bed, overbed table, nightstand, and on the floor. On August 30, 2023, at 11:48…

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 report an allegation of illegal drugs paraphernalia, and illegal drug use in the facility to the California Department of Public Health Licensing and Certification, (CDPH L&C) within 24 hours. This failure had the potential for continued use and abuse of illegal drugs in the facility. Findings: On August 15, 2023, at 2:58 p.m., an unannounced visit to the facility was initiated for two complaints regarding resident rights. On August 15, 2023, at 3:52 p.m., an interview was conducted with the Social Service Assistant, (SSA). The SSA stated that on August 2, 2023, they searched resident rooms and found methamphetamines, marijuana, and drug paraphernalia. On August 15, 2023, at 4:25 p.m., an interview was conducted with the facility's Administrator, (ADMIN). The ADMIN stated all week long we have been finding methamphetamines, marijuana, PCP, and drug paraphernalia in resident rooms. The ADMIN stated the police came and confiscated 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 diagnostic procedure was provided in a timely manner, for one of fourteen residents reviewed (Resident 3), when an x-ray (procedure used to create images of the structures inside the body, used to assess for broken bones) order was not obtained from the physician, when Resident 3 complained of a sore wrist with swelling and redness after a fall on August 27, 2023. This failure had the potential for the delay in the treatment and care for Resident 3. Findings: On August 30, 2023, at 10:10 a.m., an unannounced visit was conducted at the facility. On August 30, 2023, at 11:48 a.m., Resident 3 was observed dressed sitting on the edge of his bed. During a concurrent interview, Resident 3 stated he fell out of bed a few nights ago when his side rail broke. Resident 3 stated he sustained a bump to his right forearm and staff indicated he would be getting an x-ray. Resident 3 was observed to have a lump approximately the size of a golf…

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 bed was in safe working condition for one out of fourteen residents reviewed (Resident 3), when Resident 3's right upper side rail was broken on his bed. This failure resulted in Resident 3 falling from his bed to the floor when the side rail broke and had the potential for Resident 3 to sustain further injury when the bed rail was not repaired timely. Findings: On August 30, 2023, at 10:10 a.m., an unannounced visit was conducted at the facility. On August 30, 2023, at 11:48 a.m., Resident 3 was observed dressed sitting on the edge of his bed. During a concurrent interview, Resident 3 stated he fell out of bed a few nights ago when his side rail broke. Resident 3 stated he sustained a bump to his right forearm. Resident 3 was observed to have a lump approximately the size of a golf ball on his right forearm, no redness was noted. On August 30, 2023, at 12:11 p.m., Certified Nursing Assistant (CNA) 1 was interviewed.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) were allowed readmission to the facility following hospitalization. The resident was not permitted to return to the facility since the resident was found to be positive of Candida Auris (a type of yeast that can cause severe illness and spreads easily among patients). The resident was not re-admitted back to the facility until August 4, 2023. This failure had resulted for the resident to have an unnecessary stay at the hospital from [DATE] to August 4, 2023. Findings: On July 31, 2023, an unannounced visit was conducted at the facility to investigate an admission, transfer, and discharge issue. On August 1, 2023, Resident 1's record was reviewed. The record indicated Resident 1 was re-admitted to the facility on [DATE], and subsequently discharged back to the hospital on June 21, 2023, for treatment and management of abdominal pains. On August 1, 2023, at 11:35 a.m., during an interview with 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, for four of 11 employees reviewed to ensure infection control policy and procedures were followed when: 1. Certified Nursing Assistant (CNA) 1 and Licensed Vocational Nurse (LVN) 1 failed to change their N95 Respirator masks (type of respirator that protects both resident and staff from the transfer of microorganisms and help prevent transmission of infection) after exiting the room of a resident who was infected with the Covid-19 virus (a highly infectious respiratory virus) and entering a different resident room. This failure had the potential to increase staff and resident exposure and transmission of the Covid-19 virus resulting in illness. 2. The facility's Infection Preventionist (IP) failed to implement the facility's Covid-19 Infection Surveillance policy on staff compliance during a facility Covid-19 outbreak. This failure has the potential for residents and staff to be exposed to viral cross-contamination and experience potential Covid-19 infection. 3. CNA 2 and LVN 2 failed to wear N95 respirator…

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, interviews, and record review, the facility failed to ensure for one of three sampled residents (Resident 2), the medication Methadone (a medication used to treat severe pain and opioid addiction) was provided in a timely manner as ordered by the physician. This failure resulted in Resident 2 to not receive six doses of Methadone and had the potential to cause physical withdrawal symptoms and psychosocial harm (anxiety, anger, mental distress). Findings: On August 16, 2023, an unannounced visit to the facility was conducted to investigate the reported incident. On August 16, 2023 a review of Resident 2 ' s record indicated Resident 2 was admitted to the facility on September 16, 2022, with diagnosis of acute psychoactive substance abuse (drug addiction), depression (a persistent feeling of sadness), insomnia (a condition where a person has trouble falling asleep or staying asleep), alcohol abuse and a stress fracture (a small crack in a bone, or severe bruising within a bone) of the right ankle. The physician ' s order dated August 11, 2023, indicated to give…

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) a clean water pitcher was available for Resident 3, as the water pitcher's clear straw, had red and brown marks throughout the inside of it, and a black substance was observed on the inside rim of the water pitcher. 2) The facility failed to date the Oxygen tubing and Humidifier distilled water containers for 3 Residents (Residents 4, 5 & 6) out of 151 residents. This failure could have resulted in Resident 3 drinking unhealthy water, which could cause a sickness or disease, and could have negatively impacted the health of Resident's 4, 5, & 6, by the continued use of outdated oxygen tubing and humidified distilled water. Findings: 1) On June 23, 2023, an unannounced visit was made to the facility to investigate a Quality-of-Care issue. On June 23, 2023, at 10:04 a.m., and interview was conducted with CNA1. CNA1 stated, (Filling resident water pitchers are) part of (Staff's) morning, and afternoon routine. We make sure (The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review, the facility failed to ensure the call light system was working for all residents, as Resident's 1 and 2's call lights were unplugged from the wall, and did not work, when pushed. This failure had the potential to negatively impact the health and safety of Resident's 1 and 2, as they did not have call lights to alert nurisng staff of their needs. Findings: On June 22, 2023, at 9:10am an unannounced visit was made to the facility for a Quality-of-Care (QOC) issue. On June 22, 2023, Resident 1's medical records were reviewed, and indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis of fracture of the spine and right leg, blind in right eye, and history of falls, with a BIMS (Brief Interview for Mental Status, a cognitive test) score of 06. On June 22, 2023, Resident 2's medical records were reviewed, and indicated Resident 2 was admitted to the faciliy on August 8, 2022, with a diagnosis of mild protein malnutrition, high blood pressure,…

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.