Bayshire San Dimas Post-Acute

Based on interview and record review, the facility failed to promptly notify Resident 1's doctor of Resident 1's complaint of pain and feeling that Resident 1's right hip was dislocated. This failure had the potential for Resident 1 to not receive timely treatment for pain and correction of the hip dislocation. (Cross Reference F552, F755, F806, and F842)Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 9/10/2025 with diagnoses including fracture (broken bone) of unspecified part of neck of right femur (thigh bone), dislocation of right hip (a medical emergency where the thigh bone pops out of the hip socket), and need for assistance with personal care. The AR indicated Resident 1 was discharged to General Acute Care Hospital (GACH) 2 on 10/1/2025.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 9/17/2025, the MDS indicated Resident 1 was moderately impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident 1 was dependent (helper does all 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 and record review, the facility failed to provide routine drugs for one of three sampled residents (Resident 1) when Resident 1 was not provided scheduled medications on 9/10/2025 at 9:00 PM. This failure had the potential to result in Resident 1 experiencing increased pain due to neuropathy (damage or dysfunction of nerves).(Cross Reference F552, F580, F806, and F842)Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 9/10/2025 with diagnoses including fracture (broken bone) of unspecified part of neck of right femur (thigh bone), dislocation of right hip (a medical emergency where the thigh bone pops out of the hip socket), and need for assistance with personal care. The AR indicated Resident 1 was discharged to General Acute Care Hospital (GACH) 2 on 10/1/2025.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 9/17/2025, the MDS indicated Resident 1 was moderately impaired in 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.

Based on interview and record review, the facility failed to ensure one of three sampled residents' (Resident 1) food allergy to bananas was:a. documented in Resident 1's assessment notes according to the facility's Policy and Procedure (P&P), titled Food Allergies and Intolerances, revised August 2017.b. Indicated on Resident 1's tray card (or tray ticket/meal ticket, a document that accompanies a resident's meal tray during preparation and delivery) according to the facility's P&P, titled Dietary Tray Card, revised 3/21/2024.These failures had the potential for Resident 1 to experience an allergic reaction to bananas.(Cross Reference F552, F580, F755, and F842)Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 9/10/2025 with diagnoses including fracture (broken bone) of unspecified part of neck of right femur (thigh bone), dislocation of right hip (a medical emergency where the thigh bone pops out of the hip socket), and need for assistance with personal care. The AR indicated Resident 1 was discharged to General…

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

Based on interview and record review, the facility failed to maintain a complete and accurate medical record for one of three sampled residents (Resident 1) when:a. Licensed Vocational Nurse (LVN) 2 failed to document Resident 1's acute condition change on 9/30/2025.b. LVN 2 documentation regarding Resident 1's acute condition change, which was recorded on 10/1/2025, contained inaccurate information. This failure resulted in Resident 1's medical record to contain inaccurate information, Registered Nurse (RN) 1 to not be aware of Resident 1's acute condition change, and had the potential for Resident 1 to not receive timely treatment for pain and correction of the hip dislocation (a medical emergency where the thigh bone pops out of the hip socket).(Cross reference F552, F580, F755, and F806)Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 9/10/2025 with diagnoses including fracture (broken bone) of unspecified part of neck of right femur (thigh bone), dislocation of right hip, and need for assistance with personal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide care and services needed for one of three sampled residents (Resident 2), who required dialysis (treatment to clean one's blood by removing waste and extra fluid when the kidneys are unable to) by failing to ensure Resident 2 was provided with a means of transportation to and from dialysis treatments three times a week between 7/25/2025 and 8/13/2025. As a result of this failure, Resident 2 did not receive nine (7/25/2025, 7/28/2025, 7/30/2025, 8/1/2025, 8/4/2025, 8/6/2025, 8/8/2025, 8/11/2025, 8/13/2025) dialysis treatments. Resident 2 was transferred to General Acute Care Hospital (GACH) 1 on 8/13/2025 at 9:30 pm. Resident 1 was diagnosed with metabolic acidosis (condition where the body produces too many acids or cannot eliminate them effectively, leading to a decrease in blood pH [acidity], uremia (the build-up of urea [an organic chemical waste product that is produced in the liver and filtered from the blood by the kidneys to be excreted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure three of three sampled residents (Residents 7, 27, and 83) and/or their Responsible Parities (RP) were offered and provided information regarding the right to formulate an advance directive (AD, legal documents that provide instructions for medical care and only goes into effect if the resident cannot communicate their wishes). This deficient practice had the potential to result in lack of knowledge regarding care and treatment decision making and the potential for Residents 7, 27 and 83 to receive unwanted care/treatment or unnecessary life-sustaining treatment. Findings: A. During a record review of Resident 7's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE] with diagnosis that included kidney failure (condition where the kidneys are unable to properly filter waste products), depression, and hypertension (elevated blood pressure). During a record review of Resident 7's Minimum Data Set (MDS, a…

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

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were maintained in the kitchen when: a. [NAME] (CK) 1 was not wearing a hair net over CK 1's beard. b. A banana cream pie was observed in one of one walk-in freezer to be undated (not provided or marked with a date). c. A tray of green beans was observed in one of one walk-in refrigerator to be uncovered and undated. These failures had the potential for improper food storage and handling, which could lead to foodborne illnesses. Findings: During an initial tour of the kitchen on 2/7/2025 at 5:06 PM with CK 1, CK 1 was prepping food next to the kitchen stove. CK 1 was not wearing a hair net over CK 1's beard. CK 1 stated CK 1 should have a hair net over CK 1's beard. During an initial tour of the kitchen on 2/7/2025 at 5:08 PM with CK 1, a frozen banana cream pie was observed in the walk-in freezer to be opened. The opened container was not dated. CK 1 stated the opened banana cream pie should be thrown in the trash. During an initial tour of the kitchen on 2/7/2025 at 5:10…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 treat one of 12 sampled residents (Resident 3) with dignity and respect when Certified Nursing Assistant (CNA) 1 referred to Resident 3 as a feeder. This failure had the potential for Resident 3 to feel disrespected. Findings: During a review of Resident 3's admission Record (AR), the AR indicated the facility admitted Resident 3 on 3/12/2024, and readmitted Resident 3 on 6/10/2024, with diagnoses including compression fracture of T11-T12 vertebra (a kind of broken back bone), history of falling, and dysphagia (difficulty swallowing foods or liquids). During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool), dated 12/14/2024, the MDS indicated Resident 3 was moderately impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident 3 required partial/moderate assistance (helper does less than half the effort) from staff for toileting hygiene and showering/bathing. The MDS indicated Resident 3 required supervision or touching assistance (helper provides…

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

Based on interview and record review, the facility failed to notify the physician regarding pharmacy delays and inability to carry out the physician's order for Vagisil (a medication used to relieve vaginal itching, irritation, and burning) for one of one sampled resident (Resident 11). This deficient practice resulted in delayed provision of necessary care and services for Resident 11. Findings: During a review of Resident 11's admission Record (AR), the AR indicated the facility admitted Resident 11 on 1/18/2025, with diagnoses including malignant neoplasm of corpus uteri (endometrial cancer, a cancer of the lining of the uterus [a pear-shaped organ in the reproductive system of females]), type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), and history of falling. During a review of Resident 11's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 1/25/2025, the MDS indicated Resident 11 had moderate cognitive (the ability to think and process information) impairment. The MDS 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 observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 27) was provided a safe and homelike environment when Resident 27's toilet leaked and caused water to puddle on the bathroom floor. This failure had the potential for Resident 27 to be injured from a fall and had the potential for Resident 27 to not be comfortable in his environment. Findings: During a review of Resident 27's admission Record (AR), the AR indicated the facility admitted Resident 27 on 12/17/2024, with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), aftercare following joint replacement surgery, and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). During a review of Resident 27's Minimum Data Set (MDS, a resident assessment tool), dated 12/21/2024, the MDS indicated Resident 27 had no impairment in cognitive skills (ability to make daily decisions). The MDS 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 one of six sampled staff members (Certified Nursing Assistant 5, CNA 5) maintained current BLS (Basic Life Support, generally refers to the type of care first-responders, healthcare providers, and public safety professionals provide) with Cardiopulmonary resuscitation (CPR, emergency lifesaving procedure, consisting of a combination of chest compressions, mouth- to-mouth, or mechanical breathing [using a device to help someone breaths], performed when the heart stops beating or beats ineffectively and/or to restore breathing) certification. This deficient practice had the potential for CNA 5 not being able to provide emergency basic life support, including cardiopulmonary resuscitation (CPR), to any resident requiring such care during an emergency and prior to the arrival of emergency medical personnel. Cross Reference F726 Findings: During an interview and concurrent record review with the Director of Staff Development (DSD) of CNA 5's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide sufficient nursing services on 2/3/2025, 2/5/2026 and 2/6/2025, for two of two sampled residents (Resident 19 and Resident 27), as indicated in the facility's policy and procedure (P&P), titled, Staffing, Sufficient and Competent Nursing. This deficient practice had the potential to affect the care provided to residents, quality of life, and the potential for the residents not to receive nursing services in a timely matter. Findings: A. During a review of Resident 19's admission Record (AR), the AR indicted Resident 19 was admitted to the facility on [DATE] with diagnosis that included hemiplegia and hemiparesis (muscle weakness on one side of the body) of the right dominant side, muscle wasting, and difficulty walking. During a review of Resident 19's History and Physical (H&P), dated 1/12/2025, the H&P indicated Resident 19 had the capacity to understand and make decisions. During a review of Resident 19's Minimum Data Set (MDS,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of six facility staff (Certified Nurse Assistant 6, CNA 6) had necessary competencies (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully) and skill sets required during a medical emergency. CNA 6 was not aware of the proper compression (hands to push down hard and fast in a specific way on the person's chest) to breath (giving breaths of oxygen) to breath ratio needed to be performed for Cardiopulmonary Resuscitation (emergency lifesaving procedure, consisting of a combination of chest compressions, mouth- to-mouth, or mechanical breathing [using a device to help someone breaths], performed when the heart stops beating or beats ineffectively and/or to restore breathing) for Basic Life Support (BLS, generally refers to the type of care that first-responders, healthcare providers and public safety professionals…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 post accurate nurse staffing information of actual hours worked by the licensed and unlicensed nursing staff who were directly responsible for resident care per shift, daily. This information was not posted in a prominent location readily accessible to residents and visitors for viewing. This failure resulted in no posting of nurse staffing hours and had the potential to result in lack of nurse staffing hour knowledge for residents and family members. Findings: During an interview and concurrent record review with the Director of Staff Development (DSD), on 2/9/2025 at 10:48 AM, the facility's Daily Staffing and Posting and Census dated 2/7/2025 and 2/8/2025 were reviewed. The DSD stated actual hours worked by the nursing staff for those dates were not recorded/posted. The DSD stated actual hours were calculated by the next business day and on weekends, actual hours worked were calculated by the following Monday. The DSD stated it was important to post actual working hours worked to ensure the correct number of worked…

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

Based on interview and record review, the facility failed to follow through with the Consultant Pharmacists recommendations during the Medication Regiment Review (MRR, a review of all medications the resident is currently using to minimize adverse consequences and potential risks associated with medications) for one of five sampled residents (Resident 21). This failure had the potential for Resident 21 to not receive the necessary blood tests for Resident 21's health and wellbeing. Findings: During a review of Resident 21's admission Record (AR), the AR indicated the facility admitted Resident 21 on 1/8/2025, with diagnoses including cerebral infarction (also called ischemic stroke, occurs as a result of disrupted blood flow to the brain), urinary tract infection (UTI, an infection in any part of the urinary system, including the kidneys, bladder, or urethra),and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). During a review of Resident 21's Minimum Data Set (MDS, a resident assessment tool), dated 1/15/2025, the MDS 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 accurate medication administration documentation for one of one sampled resident (Resident 11) when, the facility inaccurately documented the administration of Resident 11's Vagisil (a medication used to relieve vaginal itching, irritation, and burning) on 2/4/2025. This deficient practice had the potential to lead to inconsistent and/or inaccurate treatments provided to Resident 11. Findings: During a review of Resident 11's admission Record (AR), the AR indicated the facility admitted Resident 11 on 1/18/2025, with diagnoses including malignant neoplasm of corpus uteri (endometrial cancer, a cancer of the lining of the uterus [a pear-shaped organ in the reproductive system of females]), type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), and history of falling. During a review of Resident 11's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 1/25/2025, the MDS indicated Resident 11 had moderate cognitive (the ability 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 maintain infection prevention and control practices for one of one sampled resident (Resident 11) by failing to ensure Resident 11's wound vacuum (a suction device that is applied after a wound is dressed) drainage tubing did not have direct contact with the floor. This deficient practice had the potential to result in the transmission of infectious microorganisms and increase the risk of infection for Resident 11. Findings: During a review of Resident 11's admission Record (AR), the AR indicated the facility admitted Resident 11 on 1/18/2025, with diagnoses including malignant neoplasm of corpus uteri (endometrial cancer, a cancer of the lining of the uterus [a pear-shaped organ in the reproductive system of females]), type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), and history of falling. During a review of Resident 11's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 1/25/2025, the MDS indicated Resident 11…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 used by residents was maintained in a safe and operable condition, by failing to ensure the wheelchair brakes were fully functional for one of one sampled resident (Resident 11). This deficient practice had the potential to result in harm and could have negatively impacted the safety, and well-being of Resident 11. Findings: During a review of Resident 11's admission Record (AR), the AR indicated the facility admitted Resident 11 on 1/18/2025, with diagnoses including malignant neoplasm of corpus uteri (endometrial cancer, a cancer of the lining of the uterus [a pear-shaped organ in the reproductive system of females]), type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), and history of falling. During a review of Resident 11's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 1/25/2025, the MDS indicated Resident 11 had moderate cognitive (the ability to think and process information) impairment. 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 and record review, the facility failed to ensure timely care was provided for eight of 11 sampled residents (Residents 4, 2, 3, 5, 6, 7, 8, and 10). This deficient practice resulted in the delay of care for Residents 4, 2, 3, 5, 6, 7, 8, and 10 and had the potential for other residents to not receive timely assistance for basic and/or emergent needs. Findings: 1. During a review of Resident 4's admission Record (AR), the AR indicated, Resident 4 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), tachycardia (heart rate over 100 beats per minute), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 4's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 8/27/2024, the MDS indicated, Resident 4's cognitive skills for daily decision-making were cognitively intact. 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 interview and record review, the facility failed to ensure timely discharge planning was implemented for one of three sampled residents (Resident 2) by failing to: 1. Consider Resident 2's caregiver (Resident 2's Representative [R2R]) capacity and capability to perform the required discharge care for Resident 2 and provide R2R with caregiver training prior to discharge of Resident 2. 2. Assess Resident 2 for the need of assistive device/s at home to safely perform activities of daily living (ADLs) and for mobility. 3. Arrange and confirm home health services (medical services provided at a person's home to treat a chronic health condition or help with recovery from illness, injury, or surgery) as ordered by Resident 2's physician before Resident 2 was discharged from the facility. These failures had the potential for increased risk of complications and adverse events during the resident's transition to a new setting. Cross Reference F661 Findings: During a review of Resident 2's admission Record (AR 2), the AR 2 indicated, the facility initially admitted Resident 2 on…

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

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) had an accurate discharge summary by failing to accurately assess and document Resident 2's discharge care needs and post-discharge plan to ensure Resident 2's safe and effective transition to Resident 2's home. These failures resulted in the lack of continuity of care and a delay in the provision of care and services for Resident 2. Cross Reference F660 Findings: During a review of Resident 2's admission Record (AR 2), the AR 2 indicated, the facility initially admitted Resident 2 on 5/20/2024, with multiple diagnoses including cerebral infarction (ischemic stroke- disrupted blood supply to the brain, causing tissue death) with hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) affecting right dominant side, aphasia (language disorder affecting person's ability to understand and speak language), gait (manner of walking) and mobility abnormalities, muscle wasting (thinning of muscle mass) and atrophy (loss of muscle mass and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide sufficient and appropriate social services to meet the needs of one of three sampled residents (Resident 1) by failing to: 1.Ensure the Social Services Director (SSD) documented evidence of timely referrals to long-term care (LTC- health-related care and services [above the level of room and board] not available in the community, needed regularly due to a mental of physical condition) facilities certified under Medicaid (a joint federal and state program that helps cover medical costs for people with limited income and resources) for Resident 1. 2. Ensure the SSD updated and individualized Resident 1's discharge care plan. These failures had the potential to cause a physical and psychosocial impact to Resident 1's well-being due to unsatisfactory discharge planning. Findings: During a review of Resident 1's admission Record (AR 1), the AR 1 indicated, the facility last admitted Resident 1 to the facility on [DATE], with multiple diagnoses…

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

Based on interview and record review, the facility failed to maintain an accurate and complete medical record for one of three sampled residents (Resident 2) when the facility did not accurately document Resident 2's legal decisionmaker/representative (R2R) on Resident 2's admission record. This failure had the potential to cause a delay in providing the care and services for Resident 2 related to the undocumented decision-making capacity of R2R regarding Resident 2's care. Cross Reference F661 Findings: During a review of Resident 2's admission Record (AR 2), the AR 2 indicated, the facility initially admitted Resident 2 on 5/20/2024, with multiple diagnoses including cerebral infarction (ischemic stroke- disrupted blood supply to the brain, causing tissue death) with hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) affecting right dominant side, aphasia (language disorder affecting person's ability to understand and speak language), gait (manner of walking) and mobility abnormalities, muscle wasting (thinning of muscle mass) 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 call lights were within reach for two of three sampled residents (Residents 2 and 3). This deficient practice had the potential to result in the delay of care for Residents 2 and 3 when Residents 2 and 3 were unable to reach their call lights to call staff for assistance. Findings: a. During a review of Resident 2's admission Record (AR), the AR indicated, the facility admitted Resident 2 on 5/21/2024, with diagnoses of viral pneumonia (an infection of the lung caused by a virus) and chronic obstructive pulmonary disease (a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe) with acute exacerbation (a sudden worsening of symptoms that lasts for several days). During a review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/28/2024, the MDS indicated, Resident 2 was understood by others and had the ability 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 interview and record review, the facility failed to ensure a safe and orderly discharge from the facility for one of three sampled residents (Resident 1) as indicated in the facility's policy and procedure (P&P) titled, Transfer or Discharge, Preparing a Resident for. This deficient practice resulted in Resident 1 being discharged from the facility without the needed services ordered by the physician. This had the potential to put Resident at risk for injury, harm, and/or rehospitalization. Findings: During a review of Resident 1's admission Record (AR), the AR indicated, the facility originally admitted Resident 1 on 4/19/2024, and readmitted Resident 1 on 5/10/2024, with diagnoses that included fractures of shaft of left tibia (big bone between the knee and ankle, shinbone), left lower leg, and lower end of left tibia, and an open wound on left ankle. During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/10/2024, the MDS indicated, Resident 1 was understood by others and had the ability to understand others. 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 2. During a review of Resident 173's admission Record, (AR), the AR indicated Resident 173 was admitted to the facility on [DATE] with multiple diagnoses including acute (sudden) respiratory failure (when the lungs can't get enough oxygen into the blood) with hypoxia (low levels of oxygen in your body tissues), diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and neoplasm (cancer, a new and abnormal growth of tissue in some part of the body) related pain. During a review of Resident 173's BIMS (Brief Interview Mental assessment) SNF (Skilled Nursing Facility) Resident Interview, dated 1/25/23, the BIMS indicated Resident 174 had no impairment in cognitive skills (the ability to make daily decisions). During a review of Resident 173's Order Summary Report, the Order Summary Report (OSR), with active orders as of 1/26/24. The OSR indicated, Resident 173 had a physician's order, dated 1/23/24, to receive O2 (oxygen) at 2L (liter, unit of volume) by nasal cannula (N/C, 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 develop and implement comprehensive person-centered care plans (CP) for two for two of two sampled residents (Residents 174 and 12): a. For Resident 174, who required oxygen (O2) therapy, the resident's care plan did not address Resident 174's respiratory (related to breathing) issues. b. For Resident 12, the facility did not develop a comprehensive CP that addressed Resident 12 had an indwelling Foley catheter (F/C, a brand for one of many brands of urinary catheters [flexible tube used to empty the bladder and collect urine in a drainage bag] and the need for dialysis (hemodialysis, a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly). These failures had the potential to result in Residents 12 and 174 not to receive interventions to address the residents' specific needs, which could result in no individualized care and specific interventions needed to attain or maintain Resident 12 and 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 two of two sampled residents (Residents 173 and 174) were provided with appropriate care and/or services for oxygen (O2) treatment: a. Resident 173 had an order for O2 at 2 liters (L, unit of volume) via nasal cannula (N/C, a tube used to deliver oxygen to help with breathing) and was observed to be receiving 4 L on 1/26/24. b. Resident 174 was receiving 2 L of O2 via N/C without a physician's order to administer O2. In addition, the facility failed to post a sign indicating Oxygen in Use outside of Resident 174's room door as indicated in the facility's P&P titled, Oxygen Administration. These failures had the potential to result too much O2 administration and the potential to result in physical declines to Residents 173 and 174. (Cross Reference F655 and F656) Findings: a. During a review of Resident 173's admission Record, (AR), the AR indicated Resident 173 was admitted to the facility on [DATE] with multiple diagnoses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 d. During a concurrent interview and record review on 1/28/24 at 4:33 p.m. with the Director of Plant Operations (DPO), updated 5/31/23, the facility's WMP, was reviewed. The WMP indicated the purpose of the WMP was to identify where bacteria can grow and/or spread and reduce that risk [of contracting Legionnaire's disease (LD, type of pneumonia [infection that inflames the air sacks in the lungs] cause by legionella bacteria). The WMP indicated If residents contract LD, it is often a result of exposure to inadequately managed building water systems which can be prevented. The WMP indicated the WMP included measures to monitor the identified areas that may promote growth of waterborne bacteria. The WMP indicated would monitor weekly the Cold Main and Hot Water Services. The WMP indicated the monitoring of the Cold Main consisted of weekly temperature checks and weekly checks of chlorine in the water. The WMP indicated the monitoring of the Hot Water Services consisted of weekly temperature checks of water…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility's Policy and Procedure (P&P) titled COVID-19 Vaccination, dated 10/25/23 when: a. For two of five sampled residents (Residents 10 and 15), the facility failed to offer a COVID-19 (a respiratory illness that can spread from person to person) vaccination (vaccine, a preparation that is used to stimulate the body's immune response against diseases). b. The facility failed to maintain documentation related to COVID-19 vaccinations for staff currently employed at the facility. These failures had the potential to result in residents and staff to acquire, transmit, or experience complications from COVID-19. Findings: a. During a review of Resident 10's admission Record (AR), the AR indicated Resident 10 was admitted to the facility on [DATE] with multiple diagnoses including pulmonary hypertension (a type of high blood pressure that affects arteries in the lungs and in the heart), unspecified fracture (broken bone) of first lumbar…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain an effective training program for facility staff: a. The facility's previous Director of Staff Development (DSD) failed to conduct staff training to address a known facility problem regarding residents experiencing pressure injuries (PIs, localized damage to the skin and underlying tissue, primarily caused by prolonged pressure on the skin, shear (mechanical force that causes skin to break of), or friction [surfaces rub against each other]). This failure had the potential to result in unsafe and incompetent care provided to residents by facility staff. Findings: During a review of Resident 14's admission Record (AR), the AR indicated Resident 14 was admitted to the facility on [DATE] with diagnosis that included muscle wasting atrophy (decrease in size or wasting away of a body part or tissue) on the left and right upper arms and needed for assistance with personal care. During a review of Resident 14's SBAR Communication Form (Situation,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews and record review, the facility failed to ensure an assessment was completed upon readmission to the facility for one of one sampled resident (Resident 71). This failure had the potential to result in unsafe and incompetent care provided to Resident 71 and had the potential to result in unaddressed changes of condition and a physical decline to Resident 71. Findings: During a review of Resident 71's admission Record (AR), the AR indicated Resident 71 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that included dementia (a decline in mental ability severe enough to interfere with daily life), insomnia (problems falling and staying asleep) and hypertension (elevated blood pressure). During a review of Resident 71's Generations Post-Acute admission Data Collection (GPAADC), dated 1/1/24 at 6:31 pm, the GPAADC indicated Resident 71 did not have a history of skin issues. The skin evaluation section indicated Resident 71's skin was intact (not damaged or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 10) who was receiving enteral feeding (medical device used to provide nutrition to people who cannot obtain nutrition by mouth) through a gastrostomy tube (G-Tube, a tube inserted through the belly that brings nutrition and medications directly to the stomach) received appropriate care and services to prevent complications and in accordance with the facility's policy and procedure (P&P), titled, Care and Treatment of Feeding Tubes. This deficient practice had the potential to cause complications such as skin irritation and local infection to Resident 10. Findings: During a review of Resident 10's admission Record (AR), the AR indicated Resident 10 was admitted to the facility on [DATE] with multiple diagnoses including gastrostomy status, dysphagia (difficulty swallowing) and unspecified dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, for two of 30 daily nurse staffing posting information, post actual worked nursing hours at the start of each shift. This failure resulted in inaccurate nursing hours posted by the facility and had the potential to result in residents and family members to obtain misleading information posted. Findings: During a concurrent interview and record review on 1/28/24 at 2:41 p.m. with the Director of Staff Development (DSD), the facility's daily nurse staffing document, untitled, dated 1/25/24 and Nursing Staffing Assignment and Sign-In Sheet (CDPH 530), dated 1/25/24 were reviewed. The facility's daily nurse staffing document indicated the facility staffed two Certified Nursing Assistants (CNA) on the night shift (11 pm. to 7 am.). The CDPH 530 indicated only one CNA worked on the night shift. The DSD stated the facility's daily nurse staffing document only indicated projected staffing hours and not actual staffing hours. During a review of the facility's P&P titled, Nurse Staffing Posting Information, dated 5/23/23, the P&P…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one sampled resident (Resident 10) was free of medication error (means the observed or identified preparation or administration of medications or biologicals) which was not in accordance with the manufacturer's specifications (not recommendations) regarding the preparation and administration of the medication, Duloxetine (a delayed-release capsule[medication designed to last longer in the body] used to treat certain mental/mood disorders and used to help relieve nerve pain). This failure could result by passing the extended time release of the capsule that could increase the risk of serious complications such as abdominal cramping, convulsions, and severe skin reactions to Resident 10. Findings: During a review of Resident 10's admission Record (AR), the AR indicated, Resident 10 was admitted to the facility on [DATE] with multiple diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 follow safe and proper food storage practices in accordance with professional standards for food service safety and the facility's policy and procedure (P&P) by failing to: a. Label, date food items and ensure opened food items were covered in one of one kitchen (Kitchen 1). These deficient practices could result in serious complications from food borne illness (illness caused by the ingestion of contaminated food or beverage) and/or affect the quality and palatability of food served to the residents. Findings: During a concurrent observation and interview on 1/26/24, at 3:35 p.m., with the Food Service Supervisor (FSS) in the initial tour of Kitchen 1, the following was observed: 1. a 17 oz (ounces, a unit of weight) can of Vegetable Oil pan coating spray had no cap on and was undated and located on the prep (preparation) counter by the stove. 2. an undated D'AllesandrO brand of Demerara sugar herbs & spices was located on the prep counter by the stove. 3. an undated tub of Salt had no cover or cap and was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the facility's Quality Assurance Performance Improvement (QAPI, governing body, a group of people that meet regularly, data driven approach to maintaining and improving safety and quality of care, a proactive approach to quality improvement) corrected identified quality facility issues regarding pressure injuries (PIs, localized damage to the skin and underlying tissue, primarily caused by prolonged pressure on the skin, shear (mechanical force that causes skin to break of), or friction [surfaces rub against each other]). This deficient practice had the potential for residents to not receive appropriate PI care and treatment and the potential for the development of new PI's. Findings: During a review of Resident 14's admission Record (AR), the AR indicated Resident 14 was admitted to the facility on [DATE] with diagnosis that included muscle wasting atrophy (decrease in size or wasting away of a body part or tissue) on the left and right upper…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 4) was provided a safe, sanitary, and comfortable environment. On 1/26/24, Resident 10's ceiling had a leak. This failure resulted in Resident 4 having trouble sleeping and feeling unnerving and Responsible Party (RP) 1 concerned about the safety of Resident 4. Findings: During a review of Resident 4's admission Record (AR) the AR indicated, Resident 4 was originally admitted to the facility on [DATE] and last readmitted on [DATE] with multiple diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily life), recurrent severe without psychotic (a mental disorder characterized by a disconnection from reality) features, dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), in other diseases…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 controlled medications for one of one sampled resident (Resident 1) were accounted for during the controlled medication reconciliation. 34 tablets of Resident 1 ' s Clonazepam (Klonopin, a Schedule IV controlled medication used for treatment of panic disorder and epilepsy [seizures]) were unaccounted for during controlled medication reconciliation. This failure had the potential risk for this medication to be used inappropriately and may result in adverse effects to the residents. Findings: During a review Resident 1's admission Record indicated Resident 1 was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included epileptic seizures (abnormal electrical brain activity) related to external causes, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and functional quadriplegia (complete inability to move due to severe…

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