Jewish Home & Rehab Center D/P SNF

Based on interview and record review, the facility failed to implement their fall policy and procedure for three of 6 sampled residents (Resident 187, 327, and 356) when: 1. There was no evidence of post fall interdisciplinary team (IDT, a group of healthcare professionals from different fields who work together to provide the best care for a patient) meeting for Resident 187. 2. There were no consent for video monitoring and evidence of post fall IDT meeting for Resident 327. 3. There was no post fall assessment and completed IDT meeting note for Resident 356. These failures could potentially result in negative outcomes for Resident 187, 327, and 356. Findings: 1. Review of Resident 187's clinical record indicated, Resident 187 was admitted to the facility with diagnoses including dementia (memory loss), hypertension (high blood pressure), and atrial fibrillation (Afib, an irregular and often rapid heart rate that commonly causes poor blood flow and can increase the risk of stroke). Review of Resident 187's Minimum Data Set (MDS, resident assessment tool), dated 2/8/24 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 observations, interviews, and record reviews, the facility failed to maintain a medication error rate below five percent (5%). During the medication pass on 8/20/24 and 8/21/24, four medication errors were observed out of twenty-six opportunities for three out of six residents, resulting in an error rate of 15%. This failure had the potential to result in harm in the health and safety of residents. Findings: 1. A review of the manufacturer insert for Flovent indicated to properly administer the Flovent HFA 220 µg inhaler, it is essential to follow the manufacturer's instructions. Begin by shaking the inhaler vigorously for five seconds to ensure that the medication is well-mixed. Hold the inhaler with the mouthpiece facing downwards, and exhale deeply through the mouth to empty the lungs as much as possible. While inhaling deeply, press the top of the canister all the way down to release the medication. After inhaling, hold your breath for up to 10 seconds, or as long as you comfortably can, allowing the medication to settle in your lungs. Once you have held your breath,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document reviews it was found that the facilities' Quality Assessment Performance Improvement (QAPI) program was ineffective. Despite its purpose to proactively identify and prevent medication administration errors, it fell short. This was evident during a medication pass observation conducted during the survey, which revealed multiple medication errors related to eye drops (See F759). Findings: The hospital policy, Specific Medication Administration Procedures - Eyedrop Administration, Section 8.5, aims to ensure the safe and accurate administration of ophthalmic solutions by outlining specific steps, such as wearing gloves, creating a pouch with the lower eyelid, and carefully dispensing drops without touching the dropper to any surface. However, during an observation on 08/20/24, Licensed Vocational Nurse (LVN) 1 administered Systane eye drops to Resident 102 but allowed the dropper tip to touch the resident's eyelashes, which is a deviation from the recommended sterile technique. Systane is used to relieve dry, irritated eyes, and maintaining…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview and record review, the facility failed to provide two of three residents, Resident 177 and Resident 248, with SNF-ABN (Skilled Nursing Facility Advanced Beneficiary Notice). FINDINGS: Review of Resident 177, resident was admitted on [DATE] for Part A services, with diagnosis of Chronic Inflammatory Demyelinating Polyneuritis (a disease of the nervous system with progressive weakness and loss of sense and function of the legs and arms). SNF Beneficiary Protection Notification Review for Resident 177, indicated, Medicare Part A Skilled Services Episodes Start date:2/28/24. Last Covered day of Part A Service: 5/1/24. NOMNC was given 4/28/24. No issues. SNF ABN form not provided to resident. Per facility, CMS-10055 not needed, Resident 177 was placed on Part A for daily skilled PT,OT and ST. Resident 177 is still in the facility for custodial care. Review of Resident 248, resident was admitted on [DATE] for Part A services, with diagnosis of Ileus (a condition when the bowel does not work correctly).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 recognize and report an allegation of abuse for one out of six sampled residents (Resident 372) when Resident 372 reported to Social Worker (SW) 1 an allegation of verbal abuse by nursing staff and Physical Therapist (PT) 1, yet it was not reported to the facility administrator or other necessary agencies. This failure has the potential for allegations of abuse that may be substantiated to not be properly corrected and keep residents at risk for continued exposure to abuse. Findings: A review of facility policy and procedure (P & P), titled Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Resident Property, last revised August 2024, defined verbal abuse as the use of oral, written or gestured communication that willfully includes disparaging and derogatory terms to resident or their families . The P & P further indicated that reports of alleged abuse .are promptly and thoroughly investigated, and report all abuse allegations to the administrator/designee, California Department of Public Health, San…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 recognize and investigate an allegation of abuse for one out of six sampled residents (Resident 372) when Resident 372 reported to Social Worker (SW) 1 an allegation of verbal abuse by nursing staff and Physical Therapist (PT) 1, yet it was not thoroughly investigated by the facility. This failure has the potential for allegations of abuse that may be substantiated to not be properly corrected and keep residents at risk for continued exposure to abuse. Findings: A review of facility policy and procedure (P & P), titled Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Resident Property, last revised August 2024, defined verbal abuse as the use of oral, written or gestured communication that willfully includes disparaging and derogatory terms to resident or their families . The P & P further indicated that reports of alleged abuse .are promptly and thoroughly investigated, and report all abuse allegations to the administrator/designee, California Department of Public Health, San Francisco Police Department…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurately assess hearing for one out of two sampled residents (Resident 356) when Resident 356 was assessed as not having hearing aids when they used hearing aids on admission to the facility. This failure has the potential for Resident 356's needs to not be met due to their communication and hearing needs not being accurately assessed. Findings: A review of Resident 356's face sheet (summary of resident's demographic and admitting information), dated 08/27/24, indicated that Resident 356 was admitted in 2024 with diagnoses including DISPLACED FRACTURE OF MEDIAL CONDYLE OF RIGHT FEMUR . (a break in the right upper leg bone). A review of Resident 356's Minimum Data Set (MDS, a tool used to measure health status in nursing home residents) dated on 08/03/2024 indicated a Brief Interview for Mental Status (BIMS, a cognitive screening tool) score of 13 out of 15 (scores of 0-7 suggests severe cognitive impairment, 9 to 12 suggests 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.

Based on observation, interview and record review, the facility failed to develop and implement comprehensive care plans that included measurable objectives and specific interventions for 1 of 35 sampled residents (Resident 327) when: 1. Care plan was not developed to address urinary tract infection (UTI, a common infection that occurs when bacteria enter the urinary tract and cause inflammation). 2. Fall care plan interventions were not implemented. These failures had the potential for not meeting Resident 327's nursing needs and goals to attain the resident's highest practicable well-being. Findings: 1. Review of Resident 327's clinical record indicated, Resident 327 was admitted to the facility with diagnoses including dementia (memory loss), anxiety disorder (a condition that causes excessive fear, worry, and uneasiness that can interfere with daily life), and urinary tract infection (UTI). Review of Resident 327's Minimum Data Set (MDS, resident assessment tool) dated 4/17/24 indicated, . Cognitive Patterns (the mental processes that people use to perceive, interpret, 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 update care plans for three of 35 sampled residents (Resident 327, 187, and 264) when: 1. Fall care plan was not updated for Resident 187 after her falls on 2/15/24, 3/23/24, and 8/2/24. 2. Fall care plan was not updated for Resident 327 after her falls on 6/30/24, and 8/21/24. 3. Care plan for pain was not updated for Resident 264. These failures had the potential to put the residents at risk of not receiving appropriate cares. Findings: 1. Review of Resident 187's clinical record indicated, Resident 187 was admitted to the facility with diagnoses including dementia (memory loss), hypertension (high blood pressure), and atrial fibrillation (Afib, an irregular and often rapid heart rate that commonly causes poor blood flow and can increase the risk of stroke). Review of Resident 187's Minimum Data Set (MDS, resident assessment tool), dated 2/8/24 indicated, her memory was severely impaired. During an interview on 8/27/24 at 2:02 PM 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.

Based on observation, interview and record review, the facility failed to ensure that a resident's assistive hearing device was functioning in one of two sampled residents (Resident 356) when Resident 356 reported that their hearing aid had been broken for multiple days and clinical staff were not aware of it. This failure has the potential to result in the residents' needs not being met due to a reduction in their ability to hear and communicate. Findings: A review of Resident 356's Minimum Data Set (MDS, a tool used to measure health status in nursing home residents) dated on 08/03/2024 indicated a Brief Interview for Mental Status (BIMS, a cognitive screening tool) score of 13 out of 15 (scores of 0-7 suggests severe cognitive impairment, 9 to 12 suggests moderate cognitive impairment, and 13 to 15 suggests that cognition is intact). During a concurrent observation and interview on 08/21/24 at 2:27 PM with Resident 356 in their room, Resident 356 was observed pointing to their left ear. Resident 356 stated that she could best hear in her left ear because her right-sided hearing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safety to prevent fall related injuries to one of one sampled resident (Resident 250) when a volunteer transported Resident 250 using a wheelchair. The facility failure resulted to Resident 250 to sustain a laceration (a tear on the skin) to the forehead, a fracture (a break in the bone) on the second cervical (neck) spinal bone (C2 dens fracture), and a fracture along the ulnar base of the first proximal phalanx of the left hand (a finger on the left hand). Findings: Review of Resident 250's admission record indicated, was admitted on [DATE] with diagnoses including repeated falls, history of multiple fracture of the left ribs, fracture of the left clavicle (collarbone, bones that connects the arm to the body), and supranuclear opthalmoplegia (a medical condition that involves the gradual deterioration of the brain, loss of balance, slowing of movements, and cognitive [includes thinking, reasoning, and remembering] impairment).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 infection control program and practices designed to help prevent the development and transmission of diseases and infections when: 1. Certified Nursing Assistant (CNA) 1 did not perform hand hygiene between Resident 327 and Resident 289 in the dining room in G ([NAME] Building) 2. 2. The facility failed to maintain 6 out of 6 wash machines per manufacturer's recommendation. These failures had the potential for spread of infection to residents and staff. Findings: 1. During an observation on 8/21/24 at 1:58 PM in the dining room in G2, CNA 1 assisted Resident 327, then cleaned Resident 327's table with a towel. Then CNA 1 went directly to Resident 289's table, then assisted Resident 289 without performing hand hygiene. During an interview on 8/21/24 at 2:03 PM with CNA 1 in the dining room in G2, CNA 1 acknowledged he did not perform hand hygiene between Resident 327 and Resident 289 when asked. CNA 1 stated, Infection when asked…

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

The facility failed to maintain equipment in safe operating condition when reach-in refrigerator #7 had condensation inside the refrigerator that was dripping on food. This had the potential to contaminate food and cause food-borne illness to 332 out of 338 medically compromised residents who receive food from the kitchen. Findings: During the initial tour of the kitchen and concurrent interview with the Director of Dining Services (DDS) on August 20, 2024 at 3:14 pm, the reach-in refrigerator #7 on the dairy side of the kitchen had condensation dripping from the ceiling of the fridge onto food. The DDS stated that the hinge of the door needs to be realigned to prevent the condensation from forming. She stated the surveyor that observed earlier discovered it. During a review of the facility policy titled Safety and Equipment Maintenance, dated January 2024, indicated, proper maintenance of the physical plant and all equipment in the department is the responsibility of the Director in cooperation with the Maintenance department. During a review of the FDA Federal Food Code, 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 implement pressure ulcer care plan for one of 3 sampled residents (Resident 1) when Certified Nursing Assistant (CNA) 1 did not reposition Resident 1 every 2 hours on 5/1/24. This failure had the potential to delay the healing of the pressure ulcer for Resident 1. Findings: Review of Resident 1's clinical record indicated, Resident 1 was admitted to the facility with diagnoses including nephritis (inflammation of the kidneys), renal and perinephric abscess (a pocket of pus in the kidney and perinephric space, surrounding the kidneys), dementia (memory loss), and pressure ulcer (same as bedsore, an injury to the skin and the tissue below the skin that are due to pressure on the skin for a long time). Review of Resident 1's Minimum Data Set (MDS, resident assessment tool), dated 4/15/24 indicated, Resident 1 was cognitively moderately impaired. During an interview on 4/24/24 at 2:27 PM with Ombudsman (a person who assists residents in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of 3 Certified Nursing Assistants (CNA) 1 was competent when CNA 1 did not know Resident 1 had dementia and urinary tract infection (UTI, a collective term that describes any infection involving any part of the urinary tract, namely the kidneys, ureters, bladder and urethra). This failure had the potential to result in Resident 1 not receiving appropriate treatments and services. Findings: Review of Resident 1's clinical record indicated, Resident 1 was admitted to the facility with diagnoses including nephritis (inflammation of the kidneys), renal and perinephric abscess (a pocket of pus in the kidney and perinephric space, surrounding the kidneys), dementia (memory loss), and pressure ulcer (same as bedsore, an injury to the skin and the tissue below the skin that are due to pressure on the skin for a long time). Review of Resident 1's Minimum Data Set (MDS, resident assessment tool), dated 4/15/24 indicated, 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 to explain the skills and techniques when two out of 4 sampled certified nursing assistants (CNAs) did not know how to apply Purewick (a female external catheter designed to provide a non-invasive option for the management of urinary incontinence in women) to residents. This failure of not having competent skills and techniques puts all residents at risk for getting wet when using Purewick. Findings: Review of Resident 1' s clinical record indicated, Resident 1 was admitted on [DATE] with diagnoses including multiple sclerosis (long-lasting disease resulting nerve damage disrupts communication between the brain and the body), generalized muscle weakness, and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Review of Resident 1's Minimum Data Set (MDS, resident assessment tool), dated 10/9/23, indicated, 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 revise the constipation care plan for one of 4 sampled residents (Resident 2) when there was no evidence that the care plan (CP) was updated after [DATE] when Resident 2 returned from the hospital with constipation on CT (a noninvasive medical examination or procedure that uses specialized X-ray equipment to produce cross-sectional images of the body). This failure had the potential to put Resident 2 at risk of not receiving appropriate care timely. Findings: Review of Resident 2' s clinical record indicated, Resident 2 was admitted on [DATE] with diagnoses including malignant neoplasm of overlapping sites of brain (a cancer that overlaps contiguous sites of brain and whose point of origin cannot be determined), aftercare following surgery for neoplasm, dysphagia (difficulty swallowing), and limitation of activities due to disability. Review of Resident 2's Minimum Data Set (MDS, resident assessment tool), dated [DATE], indicated, Resident 2 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 promptly notify the physician of result that falls outside of clinical reference ranges for one of 4 sampled residents (Resident 2) when there was no evidence if the nurse notified the physician between 6/17/23 and 6/19/23 of the X-ray result, dated 6/16/23. This failure had the potential to delay appropriate care and treatment for Resident 2. Findings: Review of Resident 2' s clinical record indicated, Resident 2 was admitted on [DATE] with diagnoses including malignant neoplasm of overlapping sites of brain (a cancer that overlaps contiguous sites of brain and whose point of origin cannot be determined), aftercare following surgery for neoplasm, dysphagia (difficulty swallowing), and limitation of activities due to disability. Review of Resident 2's Minimum Data Set (MDS, resident assessment tool), dated 6/27/23, indicated, Resident 2 was cognitively severely impaired. Review of Resident 2's clinical document titled, Palliative Care (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 implement its care plan intervention of hourly rounding (checking in with a patient once every hour to proactively address needs) for one of four sampled Residents (Resident 2) after a substantiated claim of resident-to-resident abuse. This failure has the potential to result in Resident 2 ' s continued behavioral issues and puts Resident 2 and other residents at risk for abuse. Findings: A review of Resident 2 ' s face sheet (summary of resident ' s demographic and admitting information) provided on 9/27/23 at 5:49 PM indicated, Resident 2 was admitted on [DATE] with multiple diagnoses including vascular dementia (problems with reasoning, planning, judgment, memory, and thought process due to brain damage from damaged blood flow to the brain), severe with agitation .violent behavior and other symptoms and signs involving cognitive functions and awareness. A review of Resident 2 ' s Minimum Data Set (MDS, a tool used to measure health status in nursing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurately assess residents Morse Fall Assessment (an assessment to determine the likelihood of a resident falling and why. The assessment then categorizes the resident as a low, medium, or high fall risk), provide supervision according to facility policy, and when a high fall risk was identified the facility failed to update the care, and conduct an Interdisciplinary team for three out of 15 Residents reviewed (Residents 2,3,4). This failure resulted in 1. Resident 2 falling on 11/06/23 and sustaining a right hip fracture (broken bone) 2. Resident 3 obtaining a fall on 11/02/22 and being admitted to the intensive care unit in an acute hospital for monitoring for bleeding in the brain. 3. Resident 4 falling on 1/31/23 and sustaining a left hip fracture. Findings for Resident 2: Review of Resident 2 ' s Minimum Data Set (MDS, assessment tool for residents) dated 11/6/22 Resident 2 was admitted on [DATE], is cognitively independent (able to understand 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 facility failed to use interpreter services to communicate with Resident 1 regarding care, and failed to include Resident1 and their family in care planning, for one out of 14 Residents reviewed ( Resident 1). This failure resulted in Resident 1 being unable to communicate with staff and relaying her needs and concerns (i.e., when roommates tv is loud and she wants to rest), unable to express her want to go home and obtain rehab to get stronger, unable to ask for assistance for home health, and the resident and family unable to participate in care. This failure left Resident 1 feeling frustrated, helpless, alone, and feeling like she is unwanted and uncared for. Review of Resident 1 ' s MDS (Minimum Data Set, tool used for a comprehensive Resident assessment) dated 6/7/23 indicates Resident is alert, Spanish speaking only, and is admitted with diagnoses including end stage renal diseases requiring Hemodialysis, osteoarthritis, and chronic osteomyelitis. During an observation and interview on 7/6/23 at 10:00 am in Resident 1 ' s…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Interview and record review, the facility failed to assess Resident 1's wound condition for one of three residents reviewed. This failure had potential to result to Resident 1's delayed of wound healing. Findings: During review of Resident 1 ' s clinical record, Resident 1 was admitted on [DATE] with diagnoses included after care following surgery for neoplasm (abnormal growth of cells), oligodendroglioma (rare type of brain tumor), Pressure Ulcer (Bedsore). During Review of Resident 1 ' s clinical record, dated 6/24/23 titled Wound assessment weekly Pelvic 1. No assessment on slough % and Pain with treatment. No assessment when wound identified. During Review of Resident 1 ' s clinical record, dated 6/24/23 titled Wound assessment weekly Pelvic 2. No assessment on Pain with treatment. During Review of Resident 1 ' s clinical record, dated 7/14/23 titled Wound assessment weekly Pelvic 1. No assessment on when wound identified. During an interview with RN 1 on 8/25/23 at 10:10am, stated Blank on pain…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Certified Dietary Manager (CDM), the position responsible for supervision of daily foodservice operations, was fully qualified when he did not have six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming his full-time duty at the facility. This failure had the potential for inadequate supervision of the dietary department for 337 residents who ate food from the kitchen out of a census of 337. Findings: State of California Health and Safety Code 1265.4(b)(4) describes the required qualifications for the full-time Director of Food Services (DFS). The Statue indicates a DFS who is a graduate of a dietetic services training program approved by the Dietary Managers Association and is a certified dietary manager, must have received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that the resident or family group views were considered and acted upon grievances and recommendations, when not all residents were invited to have participated in resident council monthly meeting. This failure had the potential to result to ineffective residents' consensus-building. Findings: During resident council meeting on 6/21/23, at 2:15 pm, Resident 142 stated that the facility had not invited residents' representative for every unit in the facility to participate in the resident council meeting every month. During resident council meeting on 6/21/23 at 2:00 PM, four (Resident 54, 61, 119 and 164) of seven residents stated they were not aware how to file grievances and if they have a system in place to voice out their issues or concerns. During interview with Resident 164 on 6/21/23 at 2:15 pm, Resident 164 stated that she's not free to voice out concerns for the fear that how the staff will treat them differently. During interview with Resident 119 on 6/21/23 at 2:20 pm, Resident 119 stated that Resident 142…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and interview, the facility failed to ensure current survey results were readily available to residents for every unit for three of three observations of the facility survey report book, which had the potential to affect all residents in the facility. Findings: During tour of the four units (G4, G5 and K2) including the secured unit on 6/21/23 and 6/22/23 at 4:00 pm, an observation was made that survey results were not posted. There was no notice posted in the facility units regarding the availability and location of recent survey results. During the resident council meeting on 6/21/23 at 2:00 PM, seven of seven residents revealed they had no knowledge of the location of the survey results binder. They also stated they were not aware where they were located and had not seen any signage that directed residents to their location in which they don't have to ask. During interview with CNA 1 on 6/22/23 at 3:00 pm, regarding the location of the survey results, she stated I would assume they would be upfront. She stated if family asked for the results, she would locate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents were made aware and/or educated on how to voice grievances to either the facility or other agency that hears grievances without fear of discrimination or reprisal, and that prompt efforts were made to resolve grievances the resident may have. This failure had the potential to affect resident's right to voice their concerns and have any grievance be acknowledged and processed by the facility in a timely manner. Findings: During the resident council meeting on 6/21/23 at 2:00 PM, four of seven residents stated they're not aware how to file grievances to voice out their issues or concerns. They're not aware if they have a system in place. In an interview with Resident 164 stated that she's not free to voice out her concerns for the fear that how the staff will treat them differently. During interview with the DON on 6/21/23 at 2:30 pm, DON stated they have this so called Talk to Me system (application software- based). DON acknowledged that they have to educate the residents on how to utilize this to voice…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a review of records, it was found that the facility failed to maintain a medication error rate of less than 5%. During the medication pass, two medication errors were observed out of twenty-seven opportunities, resulting in an error rate of 7.41%. 1. A review on 6/21/23 of Resident 120's physician's orders indicated (Timolol maleate 0.5% eye gel forming solution, 1 drop both eyes ) Timolol is a medication used to treat glaucoma. Glaucoma is a condition when there is too much pressure in the eye. This pressure can be bad for your eyes because it can damage the delicate parts inside. During an observation on 6/21/23 at 7:52 am, LVN 1 was observed administering Timolol solution to Resident 120. It was noted that the resident's left eye was closed when the eyedrop was instilled. Resident 120 did not receive the Timolol eye drop in her left eye. During an interview with LVN 1 on 6/21/23 at 10:25 am, it was revealed that the LVN 1 administered the Timolol eye drop medication to the resident's right eye but not the left eye. LVN 1 stated that the…

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

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were met for food storage when: 1.There was an undated blueberry sauce container in the refrigerator in the kitchen. 2.There was an expired crushed red pepper container in the kitchen. 3.There were undated individual condiments (such as Smucker's Strawberry Jam, Smucker's Sugar Free Blackberry Jam, Smucker's Pure Honey, Smucker's Sugar Free Breakfast Syrup and Jif Creamy Peanut Butter) in the original undated bottom of cardboard box containers in the storage room in the kitchen. These failures had the potential to put residents at risk for foodborne illnesses. Findings: 1. During a concurrent observation and interview on 6/20/23 at 9:50 AM with the Director of food services (DFS), Clinical Nutrition Manager (CNM), and Executive Chef (EC) in the kitchen, there was an undated red colored top of blueberry sauce container in the refrigerator. The EC stated, No when asked if she could see the date on it. She also stated, They should've used open date and used date when asked…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain effective infection prevention and control program when: 1.Nasal cannulas (a device used to deliver supplemental oxygen) were not covered and had no information on replacement or discard dates for 6 residents (Resident A, Resident B, Resident C, Resident 10, Resident 44, and Resident 210). 2.Extended use of N-95 respirators and face shields were stored in the same paper bags. 3.Trash containers in the clean and dirty areas of the laundry department had no lid covers. 4.There was no evidence of preventive maintenance for washers, dryers and [NAME] used in the laundry department. 5. Nebulizer masks were not covered and labed for Residents 44 and 19. These failures had the potential to result to spread infections among staff, residents, and visitors. Findings: 1. During an initial tour of the resident rooms on 6/20/23 that began at 9:31 AM, with the Unit Nurse Manager (UNM) 1 present, the UNM 1 confirmed the following: a) The nasal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (Resident 334) of three residents reviewed for personal inventory form was completed and signed. This failure had the potiental to result in theft or loss of resident's personal effects. Findings: During review of Resident 334's addmission/discharge personal effects dated 05/10/2023 indicated there was no recording of personal effects or signatures of charge nurse and reponsible party. During interview with unit nurse manager (UNM 1) on 6/27/23 at 9:30am, UNM 1 stated that charge nurses were responsible for intake paperwork including admission/discharge personal effects. The facility policy and procedure titled Inventory of Belongings/Valuables dated 7/2023, indicated Upon admission, an itemized three-part Inventory Form will be completed by appropriate staff in the resident's/patient's/representative's presence to account for belongings brought into the facility. The resident/patient or their representative will receive a copy of this form upon admission to the Unit. Upon discharge from the Unit/facility, 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 did not develop and implement a comprehensive, person-centered care plan for Resident 189's use of Olanzapine (an antipsychotic medication) when the care plan did not indicate target behavior/s and known or common side effect/s for which the medication was used for. This failure had the potential to not ensure the medical, nursing, mental and psychosocial needs are identified, addressed, and/or met by the resident, and monitored by staff. Findings: Resident 189 was admitted to the facility with diagnoses that included left hip fracture, heart failure, depression, and mild dementia (loss of mental functions that interferes daily life and activities). Review of Resident 189's physician orders indicated the following: Olanzapine 5 mg [milligram] tablet . Order Date: 6/9/2023 Diagnoses: DIAGNOSIS EXEMPT Frequency (Scheduled): One Time Daily (Starting 6/10/2023 1900 [7 pm]) Notes: [blank] Instructions: [blank] . Review of Resident 189's care plan, dated 5/31/23, indicated the following: Problems - Antipsychotic Use - [resident name…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents were free of accident hazards when one (Resident 245) of three residents' electrical appliances were not approved by underwriters laboratories (UL, accepted certification mark for safety standards). Findings: During observation on 6/20/23 at 10:22 am, Resident 245 had the following appliances were found in his room with no UL mark sticker: small air purifier, laptop, mini-ref held on top of box with duct tape, electric kettle, and pot. During interview with UNM 4 on 6/23/23 at 9:10 am, UNM 4 stated that it has been long while since the appliances were there in his room. During interview with maintenance supervisor (MS) on 6/23/23 at 10:00 am, he acknowledged the elecrical appliances had no UL stickers and stated that those should be checked by the facility IDT before taking in the residents' room, to ensure that it's UL approved. The facility's policy and procedure titled Electrical Appliances revised date 12/2000, indicated Only authorized electrical appliances will be permitted and approved…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medically-related social services was provided to Resident 42. This failure had the potential to not ensure appropriate social services were provided to help attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Findings: Resident 42 was admitted to the facility with diagnoses that included heart failure (a condition wherein the heart cannot pump enough blood as it should), hypertension (high blood pressure), diabetes (abnormal blood sugar levels) and history of right below knee amputation. During a concurrent interview and record review of Resident 42's medical records on 6/23/23 at 11:47 AM, with the Social Worker (SW) 1, SW 1 stated Resident 42 was admitted to the facility on [DATE] and that the resident was his own decision maker. When asked, SW 1 stated, she did not see any record that the social worker had visited the resident since admission into the facility. SW 1 said, I can't tell why…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and review of records, it has been determined that the facility did not ensure the accurate administration of all drugs and biologicals for one of three residents under review. Specifically, during the administration of an insulin injection to Resident 201, it was observed that the injection was administered on the same site, which could have potentially led to adverse medication consequences. Findings: A review on 6/21/23 of the Insulin Lispro and Insulin Glargine Manufacturer's insert it is advised to rotate the injection site with each administration to minimize the potential for adverse reactions such as pits/lumps or thickened skin. Insulin Lispro may be injected in the stomach area, thigh, buttocks, or back of the upper arm. A review on 6/21/23 of the facility's policy and procedure on Section 8.14 Injectable Medication Administration, it is indicated that the administration of injectable medications should be thoroughly documented, including the specific site used and any unusual reactions observed. Furthermore, in the case of any reactions, it 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.

Based on interviews and record reviews, it has been determined that the facility's pharmacist neglected to report medication irregularities concerning two residents (201 and 39). This failure had the potential to lead to undetected medication irregularities. Findings: Upon reviewing the facility's policy on Medication Regimen Review (MRR), it was found that the clinical pharmacist is responsible for conducting a comprehensive review of each resident's medical record at least monthly. The goal of the MRR is to promote positive outcomes, minimize adverse consequences, and identify and report medication errors or irregularities. Any irregularities, findings, and recommendations are reported to the Director of Nursing, attending Physician, and Medical Director. During a review on 6/21/23 of Resident 39's medication administration record (MAR) dated 6/2023, it was noted that there was no documentation of the insulin injection site after the medication was administered by licensed nurses. During an interview with LVN 1 on 6/21/23, LVN 1 stated she had administered both Insulin Lantus 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 ensure one (Resident 72) of three residents reviewed remained free from unnecessary medications when Resident 72 did not have specific behavioral monitoring for the use of zyprexa (antipsychotic, to reduce psychosis-related symptoms). This failure had the potential to result to medication adverse effects. Findings: Review of Resident 72's clinical record, Resident 72 was admitted on [DATE], with diagnoses included Alzheimer's (memory loss), chronic obstructive pulmonary disease (COPD, group of lung diseases that block airflow and make it difficult to breathe) and presence of cardiac pacemaker (medical device implanted to help heart beat at a normal rate and rhythm). Review of Resident 72's physician's order dated 6/15/23, indicated zyprexa 2.5 mg tab (1/2 tab = 1.25 mg) BID oral - gradual dose reduction. Review of Resident 72's behavioral monitoring record and care plan dated 6/2023 did not indicate specific behavior for the use of zyprexa. During…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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: 1.There was a specific condition, diagnosis, and/or indication for use for Resident 189's Olanzapine (an anti-psychotic medication) medication. 2.There was monitoring of targeted behaviors for Resident 189's Olanzapine medication. These failures could result in unnecessary use of, ineffective and/or lack of monitoring for an anti-psychotic medication that could negatively affect the resident's highest practicable mental, physical and psychosocial well-being. Findings: Resident 189 was admitted to the facility with diagnoses that included left hip fracture, heart failure, depression, and mild dementia (loss of mental functions that interferes daily life and activities). Review of Resident 189's physician orders indicated the following: Olanzapine 5 mg [milligram] tablet . Order Date: 6/9/2023 Diagnoses: DIAGNOSIS EXEMPT Frequency (Scheduled): One Time Daily (Starting 6/10/2023 1900 [7 pm]) Notes: [blank] Instructions: [blank] . Review of Resident 189's Medication Records (MR), for June 2023, indicated the resident…

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

Based on observation, interview, and record review, the facility failed to ensure proper disposal of garbage when there were no lids on two out of nine garbage containers in the loading dock. This failure had the potential to result to spread of infections among residents in the facility. Findings: During an observation on 6/21/23 at 10:10 AM in the loading dock of the facility, there were no lids on two out of nine garbage containers. One black colored garbage container was open without a lid and another black colored garbage container was overflown with garbage without the lid. During an interview on 6/21/23 at 10:15 AM with EVS Manager (EM, environmental services manager)/Facility Operations, in the loading dock, EM verified they were garbage containers. EM stated, There are no lids. They are broken. Review of the facility's policy and procedure titled, Section: Sanitation and Infection Prevention/Control Subject: Solid Waste Disposal revised in January 2023 indicated, . Garbage containers are clean . and covered at all times . Review of the facility's policy and procedure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical records were maintained for one of three residents reviewed, when there was no informed consent for Resident 189 completed for use of olanzapine (an antipsychotic medication.) This failure had the potential to not provide sufficient information that reflected the residents' condition, care and services provided, and to not ensure information is available to staff and/or other individuals who may use and/or need it to facilitate communication. Findings: Resident 189 was admitted to the facility with diagnoses that included left hip fracture, heart failure, depression, and mild dementia (loss of mental functions that interferes daily life and activities). Review of Resident 189's physician orders indicated the following: Olanzapine 5 mg [milligram] tablet . Order Date: 6/9/2023 Diagnoses: DIAGNOSIS EXEMPT Frequency (Scheduled): One Time Daily (Starting 6/10/2023 1900 [7 pm]) Notes: [blank] Instructions: [blank] . Review of Resident 189's medication records (MR), for June 2023, indicated the resident was given…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policies and procedures were followed for pneumococcal vaccination when medical records for one of five sampled residents (Resident 271) did not have documentation that the resident received pneumococcal immunization. This failure did not ensure the risk for acquiring, transmitting, or experiencing complications from pneumococcal disease was minimized for Resident 271. Findings: During a review on 6/27/23 at 9:10 AM, Resident 271's Immunization Consent, for pneumococcal immunization vaccine was reviewed. Resident 271's consent was marked yes, and the consent was dated and signed on 11/4/22. During a review of a facility document on 6/27/23, titled, Immunization Report, the report indicated names of residents who received pneumococcal vaccine, including the administration date. The report did not include the name and date of vaccine administration for Resident 271. During an interview on 6/27/23 at 12:01 PM, with the Infection Preventionist (IP), IP was unable to provide information when Resident 271 received 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.