San Marino Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a safe, clean, comfortable, and home like environment for two (2) of five sampled residents (Resident 8 and 20) under environment care area, when the facility failed to ensure air vents ( openings in buildings for air passage, essential for ventilation, air circulation, and maintaining indoor air quality) inside the resident's rooms were free from dust particles. This deficient practice had the potential for the residents to feel discomfort and suffer from respiratory problems which could negatively affect the residents' well-being and quality of life. Findings:1. During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was admitted to the facility on [DATE], Resident 8's diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral vascular accident (CVA, or stroke is an interruption in the flow of blood to cells in 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 notify the medical doctor (MD) of changes with the residents' condition for two (2) of 22 sampled residents (Residents 57 and 20) as indicated in the facility's policy and procedures (P&P):Resident 57's refusal of medications and meals from 11/5/2025 to 11/10/2025.Resident 20's new complaint of itching on bilateral hands and feet on 1/6/2026.These failures resulted in delayed treatments and interventions for Residents 20 and 57 with the potential for inadequate care, services and a preventable decline in Resident 20's and 57's mental, physical and psychosocial well-being.Findings:1. During a review of Resident 57's admission Record, the admission Record indicated Resident 57 was admitted to the facility on [DATE] with diagnoses that included adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity), major depressive disorder (a mood disorder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one (1) of three (3) sampled residents (Resident 39) under activities of daily living care area was provided a communication board (pre-printed board that has pictures, numbers, and user defined images that allows a resident to point or indicate on the board what he/she wants communicated) with the language that the resident was able to understand and speak (primary language) in accordance with the facility policy and procedure. This deficient practice prevented Resident 39 from communicating with the staff and had the potential to delay receiving appropriate care/treatment that the resident needed.Based on observation, interview, and record review, the facility failed to ensure resident with language barrier was provided a communication board (pre-printed board that has pictures, numbers, and user defined images that allows a resident to point or indicate on the board what he/she wants communicated) with the language 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide appropriate discharge planning (the process of preparing a resident to safely transition from a hospital or care facility to the next level of care) as indicated in the Director of Social Services job duties and the resident's care plan (a document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) for one (1) of 1 sampled resident (Resident 45) from the discharge care area. This failure resulted in a delay in discharge planning for Resident 45, with the potential for a delayed discharge from the facility.Findings:During a review of Resident 45's admission Record, the admission Record indicated Resident 45 was admitted to the facility on [DATE] with diagnoses that included (difficulty swallowing), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and schizoaffective disorder (a mental illness that can affect thoughts, mood, 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 that an alternative meal was offered and provided to one (1) of 1 sampled resident (Resident 45) from the choices care area, after his lunch meal was refused, as indicated in facility policy. This failure resulted in Resident 45 having preventable hunger with the potential risks for decreased feelings of well-being and/or malnourished (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat).Findings:During a review of Resident 45's admission Record, the admission Record indicated Resident 45 was admitted to the facility on [DATE] with diagnoses that included (difficulty swallowing), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 45's Order Summary Report…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) for two of five sampled residents (Residents 21 and 2) from the infection control care area were followed in accordance with the facility's policy and procedure when: 1. a. Certified Nurse Assistant 1 (CNA 1) and CNA 8 failed to wear proper Personal Protective Equipment (PPE, is specialized clothing or equipment worn by an employee for protection against infectious materials, such as gowns, gloves, masks, and goggles) for Enhanced Barrier Precautions (EBP, refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) room while repositioning Resident 21 and CNA 1 did not perform hand hygiene after removing CNA 1's gloves. b. Licensed Vocational…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect one of two residents (Resident 1) from physical abuse (intentional bodily injury such as pinching, slapping and hitting) when Resident 2 hit, slapped, and scratched Resident 1 on 7/1/2025 in accordance with the facility's policy and procedure (P&P) titled, Abuse Prevention Program,. This deficient practice resulted in, abrasions (wound where skin rubs off due to friction) on Resident 1's left face, left upper cheek and left side of the forehead; abrasion on the middle left outer forearm; bruising on the distal (location on the body farther away from the center of the body) left outer wrist; and an abrasion on the right Achilles (back of the lower leg connecting the calf muscles to the heel bone) and placed the resident at risk for psychosocial (combined influence of psychological factors and the surrounding social environment on physical, emotional, and/or mental wellness) harm. Findings: 1. During a review of Resident 1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent a sexual abuse (when someone touches another person in a sexual manner, unwanted touching of a sexual nature, or makes that person take part in sexual activity with them without consent) for one of two sampled residents (Resident 1) when Resident 2 touched Resident 1's buttocks and exposed Resident 2's private parts in front of Resident 1 on 4/12/2025 at around 6:50 AM. This deficient practice violated Resident 1's rights to befree from abuse and has the potential to have negative psychosocial (the combined influence of thoughts, feelings, behaviors, relationships and environment on a person's wellbeing and how they function) outcomes to the resident. Findings: During a review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that included injury of unspecified body region (means that there is an injury, but the exact area of the body affected is not identified ) open wound right…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review, the facility failed to report a sexual abuse (when someone touches another person in a sexual manner, unwanted touching of a sexual nature, or makes that person take part in sexual activity with them without consent)for one of two sampled residents (Resident 1) to the State Survey Agency (SSA), the Ombudsman (advocates for residents of nursing homes, board and care homes and assisted living facilities), and local law enforcement (Local PD) within two (2) hours from when Certified Nurse Assistant (CNA) 1 witnessed Reisdent 2 inappropriately touched Resident 1 buttocks and when Resident 2 exposed his private area in front of Resident 1 and CNA 1 on 4/12/2025 at 6:50 AM. This deficient practice had the potential to place Resident 1 and other residents for further abuse. Findings: During a review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that included injury of unspecified body region (means that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (1) of two (2) sampled residents (Resident 1) privacy was protected while Resident 1 was using the restroom/bathroom on 2/28/2025 in accordance with the facility's policy titled, Resident Rights. This deficient practice violated Resident 1's rights to privacy and has the potential to have negative psychosocial (the combined influence of thoughts, feelings, behaviors, relationships and environment on a person's wellbeing and how they function) outcomes to the resident. Findings: During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses of schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) bipolar type (mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 2/10/2025, the 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 observation, interview, and record review, the facility failed to ensure one (1) of two (2) sampled residents (Resident 1) was free from an unnecessary psychotropic drug (any medication capable of affecting the mind, emotions, and behavior) in accordance with the facility policy and procedure (P&P) titled Psychotropic Medication Use, by failing to ensure: A. Resident 1 have indication for a specific target behavior such as sudden striking or hitting another resident in the physician's order dated 2/17/2025 for the use of Risperdal (medication to treat certain mental/mood disorders). B. Resident 1 have an order to monitor and / or record occurrence of target behavior such as sudden striking for the use of Risperdal. C. Resident 1 have an order to monitor and document/report any adverse (harmful) reactions to Risperdal. These deficient practices had the potential to place Resident 1 at risk for significant adverse (harmful) consequences from the use of unnecessary psychotropic drug, which could result to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), wore the [NAME] brace (a brace used to stabilize and treat broken bones in the upper arm) as ordered by the physician and indicated in Resident 1 ' s care plan. This failure placed Resident 1 at risk for delayed healing and/or worsening of the right humerus fracture (a break in the upper arm bone on the right side of the body) and a decline in right arm range of motion (ROM, the full movement potential of a joint, usually its range of flexion and extension). Findings: During a review of Resident 1 ' s admission Record, the admission indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included a displaced fracture (two or more portions of broken bone come out of proper alignment) of shaft of humerus (upper arm bone) on the right arm, pathological fracture (a break in an area of bone that has been weakened by an underlying disease) of the right humerus 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 resident with Language barrier was provided a communication board (pre-printed board that has pictures, numbers, and user defined images that allows a resident to point or indicate on the board what he/she wants communicated) with the language that the resident was able to understand for two of three sample residents (Resident 24 and 28) in accordance with the facility policy and procedure. This deficient practice prevented the residents from communicating with the staff and had a potential to delay receiving appropriate care/treatment the residents needed. Findings: 1. During a review of Resident 24's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD-a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it harder to 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 record review, the facility failed to ensure the storage, preparation and distribution of food was done under sanitary conditions (clean and healthy) in accordance with the facility policy by failing to ensure : 1. Food items inside kitchen produce refrigerator and dry storage (a method of conserving temperature and humidity without the need for refrigeration) were labeled with a received date and/ or expiration date, and expired food items were discarded and not mixed with other non-expired foods. 2. Chlorine Test Paper strips (to measure the concentration of free available chlorine in sanitizing solutions [diluted mixture of chemical agent, most commonly a bleach solution, used to kill bacteria on surfaces like countertops, cutting boards, utensils after they have been cleaned, effectively reducing the number of germs to a safe level]) were not expired to make sure the dishwasher was sanitized (made clean, hygienic, disinfected) properly. These deficient practices had the potential to result in pathogen (germ) exposure to 57 of 57 residents 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 provide care in a manner that maintained or enhanced a resident's dignity and respect for two (2) of 15 sampled residents (Resident 37 and 42) by failing to ensure facility staff did not stand over and above resident's eye level while assisting the resident during meal. This deficient practice had the potential to affect Resident 37 and 42's self-esteem and self-worth. Findings: 1. During a review of Resident 37's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included generalized muscle weakness and polyneuropathy (conditions affecting nerve function in various parts of the body, leading to symptoms such as weakness, numbness, and burning pain). During a review of Resident 37's Minimum Data Set (MDS, a federally mandated assessment tool), dated 10/7/2024, the MDS indicated Resident 37 had moderate impairment in cognitive (mental action or process of acquiring…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 licensed staff failed to obtain an informed consent (a process in which a resident and his/her medical provider communicate about medical procedure or treatment, including its possible risks and benefits, and the resident agrees to it) from the resident's responsible party before administering Quetiapine Fumarate (an antipsychotic medication, a drug used to treat serious mental health conditions), for one (1) of 15 sampled residents (Resident 19) in accordance with the facility policy. This deficient practice violated the resident's right to be fully informed and consent to receive psychoactive medications. Findings: During a review of Resident 19's admission Record, the admission Record indicated the facility admitted Resident 19 on 9/18/2024 and was readmitted on [DATE] with diagnoses which included schizophrenia (a serious mental health condition that affects how people think, feel, and behave), anxiety (a feeling of fear, dread, 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 provide reasonable accommodation to meet the resident's needs for three (3) of 15 sampled residents (Residents 37, 45, and 208) in accordance with the facility policy when: 1. Resident 37 with limited range of motion (ROM, extent of movement of a joint) of bilateral hands was not provided with an appropriate call device (a device used by residents to call staff). 2. and 3. Resident 45 and 208's call lights was observed not within arm's reach. These failures had the potential to result in a delay in or in an inability for Residents 37, 45, and 208 to obtain necessary care and services especially during an emergency, which could result in injury and harm. Findings: 1. During a review of Resident 37's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included generalized muscle weakness and polyneuropathy (conditions affecting nerve function in various parts of the body,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow its Advance Directive (a written instruction, such as a living will or durable power of attorney for health care, recognized under State law relating to the provision of health care when the resident is incapacitated [clinical state in which a resident is unable to participate in a meaningful way in medical decisions]) policy for one (1) of four (4) sampled residents (Resident 208) by failing to inform and provide the resident a written information on the option to formulate an advance directive. This deficient practice had the potential for Residents 208 to not be informed of his right to formulate an advance directive and for the staff not to carry out the resident's wishes regarding health care decisions during an emergency. Findings: During a review of Resident 208's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] and was with diagnoses that included muscle wasting and atrophy (loss of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, clean, and homelike environment for two (2) of six (6) sampled residents (Residents 45 and 208) as indicated on the facility's policy when: 1. Residents 45's overhead lights in the resident's room did not have a bulb. 2. Resident 208's wheelchair had multiple holes and ripped edges on its seat. Resident 208's overhead lights in Residnet 28's room did not have a cord to turn the lights on and off. These deficient practices have the potential to negatively affect Resident 45 and 208's safety and quality of life. Findings: 1. During a review of Resident 45's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included muscle wasting and atrophy (loss of muscle tissue) and metabolic encephalopathy (metabolic encephalopathy (a chemical imbalance of the blood in the brain). During a review of Resident 45's Minimum Data Set (MDS, a federally mandated assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living (ADL) receives services to maintain good hygiene/ grooming for one (1) of two (2) sampled residents (Resident 8) by failing to clip Resident 8's long and dirty fingernails. This deficient practice resulted in Resident 8 not receiving fingernail care and had the potential to negatively impact Resident 8's self-esteem. Findings: During a review of Resident 8's admission Record, the admission Record indicated the facility admitted Resident 8 on 6/23/2014 with diagnoses which included depressive disorder (a common mental disorder. It involves a depressed mood or loss of pleasure or interest in activities for long periods of time), presbyopia (the gradual loss of your eyes' ability to focus on nearby objects), anxiety (a feeling of fear, dread, and uneasiness). During a review of Resident 8's H&P, dated 6/27/2024, the H&P indicated Resident 8 have the capacity to understand…

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

Based on observation, interview, and record review, the facility did not maintain an accident-free environment for one of 15 sampled resident (Resident 8) by failing to ensure there were no open A&D ointment (medication used as a moisturizer to treat or prevent dry, rough, scaly, itchy skin and minor skin irritations ,such as diaper rash, skin burns from radiation therapy) at Resident 8's bed side table. This failure had the potential to cause injury and harm in the event the medication was ingested by residemts here in La Union. Findings: During a review of Resident 8's admission Record, the admission Record indicated the facility admitted Resident 8 on 6/23/2014 with diagnoses which included depressive disorder (a common mental disorder. It involves a depressed mood or loss of pleasure or interest in activities for long periods of time), Presbyopia (the gradual loss of your eyes' ability to focus on nearby objects), anxiety (a feeling of fear, dread, and uneasiness). During a review of Resident 8's History and Physical Examination (H&P), dated 6/27/2024, the H&P indicated 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 interview and record review, the facility failed to maintain facility staff documentation of the current Coronavirus disease 2019 (COVID-19, a disease caused by a virus named SARS-CoV-2 which stands for severe acute respiratory syndrome coronavirus 2) vaccination status for four (4) of 73 facility staff as indicated in the facility's policy. This deficient practice had the potential to not accurately reflect which facility staff were at risk from contracting the COVID-19 disease which could potentially spread to other staff and the residents. Findings: During a concurrent interview and record review on 11/13/2024 at 3:50PM, the Infection Prevention Nurse (IPN) confirmed the Employee COVID-19 Vaccination log was not updated to reflect the 4 staff vaccinated with the current COVID-19 vaccine. The IPN stated the 4 staff vaccinated with the current COVID vaccine included herself, the Director of Staff Development (DSD), the Dietician and one of the Activity Assistant. The IPN also stated the Employee COVID-19 Vaccination log did not have an accurate list of staff that received…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 fall care plan (a document that outlines the facility ' s plan to provide personalized care to a resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs) for one (1) of three (3) sampled residents (Resident 1), included resident-centered interventions (programs or activities that are designed to address the specific needs of the resident to ensure their well-being) per facility policy. This deficient practice resulted in Resident 1 not having resident-centered fall prevention interventions, with the risk for potential falls with injury. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included lack of coordination, muscle wasting (weakening, shrinking, and loss of muscle) and atrophy (deterioration of a part of the body), generalized muscle weakness…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Cross reference with F610 Based on interview and record review the facility failed to report to the state agency (CDPH, California Department of Public Health), the state ombudsman (advocates for residents of nursing homes, board and care homes and assisted living facilities), and local law enforcement of an allegation of physical abuse (intentional bodily injury) for one of two sampled residents (Resident 1). This failure had the potential to place Resident 1 and other residents at risk for physical abuse, which could result to harm/injury. Findings: During a review of Resident 1's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of encephalopathy (any disease, damage, or disorder that affects the brain structure or function) and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out daily tasks). During a review of Resident 1's History and Physical Examination…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policy for abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) for one (1) of two (2) sampled residents (Resident 1) by failing to: 1. Conduct a thorough investigation of an allegation of physical abuse (intentional bodily injury) reported by Resident 1's family representative (FR) on 8/22/24. 2. Provide a written report to the State Survey Agency of the findings of the physical abuse allegation investigation within five (5) working days of the incident. This failure had the potential to place Resident 1 and other residents at risk for physical abuse, which could result to harm/injury. Findings: During a review of Resident 1's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of encephalopathy (any disease, damage, or disorder that affects the brain structure or function)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 supervise and ensure the safety of one (1) of two (2) sampled residents (Resident 1) in accordance with the facility's policy and procedure when Resident 1 left the facility through his window. This failure resulted in Resident 1 eloping (leaving the facility without the staff's knowledge and/or supervision) on 7/23/24 and is not found as of 7/31/24. Findings: 1. During a review of Resident 1's admission Record, admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of encephalopathy (any damage, disease, or disorder that affects the structure or function of the brain) and schizoaffective disorder (mental illness that occurs when someone experiences both schizophrenia and a mood disorder [a mental health condition that affects a person's emotional state or mood] at the same time), bipolar type (a serious mental illness that causes unusual shifts in mood ranging from extreme highs [mania] to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe environment to prevent accidents for one of two sampled residents (Resident 1) by: 1. Facility failed to provide supervision to Resident 1 who was identified by the facility as a low risk for elopement (to leave a secured institution without notice or permission) when the facility exit doors were not supervised and the gate was left open on 4/26/2024. This deficient practice resulted to Resident 1 eloped on 4/26/2024 at 1:48 PM which can result to serious injury, harm, and/ or death. 2. Facility failed to ensure one of four staff (Certified Nursing Assistant 3 - CNA 3) had the competency necessary to care for residents when fire alarm is on. This deficient practice placed Resident 1 and other residents in the facility at risk for elopement. 3. Findings: 1. A review of Resident 1's admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of dementia…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Amended: Based on observation, interview, and record review, the facility failed to ensure the gastrostomy tube (GT, small plastic tube inserted through the skin into the stomach to bring nutrition directly to stomach) feeding tube for two (2) of three (3) sampled residents (Residents 36 and 24) was capped with a protective covering when it was disconnected from the resident, as indicated in the facility policy. This deficient practice had the potential to place Residents 36 and 24 at risk for infection control, which could result to resident harm. Findings: 1. A review of Resident 36's Face Sheet indicated Resident 36 was admitted on [DATE] with diagnosis that included chronic viral hepatitis C (a liver disease that you get from someone else's infected body fluids, such as blood or semen), human immunodeficiency virus disease (HIV disease that destroys certain white blood cells, which can greatly weaken the immune system), and dysphagia (trouble swallowing) following cerebral infarction (Interruption of blood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 use the correct measuring scooper (a food serving utensil used to measure even portions) for the servings of pureed fruit given to nine (9) of 9 sampled residents (Residents 1, 12, 13, 20, 21, 25, 29, 36 and 42) in accordance with the facility's Measurement Chart. This failure had the potential to result in Residents 1, 12, 13, 20, 21, 25, 29, 36 and 42, not meeting their daily nutritional dietary needs. Findings: During an observation on 12/12/2023 at 6:53 AM in the kitchen, the Dietary Aide (DA) used the #8 measuring scooper (a cooking utensil that measures one half of a cup portions) to serve pureed fruit into bowls and then placed bowls onto the trays of Residents 1, 12, 13, 20, 21, 24, 25, 29, 36 and 42. During a concurrent interview and record review on 12/12/2023 at 8:05 AM with the DA, the Winter Menus, dated 12/12/23 were reviewed. The DA stated the menu indicated for the use of a #12 scooper for pureed fruit cup servings. The DA stated she should have used a #12 scooper instead of the #8 scooper for…

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

Based on observation, interview, and record review, the facility failed to ensure proper sanitation and food handling practices were followed, in accordance with the facility's policies and procedures for 55 of 55 residents in the facility by ensuring: 1. The can opener and blender base was kept clean. The can opener was observed with sticky gunk (material that is dirty, sticky, or greasy) and food residue. The blender base was observed with dirt build ups and blender metal part was falling off. 2. The kitchen knives were maintained in good repair and kept clean. The kitchen knives were observed with the handles worn out and with blackish gray discoloration. 3. The parsley flakes and italian seasoning containers were properly sealed, and flour container was covered. 4. The package of Muse Enhanced Tea was properly labeled. 5. Hand washing was performed by facility staff during an observation of the facility's tray line (a system of food preparation, used in hospitals/ facility, in which trays move along an assembly line) on 12/12/23. 6. The lasagna pasta was stored and sealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop a resident centered care plan (document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) for one of 14 sampled residents (Resident 8), when a sore (an injury that involves a break in the skin) developed on Resident 8's bottom lip. This failure had the potential for Resident 8 not to receive individualized care plan interventions, which could result in a lack or delay of treatment and worsening of Resident 8's bottom lip sore. Findings During a review of Resident 8's Face Sheet, the face sheet indicated Resident 8 was readmitted to the facility on [DATE] with current diagnoses including chronic obstructive pulmonary disease (COPD- a lung disease characterized by long-term poor airflow), dementia (a condition characterized by progressive or persistent loss of intellectual functioning), cerebrovascular disease (a group of conditions that affect blood flow and blood vessels 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 the wheelchair, occupied by a resident, was in the locked position for one of three residents (Resident 21) as indicated on the facility policy. This failure has the potential to result in Resident 21 falling and being injured. Findings: During a review of Resident 21's Face Sheet, the face sheet indicated resident was readmitted to the facility on [DATE] with diagnoses including epilepsy (a chronic disorder of the brain with recurrent brief episodes of involuntary movement that may involve a part of the body or the entire body, sometimes accompanied by loss of consciousness), dementia (a condition characterized by progressive or persistent loss of intellectual functioning), lack of coordination, ataxic gait (a loss of the ability to coordinate movements required for normal walking), and generalized muscle weakness (lack of muscle strength requiring extra effort to move) and senile degeneration (a decline that decrease in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide oxygen therapy (treatment that provides supplemental, or extra oxygen) and necessary respiratory care services for one (1) of 1 sampled resident (Resident 27) in accordance with the facility's policy and care plan when Resident 27 did not have a physician's order to receive oxygen at five (5) liters per minute (lpm, unit of measurement) via nasal cannula (device used to deliver supplemental oxygen placed directly on a resident's nostrils). This deficient practice had the potential to result in respiratory distress and/or other complications for Resident 27. Findings: A review of Resident 27's Face Sheet indicated the resident was admitted to the facility on [DATE] and re-admitted [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs), hypoxia (lack of oxygen in the body tissues), and asthma (a condition in which your…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe and functional sink in one (1) of three (3) residents shower rooms (Shower Room A) when Shower Room A's sink was observed to have sharp wood edges and metal screws sticking out. This deficient practice had the potential for residents to be placed at risk for injury. Findings: During a concurrent observation in the resident's shower room (Shower Room A) and interview with the Certified Nursing Assistant 2 (CNA 2) on 12/11/2023 at 9:45 AM, CNA 2 verified Shower Room A's sink was observed to have sharp wood edges and metal screws sticking out. CNA 2 also stated the sticking sharp wood edges and metal screw can cause injury like abrasion, cuts or splinter to residents. During concurrent observation and interview with the Maintenance Supervisor (MTS) on 12/12/2023 at 10:19 AM, MTS stated the Shower Room A's sink was broken since last weekend, 12/9/23. MTS further stated, The sink's sharp edges in Shower Room A were dangerous because these can cause accident. MTS stated Shower Room A was not safe for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy to develop a plan of care for one of six sampled residents (Resident 1) to address resident's behavior of wandering (traveling aimlessly from place to place) into other residents' room. This deficient practice had the potential to result in Resident 1 being abused by another resident or having another resident- to- resident altercations. Findings: A review of Resident 1 Facesheet (admission Record) indicated the resident was admitted on [DATE] and was readmitted on [DATE] with the following diagnosis of schizoaffective disorder (mental illness that can affect your thoughts, mood, and behavior) and depression (a group of conditions associated with the elevation or lowering of a person's mood, such as depression or bipolar disorder). A review of Resident 1 History and Physical (H&P), dated 8/19/2023, indicated the resident has the capacity to understand and make decisions. A review of Resident 1 Minimum Data Set (MDS, a comprehensive…

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