Skyline Healthcare Center - San Jose

Based on interview and record review, the facility failed to maintain an effective infection control training program for laundry staff regarding routine cleaning of dryer lint. The facility's documentation indicated laundry staff did not clean the dryer lint for several hours on multiple days. This failure had the potential to compromise the health and safety of the residents in the facility. Findings: During a record review on 6/26/25, at 1:08 p.m., the facility's laundry lint cleaning log was inspected. The laundry lint cleaning log was left blank from 2:00 p.m. to 8:00 p.m. on 4/11/25, 4/12/25, 4/21/25, 4/29/25, 4/30/25, 5/12/25, 5/14/25, 5/16/25, 5/17/25, 5/28/25, and 6/21/25. During an interview and concurrent record review with the housekeeping supervisor (HS) on 6/26/25, at 1:19 p.m., the HS reviewed the facility's laundry lint cleaning log and confirmed it was left blank on the above dates and times. The HS explained that the documentation on this log was proof that staff cleaned the laundry lint. During an interview with the infection preventionist (IP) on 6/27/25, at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the call light button (a cord with a button used by the resident to request assistance) for one of 238 residents (Resident 25) was within reach and appropriate for her condition. This failure had the potential to result in delays of care and treatment. Findings: Review of Resident 25's medical record indicated Resident 25 was initially admitted on [DATE] and had diagnoses including Epilepsy (a neurological disorder characterized by recurring seizures [sudden , uncontrolled surges of electrical activity in the brain]), unspecified, intractable, without status epilepticus, other lack of coordination, unspecified disorder of psychological development (a condition that affects a person's cognitive, emotional, and behavioral development, often originating in childhood), and delayed milestone in childhood. During an observation on 6/23/25, at 9:36 a.m., Resident 25 was asleep, and the call light button was on the floor. During a…

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

Based on interview and record review, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN, a notice that transfers potential financial liability when a resident comes off Medicare Part A) for two of three residents (Residents 95 and 186). This failure had the potential to compromise the residents' right to appeal (apply for reversal of) the facility's decision to discontinue Medicare Part A services (skilled treatments paid for by Medicare). This failure also had the potential to result in the residents or residents' representatives not being informed of their payment responsibilities to the facility after Medicare Part A services ended. Findings: Review of Resident 95's medical record indicated she was admitted under Medicare Part A on 4/30/25. Review of the Beneficiary Notice section of the Entrance Conference Worksheet, filled out by the facility and presented to the survey team on 6/24/25, indicated Resident 95 was to be discharged from Medicare Part A services on 6/26/25 and continue living in the facility. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete an annual Minimum Data Set (MDS, an assessment tool) for one of three residents (Resident 89). This failure had the potential to compromise the facility's ability to develop and implement care plan interventions. Findings: Review of Resident 89's medical record indicated she was admitted to the facility on [DATE]. The medical record indicated the facility completed an annual MDS assessment on 5/12/24. Further review of the medical record indicated the facility did not complete an annual MDS assessment for Resident 89 in May of 2025. During an interview and concurrent record review with Minimum Data Set Coordinator B (MDSC B) on 6/26/25, at 1:17 p.m., MDSC B reviewed Resident 89's medical record and stated the facility should have completed an annual MDS assessment in May of 2025. MDSC B confirmed the facility did not complete this annual MDS assessment. The Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS, an assessment tool) for two of 36 sampled residents (Residents 164 and 192) when: 1. For Resident 164, multiple falls were not coded on the MDS; and 2. For Resident 192, tobacco use was not coded on the MDS. Failure to accurately complete the MDS had the potential to compromise the facility's ability to develop and implement care plan interventions. Findings: 1. Review of Resident 164's medical record indicated she was admitted on [DATE] and had a history of falling. Review of Resident 164's SBAR (situation, background, assessment, recommendation - a communication tool used by healthcare workers when there is a change in a resident's condition), dated 11/16/24, indicated Resident 1 had a witnessed fall in her room. Review of Resident 164's Progress Notes, dated 11/21/24, indicated she slid down and was found on the floor in her room. During an interview and concurrent record review with Minimum Data Set…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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-centered baseline care plans were developed within 48 hours of admission for two of thirty-six sampled residents, (Residents 337 and 380), when: 1. For Resident 337, there was no communication problem care plan that was initiated and 2. For Resident 380, there was no baseline activity care plan that was created, and she had no activity care plan at all. These deficient practices had the potential to cause delays in the continuity of care and communication which could negatively affect residents' health, safety and delivery of care. Findings: 1. Resident 337 was admitted to the facility on [DATE] with diagnosis of Cerebral infarction (necrotic tissue in the brain resulting from a blockage or narrowing in the arteries supplying blood and oxygen to the brain), Aphasia (a disorder that makes it difficult to speak), abnormalities of gait and mobility, Dysphagia (difficulty swallowing). During a concurrent interview and record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to revise the comprehensive care plans to address the individual care needs for two of thirty-six sampled residents, (Residents 202 and 18), when: 1.Resident 202's care plan interventions were not revised or modified related to falls and cognitive function. 2.Resident 18's care plan for antibiotic, not resolved. This failure placed the residents at risk of not being provided appropriate, consistent, individualized care. Findings: 1.Resident 202 was admitted to the facility on [DATE] with diagnosis of Schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves), Cerebral infarction cerebral infarction (necrotic tissue in the brain resulting from a blockage or narrowing in the arteries supplying blood and oxygen to the brain), Hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on half of the body) , abnormalities of gait 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 the proper use of side or bed rails (adjustable rigid bars attached to the side of a bed) for one (Resident 380), of six residents who used side rails that were investigated, when Resident 380 did not have a physician's order for her use of side rails. This failure caused the resident, to not have the proper approval from the physician for her use of side rails which could jeopardize the resident's safety. Findings: During the observation of Resident 380 on 6/23/25 at 12:33 p.m., Resident 380 was lying in bed and looked calm and comfortable. She was confused and could not answer questions. Resident 380 had bilateral (both sides) half side rails that were up. Review of Resident 380's face sheet (document created when a resident is admitted to a healthcare facility, containing the vital information about the resident) indicated, Resident 380 was admitted to the facility on [DATE] with the primary diagnosis of malignant neoplasm…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review, the facility failed to ensure two of 36 sampled residents (Residents 106 and 195) received their lunch in accordance with scheduled meal times. This failure had the potential to result in reduced food palatability (quality of taste), which could negatively affect the residents' meal intake and nutritional status. Findings: During an interview with Resident 106 on 6/23/25, at 9:20 a.m., Resident 106 stated her food always came late and was cold most of the time. During an interview with Resident 195 on 6/23/25, at 9:54 a.m., Resident 195 also stated her food always came late and was cold most of the time. The facility's untitled document titled Meal Service Times was reviewed. The document indicated lunch was to be served to the residents between 11:40 a.m. and 1:00 p.m., depending on the area of the facility. During a dining observation on 6/23/25, the cart containing the lunch trays for Residents 106 and 195 arrived in their area of the facility at 1:32 p.m. Staff delivered the lunch trays for both residents at 1:34 p.m. 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 the physician orders of one of three residents (Resident 1) were followed when a nurse did not perform a blood sugar check, administer insulin, and administer the correct dose of medication to Resident 1 timely. These failures had the potential to affect the health of Resident 1. Findings: Review of Resident 1's face sheet indicated the resident was admitted with diagnoses including nausea with vomiting and Type 2 diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing). Review of Resident 1's Physician Order Report, from 11/16/24 - 12/9/24 indicated the resident had orders for the following: - Admelog SoloStar (insulin lispro [a short acting medication to helps to lower sugar in the blood]) 100 unit/ milliliter (mL, unit of measurement), per sliding scale for DM before meals 6:45 a.m., 11:45 a.m., 4:45 p.m., dated 12/4/24; - Myfortic (mycophenolate sodium [medication used to prevent the body from rejecting an organ transplant) tablet, delayed release, 360 mg (milligrams, unit…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 store medications in a safe manner when nursing staff left medications unattended on the bedside table in a resident room. This failure had the potential to allow residents and unauthorized staff to access medications. Findings: Review of Resident 1's clinical record indicated he was admitted to the facility with diagnoses including dementia (a group of symptoms affecting thinking and social abilities interfering with daily functioning) and anxiety disorder (a mental health condition characterized by fear and worry that is both intense and excessive). Review of Resident 1's physician orders indicated he had orders for cyanocobalamin (vitamin B-12) 1000 micrograms (mcg, unit of measurement) once a day and gabapentin (medication used to treat nerve pain) 100 milligrams (mg, unit of measurement) capsule once a day. During an observation in Resident 1's room on 12/11/24 at 10:18 a.m., there were medications in a medication cup on Resident 1's bedside table unattended. Resident 1 was not inside the room. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the necessary behavioral health service to maintain the highest practicable mental and psychosocial well-being in accordance with the comprehensive assessment to two of three sampled residents (1 and 2) when their psychiatric services were not being followed up. This failure had a potential to affect maintaining Resident 1 and 2's highest practicable mental and psychosocial well-being. Findings: Review of Resident 1's face sheet indicated she admitted to the facility on [DATE] and her diagnoses including Obsessive -compulsive personality disorder (is a mental health condition that cause an extensive preoccupation with perfectionism, organization and control), bipolar disorder(is a mental health condition that affects your moods, which can swing from 1 extreme to another) and major depressive disorder(is a common and serious medical illness that negatively affects how you feel, the way you think and how you act). 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.

Based on observation, interview and record review, the facility failed to follow their plan of correction from 2024's recertification survey to have immediate pest treatment to maintain an effective pest control program for ensuring facility is free of pests and rodents when pest sightings were identified, and cockroaches were seen ongoing by staff and residents in the facility. This failure affected residents' quality of life to live in a health and sanitary environment. Findings: Review of complaint intake with received date 05/29/2024 21:57, indicated complainant complained about the facility for being very dirty; cockroaches could be seen on the walls and floors in majority of residents' room and some of residents' rooms in station three broke infection guidelines. Review of the facility's plan of correction, dated 3/1/24, indicated the last survey with exit date was 1/31/24 and the plan of correction included sighting rounds and calling pest control vendor for immediate treatment when pest sightings identified. Review of the facility's pest control service record from 2/2024 to…

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

Based on observation and interview, the facility failed to ensure refuse (any disposable materials, which include recyclable and non-recyclable materials) was disposed of properly when the lid of the garbage disposal bin in the kitchen was not placed. This failure had the potential to attract insects, rodents, and other pests to the facility and could affect the 238 residents in the facility. Findings: During an observation on 6/6/24 at 10:55 a.m., three garbage disposal bins were observed in the kitchen. One garbage disposal bin with a folded box, a cup, two plastic food containers, and a metal food container on top of the closed bin was observed. One garbage disposal bin without its lid was observed, and refuse in the garbage disposal bin was exposed to air. During an observation and concurrent interview on 6/6/24 at 11:13 a.m. with the registered dietitian (RD), he confirmed the above observation. During an interview on 6/6/24 at 11:18 a.m. with the RD, he stated that the garbage disposal bin should have been closed with its lid. During a review of the facility's policy and…

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

Based on observation, interview, and record review, the facility failed to ensure the environment was free of pests, as evidenced by multiple flying insects seen in the resident's room and the hallway. This failure had the potential to cause a health hazard to the 238 residents residing in the facility. Findings: During an interview on 5/1/24 at 1 p.m. with licensed vocational nurse A, she stated there were lots of flies in Resident 1's room because of old foods in the resident's room. During a concurrent observation and interview on 5/1/24 with certified nurse assistant B (CNA B), approximately more than ten black flying insects (fruit flies) were observed in Resident 1's room. CNA B confirmed the observation. During an observation on 6/6/24 in Resident 1's room, two fruit flies were observed near bananas on the over-the-bed table in Resident 1's room. During a concurrent observation and interview on 6/6/24 with CNA B, Resident 1 was sitting up in his electric wheelchair in the hallway in front of the nursing station, and one fruit fly was observed near Resident 1. CNA B confirmed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that residents received the treatment and care in accordance with professional standards of practice related to pain management for one out of three sampled residents (Resident 1) when 1. The licensed nurses did not follow physician's order to administer the pain medications as needed (PRN) based on the pain assessment documented; 2. The licensed nurses did not update Resident 1's care plan for pain management; 3. The licensed nurses did not follow the physician's order to administer the PRN medication for severe pain; and 4. The pain scale did not include the pain levels 1, 3, 5, and 7. These failures had the potential for Resident 1's pain not being properly managed and could negatively affect Resident 1's comfort and well-being. Findings: 1. A review of Resident 1's clinical record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including generalized muscle weakness and cervical region spinal stenosis (the space…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 offer and/or attempt alternatives prior to the use of side rails (or bed rails, adjustable rigid bars attached to the side of a bed [examples include safety rails, grab bars, and assist bars]) for 38 of 39 sampled residents (Residents 65, 642, 221, 21, 33, 86, 226, 68, 120, 64, 89, 16, 182, 58, 41, 50, 31, 208, 22, 210, 83, 213, 132, 127, 443, 168, 82, 145, 160, 56, 139, 128, 792, 184, 692, 201, 229, and 192). The survey team expanded the sample and identified that a total of 230 residents had side rails. The facility failed to ensure proper use of side rails when: 1. There was no documentation that indicated alternatives were offered and/or attempted prior to the use of side rails for 230 of 230 residents with siderails; 2. There was no documentation that indicated the facility conducted consistent routine maintenance of the facility's beds and side rails; 3. For Residents 58 and 83, the residents' side rails were documented as being…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 food service staff had appropriate competencies to carry out the food service safely and effectively functions when: 1. A kitchen staff member did not demonstrate the correct technique for testing the sanitation level on the dish machine. 2. A kitchen staff member did not demonstrate thermometer calibration correctly. 3. A kitchen staff member did not demonstrate the correct techniques for testing the sanitizer in the red buckets. This failure in staff competency had the potential to result in improperly sanitized resident dishes and food contact surfaces and expose residents to food-borne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). Cross reference 812 and CCR-72345(a) Findings: 1. During a concurrent observation and interview on 1/22/24 at 10:04 am, with the Dietary Aide (DA) J, DA J demonstrated how to test the low temperature dish machine for the correct sanitation level. The DA J placed a stainless steel container through the dish machine, dipped…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure the facility approved menus were followed as printed. This failure altered the availability of foods served to residents, which could decrease food intake and compromise the nutritional status 240 of 244 medically vulnerable residents who consumed food from the kitchen. Findings: During a review of the facility's Diet Spreadsheet on 1/22/24, Week 1 Day 1, approved by the Registered Dietitian (RD) was ½ cup of cereal, omelet 1 each, ½ cup breakfast potatoes, 1 slice of wheat toast, 1 cup coffee/tea, 1 cup milk, 1 jelly packet, 1 margarine, 1 salt packet, 1 pepper packet, and 1 non-dairy creamer. The nutrition analysis for Week 1 Day 1 was 2177 calories and 91.93 grams of protein. During a kitchen observation the breakfast meal trayline on 1/22/24 at 9:28 am, the Regular breakfast meal items on the trayline included a large pan of scrambled eggs, pan of potatoes, and a pan of cream of wheat. There was a medium sized meal tray cart with 30 trays and did not have milk on the trays. During a review of 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 follow its policy related to resident food brought in from outside the facility which facilitated improper food storage not safe for resident consumption. This failure had the potential to expose 240 of 244 residents who consumed food orally to harmful bacteria that could result in food borne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). Findings: 1. During a concurrent observation and interview on 1/23/24, at 9:15 a.m., with Certified Nursing Assistant (CNA) A, in Resident 222's room, personal food items were noted on Resident 222's bedside table. A Styrofoam container of approximately half a cup of rice, a clear plastic container with approximately 5 pieces of half-eaten fish, a clear plastic container with salted fish with a use by date of [DATE] were noted on the bedside table. CNA A stated, there is rice, fish, and shrimp at the bedside, the rice and fish do not have dates, the shrimp is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a comfortable and safe water temperature level for residents in Station 6 hallway. This failure had the potential for 11 residents to have an uncomfortable water temperature. Findings: Review of Resident 58's face sheet indicated, Resident 58 was admitted to the facility with diagnoses including quadriplegia (is a form of paralysis that affects all four limbs, plus the torso), neuromuscular dysfunction of bladder (the nerves and muscles don't work together very well resulting for the bladder to not fill or empty correctly), and depression. Review of Resident 58's Minimum Data Set (MDS, assessment tool) Annual assessment dated [DATE] indicated, Resident 58's Brief Interview for Mental Status (BIMS, cognition level) score was 15 (cognition is intact). During an interview with Resident 58 on 1/23/2024 at 8:38 a.m., Resident 58 stated the water in their bathroom sink was cold. Resident 58 further stated his certified nursing assistant…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an environment free of accident hazards for three of 39 sampled residents (Residents 143, 145 and 208) when: 1. Resident 143 was smoking in his room 2. For Resident 145, cigarettes and smoking materials were at the bedside 3. Resident 208's wander guard (small device placed on the ankle or wrist of a resident, alarms to notify the staff if a resident tries to leave the facility) functionality was not tested. These failures placed the residents at risk for accidents and subsequent harm. Findings: 1. Review of Resident 143's face sheet indicated he was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder (mental disorder including schizophrenia {disorder that affects a person's ability to think, feel, and behave clearly} and mood disorder), major depressive disorder, Bipolar disorder (disorder associated with episodes of mood swings ranging from depression lows to manic highs), lack of coordination,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 infection control practices were implemented when: 1. Housekeeper did not change gloves in between rooms and did not perform hand hygiene after removal of gloves; 2. Resident 22's nasal cannula was not stored properly when not in use; 3. Restorative Nursing Assistant did not perform hand hygiene while serving and setting up lunch trays in between residents; 4. Licensed Vocational Nurse N (LVN N) did not wear the proper personal protective equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) while inside the enhanced droplet precaution (used to prevent the spread of pathogens [an organism causing disease to its host] that are passed through respiratory secretions) room; 5. Occupational Therapist LL (OT LL) did not wear the proper PPE while inside the enhanced droplet precaution room; 6. Three bins full of dirty briefs were stored inside one of Station 6's shower rooms, and a makeshift dirty linen room next to it which was a shower room, had…

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

Based on observation, interview, and record review, the facility failed to ensure three ice machines, a nourishment reach-in refrigerator, walk-in freezer's fans, a walk-in refrigerator, and two reach-in refrigerators, were maintained in a safe, operating, and fully functioning manner, according to the manufacturer's guidelines and standards of practice. This failure had the potential to expose 244 residents to food contaminants that could cause food-borne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). Findings: According to the 2022 Federal FDA Food Code, Section 4-501.11 Good Repair and Proper Adjustment, indicated Proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk .refrigeration units in disrepair may no longer be capable of properly cooling or holding time/temperature control for safety foods at safe temperatures.…

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

Based on observation, interview and record review, the facility failed to provide at least 80 square feet per resident in multiple resident bedrooms. This failure could affect the residents' safety and impede provision of care to the residents. Findings: Rm. No. # of beds/Rm. Sq. Ft./Res. 108, 109 3 73.6 114, 115, 2 76.5 210, 211 314, 315, 3 74.0 316, 317, 403, 201 thru 208 110, 111, 2 74.0 112, 217, 218, 219, 220 116, 117, 2 75.0 308, 311, 312, 619 309, 310 3 74.3 404, 405, 3 73.5 406, 409, 501 thru 509 407, 408 2 72.9 411, 412, 2 76.0 414, 415 thru 419 510, 511, 3 74.8 515, 516 512, 514, 2 71.4 601, 602, 614, 615 603, 604 3 75.6 609, 610, 3 77.0 611, 612 Interviews with staff and residents indicated the room sizes did not adversely impact the quality of care received by the residents. Recommend continuance of the room size waiver.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment when there was water leaking from the ceiling in multiple areas inside the facility due to rain. This failure had the potential to compromise the health and safety of the residents, staff, and visitors in the facility. Findings: During an observation on 1/22/24, starting at 9:11 a.m., there was water leaking from the facility's ceiling in the following locations: 1. Inside the doorway of resident room [ROOM NUMBER] under a ceiling vent; 2. In the Hallway outside resident room [ROOM NUMBER]; 3. In the Hallway outside resident rooms 114; 4. Inside the doorway of resident room [ROOM NUMBER] under a ceiling vent; 5. Inside the doorway of resident room [ROOM NUMBER] under a ceiling vent; 6. Inside resident room [ROOM NUMBER]; 7. In the Hallway by room [ROOM NUMBER]; 8. In the hallway by station 2; 11. In the lobby; 12. Near the library; 13. In the conference room at the ceiling…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 their policies on self-administration of medication (resident takes medication without staff assistance) when there were no assessments performed for self-administration of medications, and medications were left at the bedside for 3 of 35 sampled residents (33, 58, and 90). These failures had the potential for unsafe and improper administration of medications. Findings: 1a. Review of Resident 33's face sheet indicated, Resident 33 was admitted to the facility with diagnoses including paraplegia (is a form of paralysis that affects the legs and lower body). Review of Resident 33's Minimum Data Set (MDS, an assessment tool) dated 10/19/23 indicated, Resident 33's had a brief interview for mental status (BIMS) score of 14 (a score of 13 to 15 indicates cognitively intact). During an observation on 1/23/24 at 10:02, in Resident 33's room, there were two tubes of cream in a basin on the Resident 33's bedside cabinet. The pharmacy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident's needs were accommodated for one of 39 sampled residents (Resident 544) when Resident 544's call button (a red button used by residetns to request assistance) was not within reach to use. This failure had the potential to affect residents' physical and psychosocial well-being. Findings: Review of Resident 544's face sheet (is a document that contains a summary of a patient's personal and demographic information) indicated, Resident 544 was admitted to the facility with diagnoses including hypertensive chronic kidney disease with stage 1 through stage 4 (a damage to kidney due to high blood pressure), congestive heart failure (a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues), and chronic obstructive pulmonary disease, unspecified (COPD - a long lasting lung disease). Review of Resident 544's Admission's Minimum Data Set (MDS, assessment tool) assessment, dated 1/14/2024, indicated Resident 544's brief interview for mental status (BIMS,…

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

Based on observation, interview, and record review, the facility failed to protect the confidentiality of personal and medical records of one resident (Resident 116) when a Resident Face Sheet (a document that contains personal and medical information) was left on top of an unattended medication cart. This failure had the potential to put a resident at risk for identity theft, insurance fraud and discrimination. Findings: During an observation on 1/30/24, at 10:22 a.m. in nurse station B, Resident 116's face sheet was left uncovered on top of an unattended medication cart. During an interview on 1/30/24, at 10:24 a.m. with Registered Nurse (RN) U, resident face sheet should not be left unattended and should have been placed face down. During a review of undated facility policy titled Uses & Disclosures of Protected Health Information, it indicated, Protected Health Information must be safeguarded against loss and unauthorized access, use, and destruction.

Based on interview on record review, the facility failed to accurately code the minimum data set (MDS, an assessment tool) assessment, Section N - Medications for one of 39 sampled residents (Resident 213). This failure resulted in Resident 213's inaccurate MDS. Findings: Review of Resident 213's clinical record indicated she was admitted to the facility with diagnoses including metabolic encephalopathy (brain disease, damage, or malfunction caused my an imbalance of chemicals in the blood) and morbid obesity (health condition that results from an abnormally high body mass, weight 100 pounds greater than ideal body weight). Review of Resident 213's physician orders dated 10/12/23 included an order for Ozempic pen injector 0.25 milligrams (mg, unit of measurement) subcutaneous (injected into the fat tissue under the skin) once a day on Friday for weight loss. Review of Resident 213's MDS Section N - Medications, dated 10/31/23 indicated the resident received one insulin (hormone produced by the pancreas or an injectable medication used to control blood sugar levels) injection 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 observation, interview and record review, the facility failed to ensure two of 39 sampled residents (Resident 221 and 82) completed a Level II Mental Health Evaluation as part of the pre-admission screening and resident review (PASRR, a federal requirement to help ensure that individuals who have mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care). These failures had the potential for inaccurate care and services provided to residents with a mental disorder, intellectual disability or related conditions. Findings: 1. Review of Resident 221's face sheet indicated, Resident 221 was admitted to the facility with diagnoses including other specified anxiety disorders (a mental illness that causes constant fear), post-traumatic stress disorder (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), other schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and pedestrian on foot injured in collision with a vehicle in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a pre-admission screening and resident review (PASRR, a federal requirement to help ensure that individuals who have mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) was completed for two of 39 sampled residents (Residents 127 and 132). These failures had the potential for inaccurate care and services provided to residents with a mental disorder, intellectual disability or related conditions. Findings: 1. Review of Resident 127's face sheet indicated he was admitted to the facility with diagnoses including sepsis and psychotic disorder with hallucinations. Review of Resident 127's PASSR, dated 8/5/23 indicated the result of Level I Screening was negative. It also indicated for the question, Does the Individual have a serious diagnosed mental disorder such as Depressive Disorder, Anxiety Disorder, Panic Disorder, SchizophreniaSchizoaffective Disorder, or symptoms of Psychosis,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and implement a care plan for two of 39 sampled residents (Resident 83 and 135) when: 1. Resident 83's language barrier care plan was not initiated and the communication binder (it is a compilation of photos, symbols, or illustrations to help people with limited language skills express themselves) was not available for Resident 83 and staff's use; and 2. Resident 135's care plan was not implemented. These failures had the potential for inaccurate development and implementation of personalized and resident-centered care plans that would address the residents' identified concerns and needs. Findings: Review of Resident 83's face sheet (a summary page of a patient's important information) indicated Resident 83 was admitted to the facility with diagnosis of hemiplegia (one-sided muscle paralysis or weakness), unspecified affecting left non-dominant side. Further review of Resident 83's face sheet indicated she was Asian, Korean and…

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

Based on observation, interview, and record review, the facility failed to ensure proper foot care was provided to one of 39 sampled residents (Resident 221) when Resident 221's long, jagged (has a rough, uneven shape) toenails were not trimmed by either licensed nurses or podiatrist (medical specialists who help with problems that affect your feet or lower legs). This failure had the potential to increase the risk for the development of foot ulcer and infection. Findings: Review of Resident 221's face sheet (summary page of a patient's important information) indicated, Resident 221 was admitted to the facility with diagnoses including multiple fractures of pelvis (the area of the body below the abdomen that is located between the hip bones and contains the bladder and the rectum), displaced bicondylar fracture of right tibia (severe injuries where the bone in the lower leg was broken), dislocation of left knee, other specified anxiety disorders (a mental illness that causes constant fear), post-traumatic stress disorder (PTSD, a disorder in which a person has difficulty recovering…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure a resident, (Resident 210) with an unintended, unplanned severe weight loss of 12.69% in six months had acceptable parameters of nutritional status was monitored from (5/4/23-10/18/23) according to facility policy and standards of practice when: 1) The facility did not reassess the resident's nutritional status, obtain regular laboratory values, or modify the interventions after severe percent of weight loss occurred, according to facility policy and standards of practice. 2) Weekly weights to monitor Resident 210's weight status after a loss of five or ten percent of body weight was not available or provided, according to policy. 3) The resident's meals and snack/nourishment consumption were not monitored to determine the resident's actual food intake to evaluate nutrition status, according to facility policy. These failures led to Resident 210 experiencing a 12.69% weight loss and the potential to have further decline of lean…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 proper care and treatment services for oxygen (O2) was provided for one of two sampled residents (Resident 22) when Resident 22's physician order for oxygen administration was not followed. This failure had the potential to result in complications related to improper treatment while receiving O2 therapy. Findings: Review of Resident 22's face sheet indicated Resident 22 was admitted to the facility with diagnoses including paraplegia (a paralysis that occurs in the lower half of the body. It can be a result of an accident or a chronic condition), type 2 diabetes mellitus (occurs when the body is unable to regulate glucose [sugar] in the blood), hydrocephalus (a buildup of fluid in cavities called ventricles deep within the brain), hypertension (high blood pressure), and acute respiratory failure (a condition when lungs cannot release oxygen to blood causing shortness of breath) with hypoxia (occurs when oxygen level in the body organs are low). Review of Resident 22's Physician Order Report, 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.

Based interview and record review, the facility failed to ensure accurate accountability of controlled medications (those with high potential for abuse or addiction) when random controlled medication use audits did not reconcile for one out of six (6) randomly checked (Resident 168) residents. The medication was signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Record (MAR) to indicate they were given to the resident. There were two controlled medications unaccounted for. This failure had the potential for misuse or abuse of controlled medications. Finding: The Controlled Drug Records (CDRs) for six (6) random residents receiving PRN (meaning as-needed) controlled medications were requested for review during the survey. Resident 168 had a physician's order, dated 8/28/23, for oxycodone (a potent controlled medication for pain) 5 milligrams (mg, unit of measurement), 1 tablet by mouth every 6 hours as needed for moderate or severe pain. During a concurrent…

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

Based on observation, interview, and record review, the facility had a medication error rate of 10.71% when three (3) medication errors occurred out of 28 opportunities during the medication administration for one out of four residents (Resident 190). The failure resulted in medications not given according to the physician's orders and had the potential for Resident 190 not receiving the full therapeutic effects of medications. Findings: During a medication pass observation on 1/22/24 at 9:15 a.m., licensed vocational nurse (LVN) B was observed preparing and administering 15 medications to Resident 190. The medications included one lidocaine patch (to treat pain) to Resident 190's middle/upper back and one puff of Symbicort (budesonide-formoterol, medication to treat lung disease) inhaler. During a review of Resident 190's medical record indicated the following physician's orders: a. Lidocaine 4% patch, apply 1 patch to each Shoulder at 9 a.m. and remove at 9 p.m. for pain management, dated 10/26/23; b. Symbicort (budesonide-formoterol, medication to treat lung disease) 160-4.5…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 respect and dignity was maintained for 4 of 35 sampled residents (Resident 50, 58, 226, and 229) and one non-sampled resident (Resident 67) when: 1. For Residents 50, 67, and 226, staff provided feeding assistance while standing; 2. Staff failed to provide a privacy bag for Resident 58's urinary drainage device; 3. Staff referred to Resident 229 as a feeder. These failures had the potential to affect the emotional and psychosocial well-being of the residents. Findings: 1. Review of Resident 50's minimum data set (MDS, an assessment tool) dated 10/13/23 indicated her cognition was severely impaired and she was dependent on staff for eating. During a breakfast meal observation on 1/22/24 at 10:38 a.m., Resident 50 was in her room lying in bed. CNA X stood beside Resident 50 her while providing spoon-feeding assistance. During a concurrent interview with CNA X, she confirmed she was standing while feeding Resident 50. CNA X stated she…

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

Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, admission to the Facility, for one of 39 sampled residents (Resident 208), when Resident 208 was admitted to the facility without a physician's order to certify admission. This failure had the potential to affect Resident 208's care. Findings: During a review of Resident 208's Face Sheet, (undated), the Face Sheet indicated, Resident 208 was admitted to the facility on 6/7/23. During a review of Resident 208's Physician Orders, dated 1/29/24, Physician Orders indicated, no order to certify admission to the facility. During a concurrent interview and record review on 1/29/24, at 2:46 p.m., with Regional Clinical Operations staff (RCO) and Medical Records Assisstant (MRA), Resident 208's Physician Orders, dated 1/29/24 was reviewed. The Physician Orders indicated, no order to certify admission to the facility. RCO stated, she did not see an order to admit the resident in active orders or discontinued orders. MRA stated, she did not see an order to admit the resident, there should…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were free from verbal and physical abuse for two of three residents (Residents 1 and 2) when: 1. Resident 1 sustained facial injuries when Resident 2 scratched her in the face and was transferred to the emergency room (ER). 2. Resident 2 sustained emotional distress by feeling upset when Resident 1 said bad words, and complained of pain on her breast when Resident 1 grabbed her breast. This failure had caused both emotional and physical harm to Residents 1 and 2. Findings: On 9/08/2023, the facility submitted a facsimile (FAX) to the California Department of Public Health (CDPH) about an incident between Residents 1 and 2. The FAX showed Residents 1 and 2 had verbal arguments. Resident 1 grabbed Resident 2's breast, and Resident 2 grabbed Resident 1's hair and scratched her in the face. During a review of the facility's investigative summary dated 9/13/2023, the summary indicated Resident 1 and 2 were outside of the…

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

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was treated with respect and dignity when the certified nursing assistant A (CNA A) pulled the standing Resident 1 backward and did not ask for assistance in putting the Resident 1 in bed. This failure resulted in not ensuring Resident 1 ' s right to be treated with respect and dignity and could potentially result in low-self-esteem and self-worth. Findings: Review of Resident 1's medical record indicated diagnoses that includes metabolic encephalopathy (a disorder that affects brain function), schizophrenia (a mental illness that affects how a person thinks, feels, and behaves), history of displaced fracture of fifth vertebrae (a series of small bones forming the backbone), lack of coordination, difficulty of walking, and unsteadiness on feet. Review of Resident 1's minimum data set (MDS, a resident assessment tool) dated 12/14/23 indicated he is non-interviewable and with long- and short-term memory problems. He mostly needed one-person physical assist during transfers.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 supervision to prevent 1 out of 10 residents (Resident 1) who was at risk for elopement from leaving the facility when Resident 1 went out to smoke outside the facility and did not return the same day. These failures compromised Resident 1's health and safety, as she was found by police officers and was admitted to the acute hospital for treatment and evaluation the next day 12/24/2022 Findings: A review of Resident 1's medical record indicated she was admitted to the facility on [DATE] with diagnoses of anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and unspecified Schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). Further review of Resident 1's medical record indicated Resident 1 ' s conservator was her responsible party. A review of Resident 1's Elopement Risk Assessment, 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 interview and record review, the facility failed to ensure the doctor or nurse practitioner (NP)/or physician assistant (PA) was promptly promptly informed of any condition change/s for one of three sampled residents (1) when after Resident 1's fall incident on 10/31/23, she complained of severe pain (10 out of 10 ) during morning shift on 11/4/23, and on the next day 11/5/23, she developed bruise (injury appearing as an area of discolored skin on the body, caused by a blow or impact due to rupture of underlying blood vessels.) on her right hip and the vagina area. This failure could jeopardize Resident 1 ' s health and safety due to the delay in Resident 1 receiving appropriate treatment /interventions that included timely transfer to acute hospital for further management and evaluation. Findings: Review of Resident 1's face sheet indicated the responsible party (RP, is a person who has been chosen to act or make decisions on behalf of another person for signing consent form ) was her daughter. Her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 timeliness of the radiology services for one of three sampled residents (Resident 1) when the physician ' s order to do a stat (immediately) x-ray (a photographic or digital image of the internal composition of a part of the body) of right hip to rule out fracture was done as ordered.This failure had delayed meeting Resident 1's needed care and treatment. Findings: During an observation on 11/22/23, at 10:18 a.m., Resident 1 laid in bed and a long brace (equipment used to mimmobilize the leg) applied to her right leg. Review of Resident 1's physician's order dated 10/31/23 indicated a radiology (x-ray)order for right hip AP/Lat (anterior posterior/lateral) view. During an interview on 11/22/23, at 11 a.m., with the registered nurse A (RN A), she stated, Resident 1 had an unwitnessed fall on 10/31/23 when she was found on the floor next to her bed. The x-ray for her right hip to rule out fracture was done on 11/1/23 at around 4:30 p.m. During an interview on 12/8/23, at 12:35 p.m., with registered nurse B (RN…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff report one of two incidents of a resident-to-resident altercations when certified nursing assistant A (CNA A) reported to the licensed nurse about the altercation between Resident 1 and Resident 2, but the incident was not reported until four days later, when Resident 1 informed the staff about it. This failure had the potential to put the residents at risk for further abuse. Findings: Review of Resident 1's admission Record indicated she was admitted to the facility on [DATE]. Review of Resident 1's Minimum Data Set (MDS, a clinical assessment tool), dated 8/12/23, indicated her cognition was intact. Review of Resident 2's admission Record indicated she was admitted to the facility on [DATE]. Review of Resident 2's MDS, dated [DATE], indicated her cognition was intact. Review of Resident 1's Observation Detail List Report, dated 9/5/23, indicated Resident 1 reported to the staff that on 9/1/23, at the nurse station AA (NS AA), she…

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

Based on observation, interview, and record review, the facility failed to provide personal hygiene to one of three sampled residents (1) when her adult diapers were not changed as per plan of care and task schedule to keep clean and dry after each incontinent episodes. This failure had the potential risk for developing complications such as skin rash or urinary tract infection. Findings: Review of Resident 1's complaint intake information, dated on 11/28/23, indicated, Resident 1 pointed her diaper was soaking wet to her visitor during visiting on 11/21/23. At 6:35 p.m., the visitor spoke with the nurse on duty to verify the last time of diaper changes for Resident 1 was in the morning. Review of Resident 1's minimum data set (MDS, is a standardized assessment tool that measures health status in nursing home residents), dated 9/2/23, indicated her brief Interview for Mental Status (BIMS, assessment tool for cognition) score was 3 or severe cognitive impairment, her bladder status was always incontinent and she required extensive assistance for personal hygiene. Review of Resident…

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

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the facility was free of pests and rodents when cockroaches were seen by three of three sampled residents (1, 2 and 3) and 16 randomly selected residents ( (4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17,18, 19)in the facility. This failure affected the residents' quality life, and dperived them to live in a healthy and sanitary environment. Findings: During a facility tour and concurrent interview on 12/7/23, at 10 a.m., with the housekeeper supervisor (HS), in the nursing station five, room A, Resident 4 stated, he had seen cockroaches in the bathroom. At 10:05 a.m., in the nursing station five, room B, Resident 5 stated, he had seen cockroaches in his room. At 10:10 a.m., in the nursing station five, room C, Resident 6 stated, he had seen cockroaches in the building. During a facility tour and interview on 12/7/23, at 10:15 a.m., with HS, in the nursing station four, room D, Resident 7 stated, he had seen cockroaches in his room. At 10:18 a.m.,…

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

Based on interview and record review, the facility failed to provide a copy of resident's medical record upon verbal request for one of three sampled residents (1) when her responsible party (RP, is a person who has been chosen to act or make decisions on behalf of another person) made a verbal request for Resident 1's medical records over months and did not receive any response from the facility. This failure had a potential to limit resident's rights for accessing records. Findings: Review of Resident 1's complaint intake information, dated 11/28/23, indicated RP H requested Resident 1's medical records from 8/31/23 and the facility did not make a copy of Resident 1's medical records to her. During an interview on 12/7/23, at 4 p.m., with the medical record personnel F (MRP F), she stated, Resident 1's RP requested to have a copy of Resident 1's medical records in August 2023 and she forgot her request for making a copy of Resident 1's medical records. She stated, normally she would make a copy of resident's medical records right away after when they made a request. Review of the…

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

Based on interview and record review, the facility failed submit an investigation summary within 5 working days to the California Department of Public Health (CDPH, state survey agency) regarding an alleged physical abuse incident that occurred between a certified nursing assistant A (CNA A) and one of two sampled residents (Resident 1). This failure had the potential to delay the facility's recommendation for action to ensure the safety for Resident 1. Findings: Review of Resident 1's Change in Condition Narrative Notes, dated 9/5/23, indicated an incident had occurred between her and CNA A. The documentation indicated, Resident 1 accusing CNA A of hitting her right forearm with the bed control. No bruise/swelling noted. It also indicated the medical doctor MD), responsible party (RP), law enforcement agency, and Department of Health Services (DHS) were notified. Review of the final investigation transmittal report from the facility indicated the report was faxed to CDPH on 9/15/23. It was more than 5 days since from the date of incident of the allegation of physical abuse incident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 conservator (a responsible adult who manages the daily life and/or finances of an adult, who is unable to adequately care for themselves because of a cognitive or physical disability) for one of three residents (Resident 1) when there was an incident that Resident 1 reported Resident 2 punched her underneath the left side of her breast and Resident 2's conservator was not notified of the incident. This failure resulted in Resident 2's conservator not being informed of the incident and any possible change in Resident 2's condition. Findings: Review of Resident 1's admission Record indicated she was admitted to the facility on [DATE]. Review of Resident 2's admission Record indicated he was admitted to the facility on [DATE], and he had a conservator. Review of Resident 1's Observation Detail List Report, dated 4/26/23, indicated, Resident 1 reported that Resident 2 hit her repeatedly because he stated she was in his way, and she could not…

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

Based on observation, interview, and policy review, the facility failed to provide care in a manner that maintained the dignity and respect for four of six residents (1, 2, 3, and 4) when certified nursing assistant A (CNA A), CNA B, and CNA C double diapered ( two diapers were used at the same time, one diaper over the other diaper) for Resident 1, Resident 2, Resident 3, and Resident 4. This failure had the potential to cause embarrassment to the residents and negatively affect the residents' self-esteem. Findings: During an observation with CNA A on 8/29/23 at 1:45 p.m., Resident 1 was double diapered. CNA A stated other CNAs told her to put on two diapers for Resident 1. During an interview with CNA A on 8/29/23 at 2:10 p.m., CNA A acknowledged she should put on only one diaper for the residents. During an observation and interview with CNA B on 8/29/23 at 2:30 p.m., Resident 2 had a rolled-up diaper placed on his genital area; a second diaper was on top of it and wrapped around his hip. CNA B stated other CNAs told him to put on two diapers for Resident 2. CNA B acknowledged he…

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

Based on observation, interview, and policy review, the facility failed to observe proper infection control practices when laundry aid D (LA D) transferred soiled linen and clothing from the hamper to the yellow laundry bin in the hallway. This failure had the potential to result in transmission of infection and recontamination among residents and staff. Findings: During an observation on 8/29/23 at 1:25 p.m., LA D was observed transferring soiled linen and clothing from the hamper to the yellow laundry bin in the hallway in front of the storage room. There were several residents and staff present in the hallway. During a concurrent interview with LA D, he acknowledged he should have transferred the soiled linen and clothing from the hamper to the yellow laundry bin inside the storage room and not in the hallway. During an interview with the infection preventionist (IP) on 8/30/23 at 1:30 p.m., she stated the laundry aids should transfer the soiled linen and clothing from the hamper to the yellow laundry bin inside the storage room and not in the hallway. Review of the facility's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure accurate accountability of controlled medications (those with high potential for abuse or addiction); and safe and effective use and administration of medications when: 1. Random controlled medication use audits 9 out of 9 residents (Residents 11, 18, 23, 37, 116, 118, 133, 139, and 163) did not reconcile. The medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Record (MAR) to indicate they were given to the residents. There was a total of 47 controlled medications unaccounted for. This failure had the potential for misuse or abuse of controlled medications; 2. Medications for residents were not given or given late for two of 35 sampled residents (Resident 68 and 77) and Resident 133. This had the potential for residents not meeting the resident's therapeutic needs; 3. Two of 14 observed…

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

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served under sanitary conditions when: 1. Four wire rack shelves had yellowish to golden brown color; 2. Two spatulas had cracked/chipped; 3. Grater (used to shred cheese and other soft food) had yellowish substance; 4. The quaternary bucket was stored near juice boxes/juice machine; 5. Two of four ice machines had black particles; 6. Scoop was inside the ice cooler; 7. Kitchen staff did not demonstrate the proper procedure for testing the strength of sanitizer used for sanitizing food contact surfaces; 8. Unit Storage's had unlabeled food and refrigerators with high temperatures. These failures had the potential to cause foodborne illness (illness resulting from contaminated food) for 223 of 232 residents who received food from the kitchen. Findings: 1. During a kitchen observation on 7/11/22 at 8:53 a.m., the walk-in freezer's storage rack had four wire rack shelves with yellowish to golden brown color. During a concurrent interview with the dietary manager (DM), she…

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

6a. During a medication pass observation with LVN Q on 7/12/22 at 8:09 a.m., she was observed preparing 7 medications, including 5 solid tablets, for Resident 68. During this process, LVN Q put on a pair of gloves, took out the keys from her shirt pocket to open the medication cart, then removed 2 medication blister packs/cards (a pharmacy-prepared paperboard with medications in individual doses that can be punched out of the card when administered) from the medication cart. She removed the medication tablet from each blister card by punching the blister bubble with her right thumb, and placing her left gloved hand underneath the medication card to catch the pill. Then she placed it in a small medication cup. During an interview with LVN Q on 7/12/22 at 8:50 a.m., she acknowledged she caught the medication tablets with her gloved hand instead of punching it from the medication card directly into the cup. A review of the facility's Medication Pass Guidelines, dated 3/2002, indicated: Use sanitary technique to place medications into a souffle or medicine cup. Do not touch oral…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 7 of 35 residents (36, 26, 27, 58, 155, 234, and 95) received the necessary care, services, and correct diets when: 1. Resident 36 did not receive the assessment and treatment for her wound timely; 2. The fingernails of Resident 26, Resident 27, Resident 58, and Resident 155 were long, dirty and were not trimmed; 3. Resident 234's request for a diet changed was not addressed promptly; 4. Resident 95 had long yellowish finger nails; and 5. Licensed Nurse (LN) did not check food trays for correct diets before serving the residents in two of 6 stations (Station UVW and Station XYZ). These failures had the potential to affect the residents' care, health and well-being. Findings: 1. Review of Resident 36's admission Record indicated she was admitted to the facility on [DATE] with diagnosis of dementia (the loss of the ability to think, remember, and reason to levels that affect daily life and activities). During observations on 7/11/22…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 appropriate treatment and services were provided for five of seven residents (Resident 125, 228, 234, 77 and 2) when the restorative nursing assistant (RNA, program that helps residents to gain an improved quality of life by increasing their level of strength and mobility) program was not implemented. This deficient practice had the potential to result in residents' decline in range of motion. Findings: 1. Review of Resident 125's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including other sequelae of cerebral infarction (other consequences of stroke). Review of Resident 125's physician order dated 6/7/22 indicated RNA program for ambulation with front wheeled worker two times per week for 90 days and RNA program for transfer from wheelchair to bed two times per week for 90 days During an interview with restorative nursing assistant CC (RNA CC) on 7/14/22 at 1:35 p.m., RNA CC stated I was not sure when…

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

Based on observation, interview, and record review, the facility had a medication error rate of 18.75% when six (6) medication errors occurred out of 32 opportunities during the medication administration for five out of nine residents (Resident 68, 96, 115, 152, and 195). The failure resulted in medications not given according to the physician's orders, and had the potential for residents not receiving the full therapeutic effects of medications. Findings: 1. During a medication pass observation on 7/11/22 at 8:27 a.m., licensed vocational nurse (LVN) M was observed preparing and administering 3 medications to Resident 195. The medications included one tablet of citalopram (an anti-depressant medication) 20 milligrams (mg, unit of measurement). On 7/11/22, a review of Resident 195's medical record indicated: Citalopram 10 mg 1 tablet once daily for depression, dated 4/7/22. During a concurrent interview and record review with LVN M on 7/11/22 at 2:20 p.m., she reviewed Resident 195's physician's order for citalopram and confirmed it was for 10 mg, not 20 mg. She stated she had been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medications when: 1. Nine (9) insulin (medication to lower blood sugar) pens did not have patient-specific labeling on each pen to prevent mix-up errors; 2. Temperature (temp) monitoring was missing and/or not consistently documented twice daily on the temp log sheets for two of three observed medication refrigerators; 3. Expired or discontinued medications were not put away to prevent medication errors; 4. An eye drop medication was not kept in the refrigerator until opened; and 5. A heparin (an injectable medication to prevent blood clot) vial was not dated with an open date. The deficient practices had a potential for residents to receive medications with unsafe and reduced potency from being used past their discard date; medication errors due to medications not being labeled or removed from active stock; and inadequately monitored medications, which could lead to unsafe and ineffective…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prepare food that conserved nutritive value and flavor when pureed food was prepared hours before serving. This failure had the potential for 50 out 232 residents who received pureed diet with reduced nutrients or flavor. Findings: During an interview with the dietary manager (DM) on 7/12/22 at 8:58 a.m., the DM confirmed the puree food preparation starts at 10:00 a.m. During an observation on 7/11/22 at 10:08 a.m., dietary cook MM (DC MM) pureed the cooked frozen green beans. At 10:29 a.m., surveyors asked when will the cook prepare to puree the proteins. Dietary cook NN (DC NN) stated he already pureed the proteins at 9:30 a.m., and placed them at the steam table around 9:45 a.m. At 11:55 a.m., tray line (food preparation/assembly) started. At 1:33 p.m., tray line was still ongoing and meal cart for station XYZ was out in the kitchen. During an interview with the registered dietitian (RD) on 7/12/22 at 3:45 p.m., the RD was asked about the puree preparation. The RD stated I will get back about the puree…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 essential equipment in good and safe operating condition when: 1. Two out of two walk-in freezers had icicle build-up; 2. Two out of five-unit refrigerators had broken parts. These failures had the potential to cause the freezers and refrigerators to be ineffective for keeping food frozen and refrigerated for 223 residents who received food from the kitchen out of 232 residents. Findings: 1a. During an initial kitchen tour observation on 7/11/22 at 8:51 a.m., the walk-in freezer in the kitchen had icicle build up in the storage racks and the significant ice buildup was observed around a pipe. During a concurrent interview, the dietary manager (DM) confirmed the above observation and stated she will get the maintenance staff. During an observation in the kitchen on 7/12/22 at 9:26 a.m., the walk-in freezer's pipe had ice buildup. 1b. During an observation on 7/11/22 at 11:02 a.m., walk-in freezer outside the kitchen had significant ice buildup on the wall and on the floor. During a concurrent…

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

Based on observation interview, and record review, the facility failed to provide a safe and comfortable environment for residents and visitors when: 1. A housekeeping cart with cleaning chemicals was left unattended on the resident hallway; 2. A resident's room (Resident 2) had damaged walls and a hole in the wall. This had the potential to adversely affect the health and safety of residents and any visitors. Findings: 1. During observation on hall five, on 7/11/2022 at 12:12 p.m., a housekeeping cart was left unattended with a container of bleach wipes on top of the cart and mop bucket with liquid in it. During interview with laundry aide (LA), on 7/11/2022 12:12 p.m., LA confirmed the unattended cart with bleach and indicated the mop water was for the janitor. She stated she did not know where the janitor was and confirmed leaving the housekeeping cart unattended was a safety risk to residents and visitors. LA confirmed the residents would have access to the chemicals and confirmed the observation of three residents in wheelchairs passing by the unattended cart while two more…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure for two of seven sampled residents (Resident 110 and Resident 175) advance directive instructions were clear. This had the potential for staff to not honor the wishes of the resident in the event of an emergency. Findings: Record review of Resident 110's face sheet, undated, indicated the resident had a history of dementia (loss of cognitive functioning to an extent that it interferes with a person's daily life and functioning), major depressive disorder (mood disorder that causes persistent feelings of sadness and loss of interest), and received hospice services (care focused on comfort and quality of life of a person who is approaching the end of life). Record review of Resident 175's face sheet, undated, indicated the resident had a history of heart failure a chronic condition in which the heart doesn't pump as well as it should), Type 2 Diabetes (an impairment in the way the body regulates and uses sugar), and dependence on renal dialysis…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to conduct a comprehensive, Minimum Data Set (MDS, a standardized assessment tool) for one of 35 sampled residents (Resident 27), within 14 days of a significant change in the resident's condition. This failure had the potential for inadequate information to be gathered for the timely development of an appropriate plan of care, and the required modification of appropriate care and services for Resident 27. Findings: A review of Resident 27's MDS dated [DATE] indicated she required extensive assistance with two persons physical assistance with bed mobility, dressing, toilet use and personal hygiene; and to all dependence with one person physical assistance with bathing. During a record review and concurrent interview with the minimum data set coordinator (MDSC) on 7/15/22 at 2:02 p.m., she confirmed Resident 27 had improvement in her functional abilities on two or more areas but did not complete an MDS on significant change. The MDSC acknowledged having…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 submit the PASRR (Preadmission Screening and Resident Review, a federally required document to ensure residents are appropriately placed) when one of five sampled residents (Resident 110), received mental illness diagnoses and did not receive a level two screening to ensure they received the services needed. The deficient practice could potentially result in Resident 110 not receiving specialized care and services appropriate for her condition. Findings: Review of Resident 110's face sheet, undated, indicated the resident had a history of dementia (loss of cognitive functioning to an extent that it interferes with a person's daily life and functioning), major depressive disorder (mood disorder that causes persistent feelings of sadness and loss of interest), and received hospice services (care focused on comfort and quality of life of a person who is approaching the end of life). The face sheet indicated Resident 110 was admitted on 10/19 Record review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and implement care plans for four of 32 sampled residents when: 1. Resident 41's Fall Risk Evaluation was not completed and Fall risk care plan was not developed. 2. Resident 117's smoking assessment was not accurately completed and smoking care plan was not developed; and fall care plan was not implemented. 3. Resident 535's smoking reassessment and care plan were not developed when he started to smoke in the facility. 4. Resident 149's fall care plan was not updated and implemented. These failures had the potential for inaccurate development and implementation of a personalized and resident-centered care plans that would address the residents' identified concerns and needs. Findings: 1. During a record review and concurrent interview with registered nurse H (RN H) on 7/12/22 at 10:10 a.m., RN H reviewed Resident 41's clinical record and stated the charge nurse or nurse supervisor should have completed another Fall Risk Evaluation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide the necessary care and services to ensure prevention of development or worsening of an existing pressure ulcer (injury to the skin and underlying tissue) for one out of three sampled residents (Resident 116) observed for pressure ulcers when: 1. There was no treatment for a pressure ulcer on the sacral area (portion of spine between lower back and tailbone) that was identified on admission; 2. There was no staging of the pressure ulcer on the sacral area on admission; 3. When the physician prescribed treatment, there was no documentation that treatment orders were followed consistently; 4. There was no consistent skin assessment of the pressure ulcer; These failures resulted in Resident 116 developed into an unstageable pressure ulcer (full thickness tissue loss that was difficult to assess) with eschar (dead tissue that is dark in color) on the sacral area. Findings: Review of Resident 116's face sheet, dated 1/25/2022, indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure proper foot care was provided to three of five sampled residents (Resident 2, 117 and Resident 155 ) when: 1. Resident 117's long, thick toenails were not trimmed by podiatrist (medical specialists who help with problems that affect your feet or lower legs) ; 2. Resident 155's long, thick and curled toenails were not cut and trimmed by podiatrist; 3. Resident 2's long, thick toenails were not cut or trimmed by podiatrist. These failures had the potential to increase the risk for the development of foot ulcer and infection. Findings: 1. A review of Resident 117's facesheet indicated diagnoses of diabetes mellitus (a disorder in which the body does not produce enough or respond normally to insulin, causing blood sugar (glucose) levels to be high), human immunodeficiency virus (HIV) disease. During an observation on 7/11/22 at 10:53 a.m., Resident 117 claimed he had pain on his feet and showed his long, curled with sharp edges toenails…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 according to professional standards of practice and facility policy and procedures for two of 32 sampled residents (Residents 46 and 68) when: 1. Certified nurse assistant (CNA) and restorative nurse assistant (RNA) controlled the enteral feeding pump (a device used to deliver nutrition to the stomach using a tube); 2. Medications and feeding formula given via the gastrotomy tube (G-tube, a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach) was not appropriately done for Resident 68. These failures had the potential for complications related to the enteral feeding and to cause harm to the residents. Findings: 1. Review of Resident 46's clinical record indicated she was admitted on [DATE] and had diagnoses of gastrostomy status (a surgical opening into the stomach to deliver nutrition), depression (a mood disorder that causes a feeling of sadness and loss of interest), 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 Based on observation, interview and record review, the facility failed to ensure that proper care and treatment services for oxygen (O2) were provided for two of five sampled residents (Resident 53 and Resident 32) when: 1. Physician orders for oxygen administration for Resident 53 were not followed; 2. Resident 32's nasal cannula (NC, a device used to deliver oxygen) was not connected to the oxygen concentrator (a medical device that gives extra oxygen). These deficient practices had the potential for the residents to have complications related to improper treatment while receiving O2 therapy. Findings: 1. Record review of Resident 53's face sheet, undated, indicated Resident 53 has a history of chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), emphysema (a condition in which the lungs are damaged causing breathlessness), and hypertension (high blood pressure). During observation and record review with LVN S, on 7/14/2022 at 10:07 a.m., LVN S…

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

Based on observation, interview and record review, the facility failed to provide adequate pain management based on professional standards to one of five residents (Resident 234) when: 1. Licensed nurse did not notify the attending physician to get an order for PRN (as needed) medication for breakthrough pain (a flare of pain that might happen even though you are taking pain medicine regularly for chronic pain) 2. Licensed nurse did not follow the care plan to call MD (doctor of medicine) when pain relief measures failed to provide adequate relief. 3. Licensed nurse did not assess resident's pain when needed and did not document the pain medication when given. These deficient practices had the potential to effectively manage pain to help the resident attain or maintain the highest practicable level of well-being. Findings: A review of Resident 234's admission Record indicated diagnoses of chronic pain syndrome, gout (swelling and tenderness of one or more joints characterized by severe pain, redness, and tenderness), cellulitis (common bacterial skin infection that causes redness,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure three of 12 residents (27, 56, and 206) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behaviors) when: 1. Resident 56 received Zoloft (used to treat persistent feeling of sadness, loss of interest, and panic attacks) without attempts of gradual dose reductions (GDR, a tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) since 7/3/21; 2. Resident 206 received olanzapine (used to treat extreme mood swings that include emotional highs and lows) without attempts of GDR since 8/7/21; and 3. Resident 27 received trazodone (an antidepressant medication) without monitoring for the effectiveness by monitoring number of hours of sleep. These failures resulted in unnecessary medications for the residents, which had the potential for increased risks associated with psychotropic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Resident 195 was free of a significant medication error when he received citalopram (a medication for depression) twice the ordered dose. This failure resulted in the medication not given as ordered by the physician, and had the potential for increased risk of side effects (such as fatigue, dizziness, insomnia, etc.) for the resident. Findings: During a medication pass observation on 7/11/22 at 8:27 a.m., licensed vocational nurse (LVN) M was observed preparing and administering 3 medications to Resident 195. The medications included one tablet of citalopram 20 milligrams (mg, unit of measurement). On 7/11/22, a review of Resident 195's medical record indicated he was admitted to the facility with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). It indicated he had a physician's order for citalopram 20 mg once daily for depression starting on 2/30/20. On 3/30/22, the order was reduced to 10 mg. The latest order 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.