Pine Ridge Care Center

Based on observation, interview, and record review, nursing staff failed to develop a care plan for one resident (Resident 53) when there was no care for Resident 53's use of oxygen therapy. This failure decreased the facility's potential to meet Resident 53's needs, as well as cause a decline in Resident 53's physical health and emotional well-being.Findings:A review of Resident 53's face sheet indicated admission to the facility on 8/23/25 with a diagnosis that included Chronic Obstructive Pulmonary Disease (COPD, a progressive lung condition making it hard to breathe, encompassing chronic bronchitis (inflamed airways, mucus) and emphysema (damaged air sacs), Pleural Effusion (the buildup of excess fluid in the pleural space, the area between your lungs and chest wall), and Atelectasis (the partial or complete collapse of a lung or a lobe, occurring when tiny air sacs (alveoli) deflate, preventing proper oxygen exchange.A review of Resident 53's physician order report indicated Resident 53 had an order to receive supplemental oxygen at 2-3 liters per minute (LPM) and licensed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, facility staff failed to provide communication services to one resident (Resident 8) out of 21 sampled residents when translation services were not used to communicate with Resident 8 whose primary language was Mandarin.This failure decreased the facility's potential to prevent a decline in Resident 8's ability to perform Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and a decline in ensuring Resident 8 received necessary care and services.Findings:A review of Resident 8's face sheet indicated admission to the facility on [DATE] with diagnoses of Tubulo-Interstitial Nephritis (a type of kidney disease which involves damage to the small tubes and surrounding tissue in the kidney) and Malignant Neoplasm of the Breast (breast cancer). A further review of this face sheet indicated Resident 8's preferred language was Chinese, but no specific dialect of Chinese was…

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

Based on interview and record review, facility staff failed to ensure one resident (Resident 67) of 21 sampled residents was screened for a need for trauma-informed care when upon admission. This failure decreased the facility's potential to provide culturally competent care that minimized triggers or further traumatized Resident 67.Findings:A review of Resident 67's face sheet indicated admission to the facility on 2/4/25 with diagnoses of hemiplegia (complete paralysis of one side of the body) and hemiparesis (weakness of one side of the body) following a cerebral infarction (stroke) affecting right dominant side and post-traumatic stress disorder (a mental health disorder that can develop after experiencing or witnessing a life threatening or shocking traumatic event).A review of Resident 67's care plans indicated the following:-A care plan dated 2/4/25 indicated Resident 67 had behavioral problems with verbal outbursts. Resident 67's goal for this behavior was to be diverted into a productive and meaningful activity. To reach this goal, staff were directed to remove [Resident…

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

Based on observation, interview, and record review, the facility failed to ensure respiratory equipment was clean and in a usable state for one resident (Resident 76) out of 21 sampled residents when the rented oxygen concentrator in Resident 76's room had visible dust and debris in the vents and needed a filter change.This failure decreased the facility's potential to prevent bacteria and debris directly enter Resident 76's lungs, placing her at risk for infection.Findings:A review of Resident 76's face sheet indicated admission to the facility on 8/30/22 with diagnoses of Community Acquired Pneumonia (a lung infection contracted outside of the facility) and Adult Failure to Thrive (a state of significant physical and functional decline in older adults).A review of Resident 76's physician orders, dated 10/28/25, indicated, Oxygen 2-4 L [liters, a unit of measure] via nasal canula [flexible device used to deliver oxygen through the nose] for saturation [the amount of oxygen carried in your blood as a percentage of the maximum it could carry] < [less than] 90%.During an observation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) was free from abuse when Resident 2 struck her on the left cheek.This failure had the potential to result in serious physical harm to Resident 1.Findings:A review of Resident 1's admission record indicated she was admitted in 5/19 with the diagnosis of cognitive impairment (persistent function deficits that can impact a person's ability to think, learn and remember).A review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 8/16/25, indicated she had severe cognitive impairment.A review of Resident 1's nursing note, dated 8/13/25 and written by Licensed Nurse 1 (LN 1), indicated a staff person had reported to him she had witnessed Resident 1 being struck in the left cheek by Resident 2.A review of Resident 2's admission record indicated he was admitted in 8/20 with the diagnosis of dementia (a progressive state of decline in mental abilities).A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to immediately notify the responsible party (RP, a person who is designated in making decisions about health care and financial matters) for one out of two residents (Resident 1), when Resident 1's RP was not notified until 4/20/25 that Resident 1 fell on 4/18/25 and 4/19/25.This failure was a violation of residents' rights. Findings:A review of Resident 1's face sheet (front page of the chart that contains a summary of basic information about the residents) indicated Resident 1 was admitted to the facility in April of 2025 with a RP listed and a note that indicated, .[phone] number corrected to [xxx-xxx-1966] from [xxx-xxx-9518] on 4/20/25.A review of Resident 1's Nursing Progress note, dated 4/18/25 at 4:26 a.m., indicated, .[Resident 1] is found sitting on the floor next to his bed. [Resident 1] stated, '.I just fell on my butt.'.Called RP.no answer.A review of Resident 1's Nursing Progress, dated 4/19/24 at 4:40 p.m., indicated, . [Resident 1] was…

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

Based on interviews and record reviews, the facility failed to ensure a summary of the baseline care plan (BCP, a document created within 48 hours of a resident's admission to a nursing home, outlining the initial care needed to ensure residents' safety and well-being, focusing on basic needs and resident-specific information) was provided for one resident out of two sampled residents (Resident 1), when there was no documentation indicating Resident 1's responsible party (RP, a person who is designated in making decisions about health care and financial matters) was provided the BCP summary. This failure has the potential to decrease the RP's ability to be informed about Resident 1's care and services.Findings:A review of Resident 1's face sheet (front page of the chart that contains a summary of basic information about the residents) indicated Resident 1 was admitted to the facility in April of 2025 with a RP listed.A review of Resident 1's BCP, dated 4/14/25, did not indicate a copy of the summary of the BCP was provided to Resident 1's RP.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.

Based on interviews and record reviews, the facility failed to ensure one out of two sampled residents (Resident 1) was provided an environment free of accident hazards and received adequate supervision to prevent accidents, when Resident 1 fell from a wheelchair (WC) provided by the facility. This failure could result in the increased risk of accidents.Findings:A review of Resident 1s face sheet (front page of the chart that contains a summary of basic information about the residents) indicated an admission date of 4/2025 with a diagnosis of Alzheimer's Disease (AD, a disease characterized by a progressive decline in mental abilities) and Anxiety (fear, worry).A review of the Fall care plan (CP, a detailed, written document that outlines a resident's individual needs, goals, and how their care will be managed), dated 4/14/25 , did not indicate Resident 1 used a WC.A review of Resident 1's Nursing Progress Note, dated 4/14/25 at 11:00 a.m., indicated, .[Resident 1] ambulatory [walking] with cane, fall risk.Hx [history] of falls (1 fall per month) .prone to wandering behavior, 1:1 [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 report to the Department an injury of unknown source (an injury which was not observed, cannot be explained by the resident, and is suspicious because of the extent or location) for one of four sampled residents (Resident 1) when Resident 1 sustained a broken left arm. The facility was aware of Resident 1's injury on 7/6/25, but did not report it to the Department until 7/8/25.This failure resulted in a delay in the Department's investigation into Resident 1' s injury and its cause, putting Resident 1 at risk for additional harm. A review of Resident 1's Resident Face Sheet, printed 7/16/25, indicated Resident 1 was initially admitted to the facility on [DATE], with diagnoses including Alzheimer's disease (a progressive brain disorder that gradually impairs memory, thinking, and language skills, eventually affecting a person's ability to carry out daily tasks), epilepsy (defined by recurrent seizures, which are sudden, temporary disruptions of normal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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: 1. Ensure nursing staff were able to correctly state the facility ' s policy on how and when to perform Cardiopulmonary Resuscitation (CPR – an emergency procedure that combines chest compressions (the action of pushing hard and fast on the chest while performing CPR) and rescue breathing to restart a person ' s heartbeat and breathing) and Basic Life Support (BLS- a set of life-saving procedures performed on someone if/when their heart stops beating or the person has difficulty breathing until advanced medical help arrive) when four nursing staff (Certified Nursing Assistant A (CNA A), Licensed Nurse C (LN C), LN D, and LN G) of six nursing staff incorrectly stated the facility ' s policy; 2. Immediately perform CPR on one resident (Resident 1) of three sampled residents on [DATE] when she was found in bed not breathing and without a heartbeat; 3. Ensure an Automated External Defibrillator (AED- a portable medical device used to deliver an electric…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 meet professional standards of nursing care for one resident (Resident 1) of three sampled residents when laboratory tests were not completed per physican orders. This failure had the potential to delay treatment for Resident 1. Findings: A review of Resident 1 ' s admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of multiple fractures (broken bones), diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hypokalemia (a low level of potassium (an important mineral) in the blood), hypertension (HTN-high blood pressure), and atherosclerotic heart disease (a narrowing of the vessels in the heart, causing obstruction of blood flow). A review of Resident 1 ' s progress note, dated 3/12/25 at 11:49 a.m., indicated Licensed Nurse K (LN K) documented a telephone order from the Medical Director (MD, a physician) to Test norovirus [a virus that affects the digestive tract], C.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review, interview, and document review, the facility failed to complete the quarterly Minimum Data Set (MDS) for 2 (Resident #5 and Resident #22) of 18 sampled residents. The facility further failed to timely complete a quarterly MDS for 2 (Resident #1 and Resident #48) of 18 sampled residents. Findings included: The Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated 10/2024, indicated, The Quarterly assessment is an OBRA [Omnibus Budget Reconciliation Act] non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. Per the User's Manual, The MDS completion date must be no later than 14 days after the ARD. 1. A Resident Face Sheet indicated the facility readmitted Resident #5 on 08/22/2024. Resident #5's medical record revealed evidence to indicate a quarterly…

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

Based on observation, interview, record review, document review, and facility policy review, the facility failed to ensure staff provided a communication board and a pointer to 1 (Resident #189) of 2 sampled residents reviewed for communication. Findings included: An undated facility policy titled Alternative Communication Device revealed, The purpose of developing and training use of an alternative communication device is to provide the non-verbal resident with a means of functionally communicating his or her wants and needs. Background An alternative communication device is any system of communication used in place of or as a supplement to normal speech and language to facilitate functional communication. The system may be manual or electronic and may include the use of gestures, pictures, words, symbols, voice output, or writing A Resident Face sheet revealed the facility admitted Resident #189 on 02/22/2021. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of cerebral infarction due to embolism of the right middle cerebral artery…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review, and facility policy review, the facility failed to ensure the environment of a resident did not provide a means to exit the facility without staff knowledge for 1 (Resident #13) of 3 sampled residents reviewed for accidents. Findings included: An undated facility policy titled, Resident Elopement, indicated, Purpose The facility will provide a safe environment and preventive measures for elopement with the aim to monitor and document patients at risk for elopement. A Resident Face Sheet revealed the facility admitted Resident #13 on 11/14/2023. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of chronic pain, acute systolic heart failure, and epilepsy. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/11/2024, revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. The MDS indicated the resident did not display wandering behavior. Resident #13'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 observation and interview, the facility failed to ensure residents' rooms measured at least 80 square (sq) feet (ft) per resident in 7 (Rooms 26 through 29, room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) of 45 resident rooms in the facility. Findings included: On 12/11/2024 at 3:13 PM, the Environmental Services staff person measured the following rooms and confirmed the following dimensions: - In room [ROOM NUMBER], there was 74.96 sq ft for each resident. - In room [ROOM NUMBER], there was 74.96 sq ft for each resident. - In room [ROOM NUMBER], there was 73.92 sq ft for each resident. - In room [ROOM NUMBER], there was 74.29 sq ft for each resident. - In room [ROOM NUMBER], there was 71.31 sq ft for each resident. - In room [ROOM NUMBER], there was 73.92 sq ft for each resident. - In room [ROOM NUMBER], there was 70.19 sq ft for each resident. During an interview on 12/11/2024 at 3:43 PM, the Administrator stated was aware of the rooms that did not meet the regulatory guidance for 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 upon observation, interview and record review, the facility failed to ensure the safety of one sampled resident (Resident 1), when he was allowed to leave out on pass (physician approval to leave for a few hours at a time) without a physician ' s order and against facility policy. This failure resulted in Resident 1 purchasing alcohol, consuming three fifths of vodka and attempting to leave the facility against medical advice (without the doctors orders or a discharge plan) while intoxicated. Findings: During an interview on 5/23/24, at 3:11 a.m., Complainant D stated she was a response team member for Specialized Assist for Everyone,(SAFE) (A mobile crisis team through the city that attempted to work with marginalized people to prevent homelessness.). She stated she had responded to a police call on 5/19/24 at 7:20 p.m. for a resident who was intoxicated, uncooperative, verbally aggressive and had attempted to leave the facility against medical advice. She stated she observed Resident 1 in the parking…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 report an allegation of abuse within the required timeframes when allegation was not reported to authorities within the required two hours timeframe after the facility was notified of the allegation. This failure to report allegations of abuse within the federally mandated requirement of two hours, had the potential to contribute to ongoing resident physical abuse, as well as the potential for mental and emotional harm. It also delayed the timely investigation by authorities. Findings: During review of a document titled SOC 341 (a state of California form for reporting allegations of abuse), dated 3/15/24, revealed Resident 1 reported that before lunch the CNA (Certified Nursing Assistant) that was working with her put his hand on her face and around her mouth area. The report indicated the time and date of the alleged event was 3/14/24 at approximately 11:00 a.m. During a further review of SOC 341 it indicated telephone report made to law enforcement on 3/15/24 at 11:00 a.m. The form was faxed to CDPH on 3/15/24 at 1:07…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three residents (Resident 1) received care in accordance with professional standards of practice when Resident 1 had a physician's order for monthly body weights and the facility did not weight Resident 1 monthly. This failure had the potential for Resident 1 to have undetected weight loss or gain and not receive respective medical interventions. Findings: A review of Resident 1 ' s Facesheet indicated he was originally admitted to the facility on [DATE] with an admitting diagnosis of cerebrovascular disease (a disease that affects blood flow and blood vessels in the brain). A review of Resident 1 ' s physician orders indicated order dated 8/14/22 as follows: Monthly weights (start after weekly weights x [times] 4 is completed) A review of Resident 1 ' s weights for the period 8/15/22 to 7/2/23 indicated no weights on the months of December 2022 and February and March 2023. During an interview and record review on 7/21/23, at 10:15 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 interviews and a record review, the facility failed to ensure residents' privacy as well as residents' timely receipt of mail items when two residents (Resident 40 and Resident 19) had received opened mail, and all residents did not receive mail promptly on weekends. This failure had the potential to cause residents to feel isolated from society and disrespected by the facility. Findings: During an interview with Resident #40 on 8/2/21 at 11:22 a.m., he stated: All our mail is open, two state letters opened. Resident deliveries are left outside front door and the Administrator has to go through it. Resident 40 stated this was a violation of privacy. During an interview with Resident #40 on 8/3/21 at 11:07 a.m., he stated: I had a letter from CDPH that was opened. Last three months, I received CDPH, SS and Federal government and they were opened. Couldn't talk to the Administrator, not available. Mail is delayed if Administrator has not gone through it. I don't know why Administrator stole it. I know on July 12 packages for another Resident stored by front door. No log. We…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 post the results of recent Federal or State surveys, including plans of correction, in an area accessible to all residents. This failure did not ensure residents' rights to access survey results for review Findings: During an observation of the three bulletin boards on 8/3/21, at 3:00 p.m., a document indicated Facility Survey Binder is available for your review and is located on the side wall of the front lobby entryway. An observation of the side wall of the front lobby entryway did not locate a binder titled Facility Survey Binder. During an interview with Staff K, on 8/3/21, at 3:10 p.m., she stated she did not know what a survey facility binder was or where it would be located. During an interview with Administrator on 8/5/21, at 2:30 p.m., in his office, he stated he keeps the survey binder in his office. The Administrator stated if residents wanted to see survey results they had to ask.

Based on observation, interview, and record review, the facility failed to post grievance and complaint notices in a manner accessible to all residents, when it posted grievance and complaint notices in areas that were difficult for residents using wheelchairs to view. This failure did not ensure resident rights, and had the potential to delay the facility's identification and response to resident needs or complaints. Findings: During an interview with Resident #40 on 8/3/21 at 11:07 a.m., he stated: CDPH information is posted on board so high, you can't see it and there is always equipment parked there. During an observation in the main dining room, on 8/3/21 at 2 p.m., an upright piano was observed against the south wall, to the left of a bulletin board. On top of the piano was a tall flower arrangement and a black plastic basket, with arts and craft supplies and two puzzle boxes. Attached to the wall, behind the black plastic basket and flowers, was a frame holding a document titled Grievance & Complaints. On the front of the document holder was a document titled Facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 modify comprehensive care plans for five sampled residents (Residents 42, 45, 51, and 87) that were person-centered. These failures had the potential result in care and services that did not meet residents' needs, as well as cause a decline in residents' physical health and emotional well-being. Findings: Resident 42 During an observation and attempted interview with Resident 42, on 8/2/21, at 9:30 a.m., Resident 42 was observed laying on his back in bed in a dark room with the curtains closed and no lights on. When introduced, Resident 42 slowly lifted his head, moved his mouth but did not speak or respond. During observations on 8/2/21, at 10:00 a.m. and 11:15 a.m., and on 8/3/21 at 9:30 a.m., Resident 42 was observed laying on his back, in bed, in a dark room with the curtains closed and no lights on. Resident 42 opened his eyes and stared when asked if he would like to talk. During an observation on 8/5/21, at 8:45 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the safety of residents when: 1. Two residents (Residents 19 and Resident 79) left the facility without supervision; and 2. The facility disposed unused medications using sharps containers (a sturdy, puncture-resistant plastic container for sharp items) and placed sharps containers in an unlocked storage room. These failures had the potential to result in accidents and/or injuries to Residents 19 and 79 while alone and unsupervised, and had the potential to result in diversion of medication or resident injury arising from access to harmful medication. Findings: 1. During review of records, Nurse's Notes dated 4/20/21 at 1:00 PM indicated Licensed Nurse R was informed Resident 19 was not in his room. A search in and around the facility was conducted but the resident could not be found. Further review of Nurses' Notes dated 4/20/21 at 3:13 PM indicated the Resident went out for a walk to get fresh air and had destroyed the wander…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain the usual body weight of one resident (Resident 42) as evidenced by repeated delayed assessment and follow-up by the registered dietitian and repeated delayed implementation of registered dietician's recommendations. This failure could lead to the potential for further decline for Resident 42 who was considered at nutritional risk and experiencing impaired nutrition status. Weight loss is also associated with other negative outcomes such as impaired wound healing or increased risk of death. Findings: Review of resident records indicated Resident 42 was admitted on [DATE] with unspecified dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), major depression, mild cognitive impairment, dysphagia (difficulty swallowing) and history of alcoholism. Review of Registered Dietician's (RD) initial nutritional assessment dated [DATE] 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 did not ensure attending physicians responded to the Consultant Pharmacists recommendations for Antipsychotic Medications (e.g., medication that alters brain chemistry to reduce psychotic symptoms such as harmful behaviors, hallucinations, delusions, and disordered thinking) for 10 residents (Residents 86, 62, 45, 55, 76, 59, 75, 66, 71 and 37). This failure had the potential for resident harm, including death, due to the increased risk of adverse side effects related to Antipsychotic Medication use. Findings: (Reference F758) During an observation and interview, on 8/2/21, at 9:30 a.m., Resident 62's bed was observed in the low position with a mat on the floor next to the bed. Licensed Staff Q stated the mat beside his bed was there to prevent injury if he fell out of bed. She stated Resident 62, sometimes would not call for help when he tried to get out of bed. During an observation on 8/2/21, at 12:30 p.m., Resident 45 was observed seated in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to initiate Gradual Dose Reductions (GDR), for 10 residents (Residents 86, 62, 45, 55, 76, 59, 75, 66, 71, and 37) on Antipsychotic Medication (e.g., medication that alters brain chemistry to reduce psychotic symptoms such as harmful behaviors, hallucinations, delusions, and disordered thinking), when the facility did not implement a GDR as recommended by the facility's pharmaceutical consultant, or document specific clinical contraindications for a GDR when a GDR was not performed. These failures had the potential to cause harmful side effects for residents receiving due to prolonged use of antipsychotic medications, including death. Findings: During an interview with Physician U, an attending physician, on 8/6/21, at 11:00 a.m., he stated he evaluated the risk-versus-benefit of GDR for residents on Antipsychotic medications and either accepted or declined the recommendation for GDR made by the consultant pharmacist. When asked, Physician U…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 there was enough dietary and food nutrition staff in the kitchen to carry out the functions of the food and nutrition service safely and effectively. This failure resulted to the Dietary Manager cooking dinner and breakfast for two days in the absence of a cook. Findings: During the initial tour on 8/2/21, a review of the dietary staff schedule for the day did not indicate the facility had assigned a cook to work the afternoon shift. During interview on 8/2/21 at 4:00 PM, the Dietary Manager stated the facility had been advertising for an additional cook. The Dietary Manager also stated she was cooking dinner that evening. During interview on 8/3/21 at 9:30 AM, the Dietary Manager stated the cook scheduled to prepare breakfast called off, so she prepared breakfast that morning. The Dietary Manager stated she appreciated having the cook scheduled for the afternoon shift coming in early to help with food preparation. During review of the Facility Assessment, developed 11/29/2017 and revised 3/15/21, the…

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

Based on observation and record review, the facility failed to follow the approved menu and physician diet orders for 1 of 15 residents on puree diet (Resident 24), 1 of 2 residents on low fat low cholesterol renal diet (Resident 43), 1 of 7 residents on small portion regular diet (Resident 9), and 1 of 13 residents on low fat low cholesterol diet (Resident 93). This failure can result in undesirable changes of nutritional status, impaired healing, or poor well-being of residents in the facility. Findings: During review of the facility's menu for 8/2/21, a regular portion lunch would consist of 4 ounces of meatloaf, ½ cup garlic mashed potatoes, ½ cup spinach, and one wheat roll. During continuous tray line observation on 8/2/21 at 12:00 PM, [NAME] F prepared the following food items for the following resident plates: Resident 9 - whose tray ticket read small portions, regular should have received ¼ cup mashed potatoes and ½ wheat roll; however, the resident received a regular portion of mashed potatoes and 1 wheat roll. Resident 24 - whose tray ticket read regular pureed 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.

Based on observation, interview and record review, the facility failed to ensure: 1. Kitchen staff practiced safe food handling habits to prevent contamination of food; and 2. Expired food items were disposed by expiration date. These failures could potentially result to food safety hazards, food contamination and outbreak of foodborne illness among residents of the facility. Findings: 1. During observation of the kitchen and staff on 8/2/21 at 12:20 PM, [NAME] F was observed wearing a bracelet and two rings on his right ring finger. [NAME] F washed his hands but did not remove his bracelet and rings. He proceeded to don gloves and work at tray line wearing his rings and bracelet. During observation on 8/2/21 at 12:20 PM, Dietary Aide E, was noted not to be wearing her apron while assisting the cook at tray line. During observation on 8/3/21 at 9:30 AM, Dietary Aide E was observed wearing a plastic apron while working at the washing section of the kitchen. She was removing food items from used residents' trays. During continued observation on 8/3/21 at 12:42 PM, Dietary Aide E was…

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

Based on interview and record review, the facility failed to ensure its Medical Director coordinated physician services for residents, when the Medical Director did not ensure attending physicians followed policy for Gradual Dose Reductions (GDR) and monitoring of residents on antipsychotic medications. This failure did not demonstrate appropriate physician leadership and had the potential to cause resident harm related to side effects of prolonged use of antipsychotic medications. Findings: (Refer to F756 and F758) During an interview on 8/6/21, at 11:00 a.m., Physician U stated for residents on Antipsychotic medications he evaluated the risk-versus-benefit of GDR for the antipsychotic medication prescribed, and either accepted or declined the recommendation from the pharmacist. Physician U was unable to state if he had recently approved any GDRs for his residents. Physician U stated ultimately he would be the one to decide how to treat his residents. Physician U was unable to generally describe the facility Policy and Procedure for Antipsychotic Medication Monitoring. During an…

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

Based on interview and record review, the facility's Quality Assessment and Performance Improvement (QAPI) committee failed to identify and address quality deficiencies, when the facility's QAPI committee: 1. Had knowledge of a concern raised by its pharmaceutical consultant but the committee did not develop an action plan to correct the concern; 2. Did not prioritize known deficiencies, or establish goals for monitoring, tracking, and correcting deficiencies for Resident Care. These failures did not ensure the facility implemented QAPI system, and had the potential to negatively impact residents' quality of care and quality of life through the facility not addressing resident care issues or ensuring its provision of care was performed at the highest level and in the safest environment. Findings: (Refer to F756 and F758) Review of the QAPI meeting minutes for the months of January, February, and March of 2021 indicated a report from the facility's pharmaceutical consultant, which recommended the facility initiate Gradual Dose Reductions (GDR's) for residents on antipsychotic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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's Quality Assessment and Performance Improvement (QAPI) committee failed to develop and implement a plan of action to correct an identified quality deficiency, when the facility's QAPI committee did not develop or implement a plan of action to correct a quality deficiency concerning antipsychotic prescribing and gradual dose reductions (GDR). This failure did not comply with facility policy or ensure care to maintain the highest level of resident functioning. Findings: (Refer to F865) During an interview on 8/10/21 at 12:45 p.m., the Administrator spoke about the facility's QAPI committee. The administrator stated he wrote notes on all the reports submitted from the departments for the meeting, and placed those notes into the QAPI binder. The Administrator was asked to provide documentation for any corrective action plans on any topic, including the monitoring and evaluation of the effectiveness of the plans, but the Administrator did not respond or provide any documentation. The Administrator stated the facility's 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 maintain a safe and sanitary environment in the kitchen as evidence by cracked tiles on several areas in the kitchen floor. This failure could cause trips and falls among the kitchen staff and cause dirt to build up on the floor attracting cockroaches and rodents. Findings: During an observation in the kitchen on 8/3/21, at 11:07 AM, cracked tiles were noted on several areas of the kitchen floor. During interview on 8/5/21, at 10:41 AM, the Dietary Manager stated that she had spoken to maintenance the previous week the need to replace the cracked tiles in the kitchen. The Dietary Manager stated there is no time frame, but she plans to follow-up with maintenance to address the problem as soon as possible. Review of the Food Code 2017 indicated: It is the standard of practice to ensure materials for indoor floor, wall, and ceiling surfaces under conditions of normal use shall be: smooth, durable, and easily cleanable for areas where food establishment operations are conducted.