San Rafael Healthcare & Wellness Center, LP

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to honor the residents' right to be informed of the plan of care when five of nine sampled residents were not told before admission that their physical therapy (treatment that helps improve how the body performs physical movements) would be done via telehealth (health-related services through live video call) or that they would only receive one session per week. This failure caused residents to feel let down, feel that their progress was slower than they expected, and caused Resident 7 and Resident 8 to not participate in physical therapy. Finding: During an observation on 4/3/25 at 10:35 a.m., a staff member donned a gown and gloves at the doorway to Resident 1's room, and then entered the room bringing a walker and an iPad on wheels to Resident 1's bedside. A voice from the iPad gave instructions to Resident 1 to get up from the bed and go for a walk. The staff in the room assisted Resident 1 to get up and put a gait belt on the resident.…

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

Based on interviews and record reviews, the facility failed to ensure a copy of the notice of transfer was sent to the representative of the Office of the State Long-Term Care (LTC) Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) for one out of two sampled residents (Resident 1), when the facility was not able to provide evidence that the notice of transfer was sent to the Ombudsman. This failure had the potential to put Resident 1 at risk of being inappropriately transferred or discharged from the facility. Findings: A review of Resident 1's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated Resident 1 admitted to the facility in November of 2024. During an interview on 3/24/25 at 12:05 p.m., the Social Services Director (SSD) stated a notice of transfer form should have been completed by the nurse when Resident 1 was transferred out of the facility to an emergency department (ED, a hospital facility that provides immediate, unscheduled medical care for those…

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 free from unnecessary psychotropic medications (drugs that affect the brain and central nervous system to treat mental health conditions) when prescribed a psychotropic medication without: 1. non-pharmacologic interventions (NPIs, treatments or therapies that do not involve the use of medications) in place to address residents' behavior, and 2. monitoring of behaviors, response to the anti-anxiety (AA, psychotropic medication used to reduce symptoms of anxiety- fear, worry) medication, including side effect (SE, reaction to a medicine) or adverse drug reaction (ADR, dangerous harmful reaction to drugs) in place These failures put the Resident 1 at risk of side effects and adverse drug reactions related to psychotropic medication use. Findings: A review of Resident 1's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated Resident 1 admitted to the facility in November of 2024 with diagnoses of dementia (a…

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

Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice when: 1. Resident 54 did not receive scheduled medications in a timely manner. 2. Certified Nurse Assistant (CNA) 1 was observed laying in Resident 37's bed using her personal cellphone. These failures increased the resident's potential to have unmet health needs and decreased the facility's potential to provide responsible and accurate care for residents. Findings: 1. During a concurrent observation and interview on 3/17/25 at 11:44 a.m. with Resident 54 in her room, Registered nurse (RN) 1 brought Resident 54 a medicine cup with 10 pills in it. RN 1 informed Resident 54 the medications in the cup were ibuprofen (medication used to treat pain), docusate (medication used to treat constipation), multivitamin and ascorbic acid (vitamin c supplement). Resident 54 stated her medications were always late and they should have been given with breakfast around 8 a.m. During a concurrent interview and record review on 3/20/25 at 3:21 p.m. with 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 ensure insulin (medication used to reduce blood sugar) was not administered when blood sugar was below 120 (target range for blood sugar when insulin is not required) for one of 26 sampled Residents (Resident 7) for 10 out of 19 days in March 2025. This failure had the potential to result in low blood sugar symptoms for Resident 7. Findings: During a review of Resident 7's Face Sheet (demographics), the Face Sheet indicated Resident 7 was admitted on [DATE] with the diagnoses including diabetes mellitus type 2 (disease that causes high blood sugar), hypertension (high blood pressure, Cognitive Communication Deficit (medical condition involving thinking process and attention), need for assistance with personal care. During a concurrent observation and interview on 3/19/25 at 7:51 a.m. with Licensed Vocational Nurse (LVN) 1, in Resident 7's room, LVN 1 administered Insulin Glargine 15 units via prefilled syringe to Resident 7. LVN 1 stated…

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 medications, supplements, and supplies were appropriately labeled and stored in accordance with accepted standards of practice when: 1. A prescription nystatin powder (a medication to treat yeast or fungal infection of the skin) was found at Resident 9's bedside table. 2. Two medication bubble packs were left unattended on top of a medication cart. 3. Two used topical medications had no caps to cover the tubes in the treatment cart. 4. A collagen matrix dressing (a type of wound dressing that promotes wound healing) package and a Xeroform (a type of wound dressing that promotes wound healing) package dressing were found open in the treatment cart. 5. Five expired syringes with needles were found in the emergency cart. 6. The refrigerator storage for medications was not maintained at a safe temperature. 7. Expired medications were observed in one of two medication carts, cart one. 8. Unsecured medication was observed at the bedside…

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 food was stored in safe and sanitary conditions in the food service department when: 1. The kitchen refrigerator and the Dry Food Storage Area contained food that was not labeled and not covered. 2. The emergency food storage area contained food that was not labeled and expired. These failures had the potential to expose residents to food contamination and food-borne illnesses (sickness by consuming contaminated food or drinks). Findings: 1. During an observation on 3/17/25 at 8:30 a.m., in the kitchen refrigerator, there were seven cucumbers, inside an open box uncovered with no date. During an interview on 3/17/25 at 8:36 a.m. with DM in the kitchen, DM stated the expectation was for staff to label and date all food to prevent cross-contamination and food-borne illnesses. DM further stated the expiration date was important to ensure the residents consumed a safe food product. During an observation on 3/17/25 at 8:46 a.m., in the Dry Food Storage Area, there were individual-packed Italian…

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 for one of 26 sampled residents (Resident 13) was within her reach. This failure had the potential for Resident 13's needs not being met. Findings: During a review of Resident 13's admission Record, dated 3/18/25, the admission Record indicated Resident 13 was admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD, a chronic lung disease causing difficulty in breathing). During a concurrent observation and interview on 3/17/25 at 10:53 a.m., in Resident 13's room, Resident 13 was lying in bed. Resident 13's call light was tied on the left bed rail and was hanging off the bed. Resident 13 stated she could not reach the call light where it was located. Resident 13 stated she uses her call light to call for assistance. During a concurrent observation and interview on 3/17/25 at 10:55 a.m., in Resident 13's room with the Director of Nursing (DON), the DON confirmed the location…

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 26 sampled residents (Resident 1) was notified of a room/roommate change with a written notice that included the reason before the facility had changed the resident's room. This failure had the potential to result in negatively impacting Resident 1's emotional and psychosocial well-being. Findings: During an interview on 3/17/25 at 9:05 a.m. with Resident 1, Resident 1 stated she woke up to multiple male staff standing over her bed and was told to get up because she was moving to a different room. Resident 1 stated she was not notified of the room change prior to moving and did not want to change rooms. During a concurrent interview and record review on 3/19/25 at 4:51 p.m. with the Administrator (Admin), Resident 1's Electronic Health Record (EHR) was reviewed. The EHR did not show a bed change notification. The Admin confirmed Resident 1's room was changed in June 2023. The Admin stated, this is a problem and Resident 1 should have been notified. During a review of Resident 1's Progress Note, dated 6/15/23,…

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 shower's water temperature was comfortable for one of 26 sampled residents (Resident 1). This failure resulted in Resident 1 not receiving a comfortable shower. Findings: During an interview on 3/17/25 at 9:05 a.m. with Resident 1, Resident 1 stated the shower's water never stayed warm. During a concurrent observation and interview on 3/19/25 at 7:55 a.m. with the Maintenance Director (Main) in the Spa Shower Room, the Main checked the shower's hot water temperature, and it read 90 degrees Fahrenheit after 3 minutes. The Main stated the temperature should have been 110 degrees Fahrenheit. During a review of the facility's policy and procedure (P&P) titled, Water Temperatures, dated 1/2/12, the P&P indicated, The Facility ensures water is maintained at temperatures suitable to meet residents' needs.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a copy of notice of transfer/discharge was sent to the Ombudsman (an advocate for residents of nursing homes) for two of 26 sampled residents (Residents 58 and 59) when: 1. Resident 58 was transferred to the hospital on 2/26/25. 2. Resident 59 was discharged home on [DATE]. These failures had the potential for residents to be inappropriately transferred or discharged which could result in violating their rights. Findings: 1. During a review of Resident 58's admission Record, dated 3/19/25, the admission Record indicated Resident 58 was admitted to the facility on [DATE] with a diagnosis of acute (short duration and requires immediate attention) pyelonephritis (kidney infection). During a review of Resident 58's Nursing Progress Note, dated 2/26/25, the Nursing Progress Note indicated Resident 58's had a fever of 100.6 Fahrenheit and a nurse practitioner ordered to send Resident 58 to the emergency room for further evaluation for possible sepsis…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to assess and submit accurate data for one of 26 sampled residents (Resident 37) when: 1. the Level I PASRR (Preadmission Screening and Resident Review- used to receive needed mental health services) screening was not reassessed upon admission to the facility. This failure had the potential for Resident 37 to not receive specialized mental health services to meet their needs. 2. the Minimum Data Set (MDS- an assessment tool used to guide resident care) did not reflect Resident 37's current status. This failure resulted in the transmission of inaccurate data to the Centers for Medicare and Medicaid Services (CMS). Findings: 1. During a review of Resident 37's admission Record, dated 3/20/25, the admission Record indicated Resident 37 was admitted to the facility on [DATE] with diagnoses of post-traumatic stress disorder (PTSD-mental health condition caused by experiencing or witnessing a traumatic event) anxiety disorder (mental health condition that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop care plans for two of 26 sampled residents (Resident 1 and 9) when: 1. There was no fall care plan for Resident 1. This failure had the potential to cause multiple falls due to lack of interventions and proper monitoring. 2. There was no physical therapy (PT, the treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise) care plan for Resident 9. This failure had the potential for Resident 9 to not receive the specific services necessary to meet her needs. Findings: 1. During a review of Resident 1's admission Record, dated 3/20/25, the admission Record indicated Resident 1 was admitted on [DATE] with diagnoses of dementia (a decline in mental abilities, such as memory, thinking and reasoning), abnormalities of gait and mobility (abnormal movements and walking pattern), and difficulty in walking. During a concurrent observation and interview on 3/19/25 at 7:55 a.m. with Resident 1 in her room,…

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 assist one of 26 sampled residents (Resident 50) with feeding in a timely manner. This failure had the potential for Resident 50 to lose weight. Findings: During a review of Resident 50's admission Record, dated 3/19/25, the admission Record indicated Resident 50 was admitted to the facility on [DATE] with diagnoses of spinal stenosis (a condition where the spinal canal, the bony tunnel that protects the spinal cord and nerve roots, becomes narrowed), failure to thrive (FTT- lack of appropriate weight gain or a decline, which can lead to further health problems) and need for assistance with personal care. During an observation on 3/17/25 from 12:37 to 1:14 p.m. in Resident 50's room, Resident 50 was lying in the bed with lunch tray on his bedside table. Resident 50 was nonverbal and staring at his lunch tray, but was unable to move his arms/hands to feed himself. During an interview on 3/17/25 at 1:14 p.m. with Director of Nursing (DON)…

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 services to attain the highest practicable physical, mental, and psychosocial well-being for one of 26 sampled residents (Resident 9) when physician's orders for physical therapy treatment (PT, the treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise) were not provided. This failure resulted in Resident 9 feeling frustrated on her functional and physical progress. Findings: During a review of Resident 9's admission Record, dated 3/18/2025, the admission Record indicated Resident 9 was admitted to the facility on [DATE] with diagnoses of obesity and difficulty in walking. During an interview on 3/17/25 at 11:22 a.m., with Resident 9, Resident 9 stated she was in the facility mainly to receive rehabilitation services because she shattered her kneecap and broke her left femur last year. Resident 9 stated she had not been receiving physical therapy for some time now which…

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 label an enteral feeding (a method to provide food through a tube placed in the nose, the stomach, or the small intestine) bottle, an enteral feeding pump bag (a feeding bag consists of a feeding bag and tubing), and a syringe used for enteral feeding for one of 26 sampled residents (Resident 22). This failure had the potential for enteral feeding supplement and equipment to be misused by staff causing cross contamination for Resident 22. Findings: During a review of Resident 22's admission Record, dated 3/18/25, the admission Record indicated Resident 22 was admitted to the facility on [DATE] with a diagnosis of gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach) malfunction. During an observation on 3/17/25 at 9:50 a.m., in Resident 22's room, a Glucerna 1.5 (an enteral feeding formula) was observed infusing at 60 ml/hr (milliliter per hour, a unit of measurement). Upon…

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 Licensed Vocational Nurse (LVN) appropriately primed (removing air bubbles from the needle to ensures that the needle is open and working) a Lantus insulin (a long acting medication used to control high blood sugar) pen (a device resembling a pen that delivers insulin injection) before administering to one of 26 sampled residents (Resident 7). This failure had the potential to compromise the medication dose given to Resident 7. Findings: During a review of Resident 7's admission Record, dated 3/18/25, the admission Record indicated Resident 7 was admitted to the facility on [DATE] with a diagnosis of diabetes mellitus type 2 (high blood sugar). During a concurrent medication administration observation and interview on 3/19/25 at 8:05 a.m., of Resident 7's morning medications, with LVN 1, LVN 1 removed the cap of the Lantus insulin pen, turned the dial, and pressed the injection button. LVN 1 then attached and screwed the needle…

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 medication error rate was not greater than five percent when three identified medication errors out of 36 opportunities were observed: 1. Losartan Potassium (medication to manage high blood pressure) was administered without obtaining a blood pressure prior to administration for one of 26 sampled residents (Resident 7). 2. Insulin Glargine [Lantus] (medication to manage high blood sugar) was administered outside of dosing parameter instructions for one of 26 sampled residents (Resident 7). 3. Metoprolol Succinate ER(medication to manage high blood pressure) was not administered per the physician's order for one of 26 sampled residents (Resident 7). These failures resulted in an overall facility medication error rate of 8.33% and had the potential to result in adverse health outcomes for Resident 7 and Resident 12. Findings: 1. During a review of Resident 7's Face Sheet (demographics), the Face Sheet indicated Resident 7 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide physical therapy treatment (PT, the treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise) as ordered by a physician for one of 26 sampled residents (Resident 9). This failure had the potential for Resident 9 to not attain her highest possible level of physical and functional well-being. Findings: During a review of Resident 9's admission Record, dated 3/18/25 admission Record indicated Resident 9 was admitted to the facility on [DATE] with diagnoses of obesity and difficulty in walking. During an interview on 3/17/25 at 11:22 a.m., with Resident 9, Resident 9 stated she was in the facility mainly to receive rehabilitation services because she shattered her kneecap and broke her left femur last year. Resident 9 stated she had not been receiving physical therapy for some time now which concerned her because she had been in the facility for months. During a review of Resident 9's Physician'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 follow and implement infection control practices for three of 26 sampled residents (Residents 7, 55, and 1) when: 1. Physical Therapist Assistant (PTA) 1 was not wearing a gown while proving care to Resident 7 who was on Enhanced Barrier Precautions (EBP, are infection control intervention designed to reduce the spread of multidrug-resistant organism, MDROs - a germ that is resistant to many antibiotics) 2. Restorative Nursing Assistant/ Certified Nursing Assistant (RNA) 1 was not wearing a gown while repositioning and changing blanket of Resident 55 who was on EBP. 3. Resident 1 was not placed on EBP. This failure had the potential to result in the spread of infectious diseases among residents, staff, and visitors. Findings: 1. During a review of Resident 7's admission Record, dated 3/18/25, the admission Record indicated Resident 7 was admitted to the facility on [DATE] with a diagnosis of chronic ulcer (open sore or wound) of the right…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide a sanitary environment when one of 26 sampled residents (Resident 3) was observed with black insects crawling in her bed. This failure had the potential to result in Resident 3 being exposed to insect bites and potentially triggering an allergic reaction. Finding: During a review of Resident 3's Face Sheet (demographics) dated 3/20/25, the Face Sheet indicated Resident 3 was admitted to the facility on [DATE] with the diagnoses including cognitive communication deficit (communication difficulties arising from impairments in thinking process, memory, attention span, executive functions), need for assistance with personal care, and generalized muscle weakness. During a concurrent observation and interview on 3/20/25 at 12:30 p.m. with Certified Nursing Assistant (CNA) 2 in Resident 3's room, Resident 3 was observed lying in bed. CNA 2 pulled back Resident 3's blankets and tiny black insects scattered around the bed linens and on…

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

Based on interviews and record review, the facility failed to provide a written notice to a resident's Responsible Party (RP) for one resident (Resident 2) of three sampled residents when Resident 2 was moved to a different room without prior notification of the reason why, when the change would occur, and the opportunity to participate in the decision. This failure decreased the facility's potential to respect the resident or the RP's right to participate in the decision to move to a different room which had the potential to affect the resident's psychosocial well-being. Findings: A review of Resident 2's admission record indicated admission to the facility in October 2024 with diagnoses which included autistic disorder (a developmental disability caused by differences in the brain characterized by problems with social communication and interaction), anxiety disorder (a group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can significantly interfere with daily life), schizoaffective disorder bipolar type (a rare type 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 review, the facility failed to develop and implement a person-centered care plan for one resident (Resident 1) when the facility did not initiate a care plan for Resident 1's wandering and high risk of elopement behavior. This failure contributed to a breakdown in the facility's system to provide the person-centered supervision required for Resident 1 when she eloped from the facility unsupervised in her wheelchair. Findings: A review of Resident 1's admission record indicated she was admitted on [DATE], with a primary diagnosis was Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities). A review of Resident 1's Minimum Data Set (MDS- an assessment tool) dated 1/23/25 indicated a Brief Interview for Mental Status (BIMS- a screening tool used to assess a person's orientation and short-term memory) score was 3 which meant a severe impairment in cognition (the mental process of acquiring knowledge and understanding through thought, experience, 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 interviews and record review, the facility failed to provide adequate supervision to one resident (Resident 1) of three sampled residents when Resident 1 eloped from the facility. This failure resulted in Resident 1 leaving the facility without staff knowledge and decreased the facility's potential to prevent accident and injury to Resident 1. Findings: A review of Resident 1's admission record indicated admission to the facility in January 2024 with a primary diagnosis of Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities). A review of Resident 1's Minimum Data Set (MDS- an assessment tool) dated 1/23/25 indicated a Brief Interview for Mental Status (BIMS- a screening tool used to assess a person's orientation and short-term memory) score was 3 which meant a severe impairment in cognition (the mental process of acquiring knowledge and understanding through thought, experience, and senses). The MDS also indicated Resident 1 used a manual wheelchair for mobility. A review of Resident 1's Medication Administration Record (MAR) 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 on interview and record review, the facility failed to manage the dialysis (use of a machine to clean the blood when the kidneys are no longer able to do this) care of one of two sampled residents (Resident 1) when facility staff did not obtain a physician's order for Resident 1's dialysis, did not include his dialysis schedule in his care plan, did not transport Resident 1 to his scheduled dialysis appointments or transported Resident 1 late to his appointments, did not document Resident 1's missed appointments, did not notify Resident 1's physician about his missed appointments, and did not document the reason the appointments were missed. These failures had the potential to result in negative health outcomes for Resident 1 when his caregivers may not have readily available all the information they need regarding his dialysis care and potentially left his doctor unaware of how many dialysis appointments he is missing. Finding: During an interview on 7/1/24 at 1:03 p.m., an anonymous complainant stated the facility had been having issues with transporting Resident 1 to his…

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 develop a system for validating the competencies of registry nurses. This failure had the potential to result in residents being cared for by nurses who may not have all the skills needed to provide safe care. Finding: During an interview on 5/7/24 at 12 p.m., the personnel file of a registry nurse who was involved in a facility reported incident was requested for review. Director of Nursing (DON) stated the nurse's personnel records were on file with the staffing agency and copies would need to be requested from the agency. DON took down a list of records this surveyor wanted to see, which included the nurse's competency evaluation. Review of an email correspondence on 5/9/24 at 10:43 a.m. revealed Administrator indicated he had requested the nurse's competency evaluation from the staffing agency with a request that it be sent urgently. On 5/10/24 at 8:56 a.m. and 4 p.m., phone calls were made to DON and Administrator requesting a status update on the nurse's competency evaluation with no reply. During an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect one of three sampled residents (Resident 1's) right to be free from financial abuse when the Social Services Director (SSW) used Resident 1's ATM (Automated Teller Machine) card for her personal use without authorization. This finding caused Resident 1 anxiety and sadness, and had the potential to result in severe psychological and emotional distress in addition to financial exploitation. Findings: Record review indicated Resident 1 was admitted to the facility on [DATE] with medical diagnoses including Congestive Heart Failure (A long-term condition in which the heart cannot pump blood well enough to meet the body's needs), Major Depressive Disorder (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and Anxiety Disorder (A mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one'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 and concurrent interview with the Administrator on 8/2/23, the facility failed to provide bedrooms measuring at least 80 square feet per resident in 4 of 27 resident rooms (rooms 6, 8, 9,& 17). This failure resulted not having the minimum required space in rooms 6, 8, 9, and 17. Findings: During a tour of the facility with the Administrator on 8/2/23 at 10:00 a.m. the Administrator showed and stated rooms 6, 8, 9, and 17 did not provide at least 80 square feet of space per resident. The Administrator provided a copy of the Client Accommodations Analysis (CDPH 709) dated 4/27/23, which indicated rooms 6, 8, 9, and 17 provided 77.7, 72.6, 77.7, and 66.4 square feet of space per resident respectively. No adverse effects to resident health and safety was reported. The Administrator stated the facility was requesting a renewal of the room size waiver for rooms 6, 8, 9, and 17. The Department recommends the facility be granted a room size waiver for rooms 6, 8, 9, and 17.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices requirement were met in the kitchen when: 1. The Ansul System (an automatic fire suppression system) pipeline was observed to have brown and black debris. 2. Two kitchen cabinets that stored kitchen equipment had peeling paint and wood and had yellow and brown stains. 3. Four clear rectangular plastic containers were stored right side up. 4. Four one-gallon clear plastic containers were stored stacked up with visible water in them. 5. The foil and saran wrap holders had the cutters with brown rust. 6. The window air conditioner vents had visible gray debris. 7. A dietary staff did not change gloves and perform hand hygiene in between cleaning kitchen equipment and preparing food. 8. A dietary staff did not wear gloves while preparing food. These failures had the potential to expose 47 residents who consume food prepared in the kitchen to foodborne illnesses. Findings: 1. During a concurrent observation and interview on 5/22/23, at 8:41 a.m., 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 2. During a concurrent observation and interview on 5/22/23, at 8:50 a.m., with the Infection Preventionist (IP), Resident 28's oxygen cannula and tubing (a system to deliver oxygen from a tank to the Resident's nose) was observed with no date or time labeled on the tubing. The IP stated, the tubing should be labeled with date and time at least every seven days. Review of facility's policy and procedure titled, Oxygen Therapy, Nursing Manual - General, dated November 2017, indicated, Policy: Oxygen is administered under safe and sanitary conditions to meet resident needs . II. Oxygen - Storage, Maintenance, and Handling . C. Oxygen tubing, mask, and cannulas will be changed no more than every seven (7) days and as needed. The supplies will be dated each time they are changed. Based on observation, interview, and record review, the facility failed to ensure: 1. A staff performed hand hygiene while delivering meal trays to one of 21 sampled residents (Resident 11) and one of two unsampled residents (Resident 33).…

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 did not record accurate diagnoses on the Minimum Data Set Reports (MDS- an assessment tool) and the admission Record (a document containing resident profile information) for Residents 29, 39, 43, 47, 152 and 153. This failure had the potential to result in inaccurate care plans and inappropriate medical care for these residents. Findings: Resident 29: During a review of Resident 29's admission Record, dated 1/12/23, the admission Record indicated, Resident 29's admission date was 1/12/23. Diagnosis information on the admission Record listed the onset date of Paraplegia (loss of muscle function in the lower part of the body) as 1/12/23. However, during a review of Resident 29's Discharge Summary, dated 1/12/23, the Discharge Summary indicated, Resident 29's Paraplegia was a diagnosis of past medical history from 1970. Resident 39: During a review of Resident 39's admission Record, dated 5/22/23, the admission Record indicated, Resident 39 was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete and obtain informed consents (a consent that provides the risks and benefits of taking a medication, possible side effects, alternate treatments, and risk of no use) for three psychoactive medications (chemical substances that affect mental processes such as perception, mood, cognition, and behavior) for one of 21 sampled residents (Resident 14). This failure had the potential for Resident 14's representative to not be fully informed and consented for Resident 14 to receive psychoactive medications. Findings: During a review of Resident 14's admission Record (a document that gives a resident's information at a quick glance), dated 5/24/23, the record indicated resident was admitted to the facility on [DATE], with diagnoses of Parkinson's Disease (a progressive disorder of the nervous system that affects movement, often including tremors), dementia (a progressive decline in memory that affects the ability to perform everyday activities),…

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 and the phone were within reach for one of 21 sampled residents (Resident 37). This failure had the potential for Resident 37 to be unable to contact staff when in need of assistance. Findings: During a review of Resident 37's Physician Note, dated 11/4/22, the note indicated, Resident 37 was admitted to the facility on [DATE] with a diagnosis of moderate dementia (a progressive decline in memory that affects the ability to perform everyday activities). During a review of Resident 37's Minimum Data Set (MDS - an assessment tool) section G (functional status), dated 3/8/23, section G indicated, Resident 37's bed mobility required limited assistance from staff. During a concurrent observation and interview on 5/22/23, at 9:58 a.m., with Resident 37, Resident 37 was lying in bed with the head of the bed elevated. Resident 37's call light was on top of the bedside drawer, not within Resident 37's reach. Resident 37…

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 21 sampled residents (Resident 37) had a Physician Orders for Life-Sustaining Treatment (POLST - a form that communicates a person's wishes of medical orders during an emergency) that was signed by the resident's durable power of attorney (DPOA - a person who makes medical decisions anytime a resident is incapable to do it on her/his own). This failure had the potential for Resident 37 to receive inaccurate treatment during an emergency. Findings: During a review of Resident 37's Physician Note, dated 11/4/22, the note indicated, Resident 37 was admitted to the facility on [DATE] with a diganosis of moderate dementia (a progressive decline in memory that affects the ability to perform everyday activities). During a review of Resident 37's Order Summary Report, dated 5/23/23, the report indicated, Resident is incapable of making health decisions. If incapable, state reason:_Dementia_Healthcare decision maker assigned: (name 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a physician's order for a floor pad next to the bed was implemented for one Resident, with a history of falls (Resident 20), of 21 sampled residents. This failure had the potential for Resident 20 to sustain injuries in a fall from the bed to the unpadded floor. Findings: A review of Resident 20's Order Summary Report, date 5/25/23, indicated, Resident 20 was admitted to the facility on [DATE], with diagnoses which included dementia and a history of falling. The report included a physician's order dated 4/2/19, for floor pad to the right side of bed for prevention of injury during fall, every shift. During an observation on 5/24/23, at 10: 31 a.m., Resident 20 was observed in her room, lying in bed. There was no pad on the floor next to the bed. During a concurrent observation and interview on 5/24/23, at 10:44 a.m., with the Director of Nursing(DON), Resident 20 was observed lying in bed. There was no pad on the floor next to 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 ensure two of 21 sampled residents (Resident 5 and Resident 37) were provided juice supplement per physician's orders. This failure had the potential for Resident 5 and Resident 37 nutritional needs not being met. Findings: 1. During a review of Resident 5's Physician Note, dated 10/13/22, the note indicated, Resident 5 was admitted to the facility on [DATE], with a diagnosis of congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should). During a concurrent meal observation, interview, and record review on 5/22/23, at 12:48 p.m., with Resident 5, Resident 5 was in bed eating her lunch meal. A review of Resident 5's lunch ticket indicated, Beverages: 8 oz (ounce) Water, 6 oz Juice Supplement (a high calorie, high protein nutritional juice drink that is an alternative to dairy based shakes). Resident 5 had a glass of water, but no juice supplement. Resident 5 stated, she did not get her juice…

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. The Residents' Refrigerator was free of ice buildup. 2. The Residents' food that was brought into the facility was labeled and had received dates. This failure had the potential for the quality of the Residents' food to be diminished and the food to be consumed beyond the expired date. Findings: 1. During a concurrent observation and interview on 5/23/23, at 9:28 a.m., with the Certified Dietary Manager (CDM), the Residents' Refrigerator was observed to have ice buildup on the walls of the freezer and on the back of the refrigerator. The CDM stated, there should not have been ice buildup in the freezer and refrigerator. During an interview on 5/24/23, at 1:47 p.m., with the Director of Housekeeping (DH), the DH stated, his staff cleaned the Resident's Refrigerator every Friday. The DH stated, there was no cleaning log for the Resident's Refrigerator. 2. During a concurrent observation and interview on 5/23/23, at 9:28 a.m., with the Certified Dietary Manager (CDM), the following items were found 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.

Based on observation and interview, the facility failed to ensure the garbage was disposed of properly when one of the garbage dumpster lids was not closed, and the surrounding area had trash on the ground. This failure had the potential to attract pests and rodents. Findings: During a concurrent observation and interview on 5/23/23, at 9:21 a.m., at the outside corner of the facility, with the Certified Dietary Manager (CDM), one of the garbage dumpster lids was opened and the surrounding area had trash on the ground. The CDM stated, the garbage dumpster lids should have been closed and the surrounding area did not look good. The CDM stated, maintenance and housekeeping oversaw the garbage dumpster and the area surrounding the garbage dumpster. During an interview on 5/23/23, at 9:41 a.m., with the Director of Housekeeping (DH), the DH stated the garbage dumpster lid had to be closed at all times and the area around it should be clean. According to the United States Food and Drug Administration (USDA) Food Code 2022, Section 5-501.110 Storage Refuse, Recyclables, and Returnable,…

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 Medication Administration Records (MAR) for two sampled residents (Resident 5 and Resident 37) accurately reflect that a 6 oz (ounce) of juice supplement was documented as not given during a meal. This failure resulted in an inaccuracy of nutritional supplement intakes for Resident 5 and 37. Findings: 1. During a review of Resident 5's Physician Note, dated 10/13/22, the note indicated, Resident 5 was admitted to the facility on [DATE], with a diagnosis of congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should). During a concurrent meal observation, interview, and record review on 5/22/23, at 12:48 p.m., with Resident 5, Resident 5 was in bed eating her lunch meal. A review of Resident 5's lunch ticket indicated, Beverages: 8 oz Water, 6 oz Juice Supplement (a high calorie, high protein nutritional juice drink that is an alternative to dairy based shakes). Resident 5 had a…

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

Based on observation, interview, and record review, the facility failed to maintain a safe environment for one resident, with an intellectual disability (Resident 101), out of 21 sampled residents, when potentially hazardous items were kept at Resident 101's bedside. This failure had the potential for Resident 101 to injure himself with unsupervised use of the items. Findings: A review of Resident 101's admission Record (demographic information), dated 5/5/23, indicated, he was admitted to the facility with diagnoses which included Down Syndrome (a condition which includes intellectual disability) and Alzheimer's Dementia (a progressive decline in memory that affects the ability to perform everyday activities ). During an observation on 5/22/23, at 11:29 a.m., in Resident 101's room, a blue plastic, gallon-sized basket was observed on the floor next to the bed. The basket held a container of medicated gauze packing strips (used for wound care), a container of medicated skin cleanser, a pill cutter with a metal blade, and a disposable razor. During a concurrent observation 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 provide oversight and supervision, by a Registered Dietician, to kitchen staff (Cook C). This failure resulted in the Registered Dietician not carrying out competency and skills assessments for [NAME] C, thereby compromising the functions of the food and nutrition services. Finding: During an interview on 1/13/20 at 4:30 p.m., in the kitchen, [NAME] C stated he had worked at the facility for 8 months. When asked to explain his process for Potentially Hazardous Food Cool Down (PHF), [NAME] C stated, I am not familiar with Hazardous Food cool down procedures. When asked where the cool down logs were kept, [NAME] C stated, we don't have any. During an interview on 1/14/20 at 10:00 a.m., in the kitchen, Certified Dietary Supervisor (CDS) stated, I am new here and have only been here for one week. CDS stated, she was familiar with PHF Cool down procedures and would try to find out where the logs were kept. During a concurrent interview and document review on 1/14/20 at 2:10 p.m., CDS stated, I did find our Cool…

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 review of documents, the facility failed to ensure food was prepared, stored, served or distributed in accordance with professional standards of food service safety when: 1) Mixer was not cleaned and sanitized, and, 2) Potentially Hazardous Food (food that supports the rapid and accelerating growth of infectious or toxic microorganisms) Cool Down Log procedures were not followed. These failures to ensure effective food and nutrition service operations may result in placing residents at risk for food borne illness and the growth of microorganism as well as chemical contamination of ingested items. Findings: 1) During a concurrent observation and interview on 1/13/20 at 4:15 p.m., in the kitchen with [NAME] C, he was asked what the material was on both the mixer and the shaft of the mixer. [NAME] C stated, it was old white cake batter. [NAME] C stated, the white old material was moldy and could cause a food borne illness if the residents ingested it. When asked what the facility's kitchen cleaning procedure was for the mixer, [NAME] C stated, I am…

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 did not maintain infection control practices when one resident ( Resident 23) was not offered hand hygiene prior to his meal and when one licensed nurse did not sanitize the glucometer between residents. Not offering hand hygiene prior to a meal and not sanitizing the glucometer between residents had the potential to contribute to transmission based infections. Findings: During an observation with concurrent interview on 1/15/2020 at 4:30 p.m., Licensed Nurse A used the facility glucometer to test the blood sugar level of Resident 23. When finished with the test, Licensed Nurse A placed the glucometer on Resident 23's bedside table. When finished checking Resident 23's blood sugar, Licensed Nurse A placed the glucometer directly into the drawer of the medication cart. Licensed Nurse A proceeded to Resident 21's room with the medication cart, took the glucometer out of the drawer, and started walking into Resident 21's room. When asked by this writer if she was going to sanitize the glucometer, Licensed Nurse A stopped,…

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

Based on observation, interview and record review, the facility failed to ensure one sampled resident (Resident 38) received oxygen therapy per physician's order and facility policy. This failure had the potential to contribute to Resident 38's discomfort and decreased ability to breathe. Findings: During an observation on 1/13/20 at 10 a.m., in Resident 38's room, the oxygen was observed to be infusing at 3.5 liters. Resident 38 stated, the air in my nose seems to be blowing more than usual. Resident 38's oxygen gauge was set to deliver 3.5 liters of oxygen. Also, the facility nursing staff had not dated Resident 38's oxygen tubing. During an interview in Resident 38's room on 1/13/20 at 10:05 a.m., Licensed Nurse B stated, the oxygen gauge was just above 3 liters. Licensed Nurse B left the room to check the physician's order. Upon returning, Licensed Nurse B stated, the physician's order indicated not to exceed 2 liters of oxygen because of Resident 38's diagnosis of Chronic Obstructive Pulmonary Disease (a lung disease characterized by chronic obstruction of lung airflow that…

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