Plaza Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to report an abuse allegation to CDPH, L&C Program and Ombudsman for one of four residents (Resident 82) reviewed for abuse as evidence by: * The facility failed to report Resident 82's allegation of feeling harassed and threatened by Resident 15. This failure of not reporting abuse allegation put the resident at risk for further abuse. Findings: Review of the facility's P&P titled AN01 Abuse Prevention and Management revised 5/2024 showed the facility does not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation, and/or mistreatment. The facility develops policies, procedures, training programs, and screening and prevention systems. The facility will report all allegations of abuse and criminal activity as required by law and regulations to the appropriate agencies. The P&P further showed the health, safety, welfare, dignity, and respect of residents are addressed. Reports of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to follow their protocol for written notification of transfer or discharge for four of four final sampled residents reviewed for hospitalization (Residents 10, 15, 86, and 122), one of three residents (Resident 117) reviewed for closed records, and one of three residents (final sampled resident, Resident 122) reviewed for hospice and end of life. * Resident 137's medical record did not show the resident received a discharge summary and a recapitulation of their stay when they discharged to the community. * Resident 10's Notice of Proposed Transfer and Discharge form was not completed for three acute care transfers, and the resident's record failed to show the Ombudsman was notified of the resident's acute care transfer for one of two completed Notice of Proposed Transfer and Discharge forms. * Resident 117's Notice of Proposed Transfer and Discharge form failed to show who was notified of the transfer and Ombudsman…

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, medical record review, and facility P&P review, the facility failed to ensure one final sampled resident (Resident 45) reviewed for ADL care was provided with the necessary care and services to maintain their ADL capabilities. * The facility failed to ensure care and services was provided to maintain good grooming and personal hygiene when Resident 45's fingernails were left dirty and untrimmed. This failure had the potential to result in injuries from scratching and spread of germs when eating. Findings: Review of the facility's P&P titled Grooming Care of the Fingernails and Toenails revised 10/21/21, showed the nail care is given to clean the nail bed and keep the nails trimmed; Medical record review for Resident 45 was initiated on 6/12/25. Resident 45 was admitted to the facility on [DATE]. Review of Resident 45's H&P examination dated 5/23/24, showed Resident 45 had the capacity to understand and make decisions. On 6/10/25 at 0840 hours, during the initial tour of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the orthostatic hypotension was accurately monitored for one of 26 final sampled (Resident 74). This failure had the potential to not provide the necessary care for the resident monitored for orthostatic hypotension. Findings: Review of the facility's P&P titled Orthostatic Hypotension revised 1/2012 showed the orthostatic vital signs will be taken and recorded when ordered by the physician, and when a sudden drop in blood pressure is suspected as the cause of resident falls, vertigo, feelings of dizziness, and similar occurrences. Orthostatic hypotension is a 20 mmHg drop in your systolic blood pressure or a 10 mmHg drop in your diastolic blood pressure within three minutes of standing up. However, even smaller drops in blood pressure may be significant in the elderly. Medical record review for Resident 74 was initiated on 6/10/25. Resident 74 was admitted to the facility on [DATE], and readmitted to the 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, medical record review, and facility P&P review, the facility failed to complete the post-fall neurological assessments for 72 hours for two of five final sampled residents reviewed for accidents (Residents 10 and 47). This failure had the potential for a delay in identifying and intervening with neurological changes. Findings: Review of the facility's P&P titled Fall Management Program revised 3/31/21, showed for unwitnessed falls, the nurse will conduct neurological assessments for 72 hours following the fall, to be done every 15 minutes for one hour, then every 30 minutes for one hour, then every hour for four hours, and then every four hours until 72 hours post fall. 1. Medical record review for Resident 47 was initiated on 6/10/25. Resident 47 was admitted to the facility on [DATE]. On 6/10/25 at 0907 hours, an observation and interview with Resident 47 was conducted. Resident 47 was observed sitting on the floor next to her bed, a water pitcher was on the floor with a puddle…

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, medical record review, and facility P&P review, the facility failed to administer G-tube enteral feeding formula administration for one of two final sampled residents reviewed for tube feeding (Resident 12). This failure had the potential for the resident to have undesirable outcomes, including aspiration. Findings: Review of the facility's P&P P-DD-16 Enteral Feedings effective 9/7/23, showed when administering enteral feedings, the head of the bed should be elevated 30 degrees during feedings, to check the G-tube placement by aspirating stomach contents. Medical record review for Resident 12 was initiated on 6/10/25. Resident 12 was readmitted to the facility on [DATE]. Review of Resident 12's Order Summary Report showed the following physicians' orders: - dated 5/5/25, for Glucerna 1.5 (an enteral feeding formula) to be administered at 75 ml/hr via a pump for 20 hours a day. - dated 4/1/25, to elevate the head of the bed 30-45 degrees during tube feedings. On 6/12/25 at 1320…

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, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care and services for two of 26 final sampled residents (Residents 22 and 63) reviewed for oxygen therapy. * The facility failed to ensure Resident 22's nasal cannula tubing was dated and labeled as per the facility's P&P. In addition, the facility failed to ensure the nasal cannula tubing was stored in a set-up bag when not in use for Resident 22. * The facility failed to ensure Resident 63's respiratory changes were identified timely and care planned. These failures had the potential for the residents to not receive the appropriate care and may negatively impact the residents' medical conditions. Findings: 1. Review of the facility's P&P titled Oxygen Therapy revised 11/2017 showed the oxygen is administered under safe and sanitary conditions to meet the resident needs. The oxygen tubing, mask, and cannulas will be changed no more than every seven days and as needed. 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, medical record review, and facility P&P review, the facility failed follow their pain protocol and physician's orders for one of two final sampled residents (Resident 47) reviewed for pain. * Resident 47's order for hydrocodone-acetaminophen (a controlled pain medication) to be administered prior to therapy (PT/OT) was administered daily at 0800 hours, regardless of the resident's actual therapy time, including on days no therapy was received. * Resident 47 had two PRN medications orders for pain without pain level parameters. * Resident 47's MAR showed the resident was administered PRN pain medications for a pain level of zero. These failure resulted in the resident receiving unnecessary pain medication as well as putting the resident at risk for pain during therapy services. Findings: Review of the facility's P&P titled P-PA01 Pain Management effective 5/26/23, showed the pain medications will be administered as ordered. Medical record review for Resident 47 was initiated 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, medical record review, facility P&P review, and facility document review, the facility failed to ensure the orders for NPO were followed and the Pre and Post Dialysis Assessment forms were completed for one of one final sampled resident investigated for dialysis (Resident 33). This failure had the potential of not identifying potential negative outcomes for the dialysis residents. Findings: Medical record review for Resident 33 was initiated on 6/10/25. Resident 33 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 33's H&P examination dated 12/4/24, showed the resident had the capacity to make decisions. Review of Resident 33's Order Summary Report for 6/2025 showed the following physician's orders: - dated 12/3/24, to observe AV shunt dressing LUA and change as directed by the physician - dated 2/28/25, for Enhanced Barrier Precautions related to dialysis catheter - dated 3/7/25, for Hemodialysis every Monday, Wednesday, and Friday - 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 observation, interview, facility P&P review, and facility document review, the facility failed to ensure to follow the puree recipe for puree vegetables for 21 residents on puree diet. This failure posed the risk of the residents not receiving food prepared by methods that conserve nutritive value. Findings: Review of the Diet Type Report dated 6/11/25, showed 21 of 133 residents received puree food prepared from the kitchen. Review of the facility's P&P titled Standardized Recipes date revised 7/1/14, showed the food products prepared and served by the dietary department will utilize standardized recipes. On 6/11/25 at 1045 hours, an observation of the puree meals preparation was conducted with [NAME] 1. [NAME] 1 stated she was preparing to puree the vegetables for a total of 21 residents and would prepare the vegetables for 24 servings. During the puree preparation for the broccoli and carrots, [NAME] 1 was observed measuring three cups of cold milk poured into a measuring cup and adding the cold milk to the cooked broccoli and carrots while the recipe showed for 24…

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 3. Review of the facility's P&P titled Hand Hygiene revised 9/1/20, showed hand hygiene is the primary means to prevent the spread of infections. Hand hygiene should be performed before donning and after doffing personal protective equipment, immediately upon entering, and exiting a resident's room. On 6/11/25 at 0819 hours, a medication administration observation for Resident 39 was conducted with LVN 5. LVN 5 was observed checking Resident 39's BP at his bedside. LVN 5 then left the resident's room and went to the medication cart just outside the resident's doorway. LVN 5 donned gloves, used disinfectant wipes to clean the BP equipment, removed the gloves, wrote the BP results on a pad of paper using a pen, retrieved the resident's medication and placed it in a small medication cup and brought the medication to the resident in his room. After the medication administration, LVN 5 removed the breakfast tray from the roommate's bed (Resident 100) as Resident 100 entered the room in his wheelchair. LVN 5 lifted…

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, medical record review, facility P&P review, and facility document review, the facility failed to ensure one of three final sampled residents (Resident 22) reviewed for pressure injury was provided the necessary care and services when the LAL mattress was set incorrectly for Resident 22. In addition, Resident 22 was left lying on multiple layers of bedding, absorbent pad, and an incontinent brief. These failures had the potential for the resident not to receive the appropriate care and services to promote skin healing. Findings: Review of the facility's P&P titled Mattresses revised 1/1/12, under the Procedure section showed for the facility staff to make sure the mattress is inflating properly, check air mattress routinely to ensure that it is working properly, and alternating air mattress are used to relieve pressure as indicated by the resident's physical condition. May use an incontinent pad, if necessary, between resident and bottom sheet to maximize the effect. a. On 6/10/25…

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 facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent further falls and/or injuries for two of four sampled residents (Residents 3 and 7). * The facility failed to ensure Resident 3's post fall neurological assessment and monitoring were completed. Additionally, Resident 3's attending physician and responsible party were not notified after the resident had sustained a fall on 4/15/25. * Thefacility failed to provide the necessary care and services Resident 7 post fall sustaining injury and documented abnormal findings from neurological assessment. In addition, Resident 7's post fall assessment was not completed accurately. These failures posed the risk of the residents to not receive timely interventions to address their post fall status. Findings: Review of the facility's P&P titled Change in a Resident's Condition or Status revised 4/1/2015 showed the following: - The facility will promptly inform the resident, consult…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the necessary pharmacy services were provided to one of three sampled residents (Residents 1). * The facility failed to ensure the Geodon medication administered to Resident 1 was not from another resident's Geodon medication vial. In addition, the facility failed to ensure the discontinued Geodon medication was kept in the designated area to be disposed. These failures had the potential to cause unsafe administration and handling/storage of the residents' medications. Findings: Review of the facility's P&P titled Storage of Medications dated on 4/2008 showed medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized. The P&P further showed except for those requiring refrigeration,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of three final sampled residents (Resident 1) was properly monitored as evidenced by: * The facility failed to ensure the order for Resident 1's Geodon (antipsychotic medication) was transcribed and documented after obtaining the verbal order from the NP. * The facility failed to ensure the consent for the use of Geodon medication was obtained from Resident 1's conservator. * The facility failed to ensure the administration of the Geodon medication and the side effects monitoring were documented in Resident 1's MAR. * The facility failed to ensure a care plan was initiated to address Resident 1's Geodon medication use. These failures had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Physician Orders revised 11/2022 showed the licensed nurse receiving the telephone or verbal order will transcribe the order in the resident'smedical record at the time…

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, observation, medical record review, and facility P&P review, the facility failed to provide the necessary interventions and services for two of four sampled residents (Residents 1 and 2) to prevent further decline in their ROM functions. This failure posed the risk of the decline to the residents' ROM functions. Findings: Review of the facility's P&P titled Restorative Nursing Program Guidelines dated 9/19/19, showed the RNA carries out the restorative program according on the care plan. The RNA documents the frequency of the program, the amount of time the resident spent in the activity and their tolerance to the program. In addition, the RNA completes a written weekly summary for all the residents on a Restorative Nursing Program. The Restorative Nursing Program Coordinator co-signs the weekly progress note. 1. Medical Record review of Resident 1 was initiated on 10/2/24. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Order Summary Report dated…

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

Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure safeguarding of the controlled medications for Residents 3, 4, 5, and 6. This failure posed the risk for the diversion of the controlled medications. Findings: Review of the facility's P&P titled Medication Storage in the Facility dated 8/2014, under the section for Controlled Medication Storage, showed Schedule 11-V medications and other medications subject to abuse are stored in a separate area under double lock. If a key system is used, the medication nurse on duty maintains possession of the key to controlled medication storage areas. At each shift change, a physical inventory of all controlled medication, including the emergency supply is conducted by two licensed nurses and is documented on the controlled medication accountability record. Review of the facility's Letter dated 8/20/24, showed the facility reported an unusual occurrence on 8/18/24, when the controlled medications were missing. Review of the facility's Conclusion Letter…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation guidelines as evidenced by: * The facility failed to ensure the hamburgers served on 7/20/24, were well cooked for Residents 1, 2, 3, 4, A, and B. * The kitchen staff failed to wear the beard restraint while working in the kitchen. These failures had the potential risk of foodborne illness to residents, staff, and visitors who consumed hamburgers prepared in the kitchen. Findings: 1. Review of the facility's P&P titled Meat Cookery and Storage revised on 7/1/24, showed the dietary department should ensure that food is prepared in a manner that preserves quality, maximizes nutrient retention, and obtains the maximum yield of the product. Review of the facility's P&P titled Residents Rights revised on 1/1/12, showed the facility should promote and protect the rights of all residents at the facility. Residents of skilled nursing facilities have a number of rights…

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, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to promote the wound healing for two of two sampled residents (Residents 1 and 2). * The facility failed to ensure the physician's order for wound care was followed for Resident 1's Stage 4 pressure injury. * The facility failed to ensure Resident 1 who had a Stage 4 pressure injury to the sacral coccyx area was repositioned while in bed to promote the wound healing. * The facility failed to carry out the physician's wound care order written by the wound care physician for Resident 2's pressure u injury. These failures posed the risk for complications and delayed wound healing. Findings: Review of the facility's P&P titled Pressure Injury and Skin Integrity Treatment revised 8/12/16, showed the treatments to pressure injuries and other skin integrity problems will be provided as ordered by the physician. 1.a. Medical record review for Resident 1 was initiated on 7/30/24.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, observation, facility document review, and facility P&P review, the facility failed to protect the resident's rights to be free from the physical abuse by another resident for one of seven sampled residents (Resident 7). * Resident 7 was hit by Resident 8 causing a laceration to her left outer eye and a skin tear to her right elbow. This failure had the potential to negatively impact the resident's well-being. Findings: 1. Review of facility's P&P titled Abuse Prevention and Management revised 5/30/24 and effective on 6/12/24, under the section for Definitions showed the following: - Abuse is defined as the willful, deliberate infliction of injury, unreasonable confinement, involuntary seclusion, and physical or chemical restraint not required to treat symptoms, and/or imposed for the purposes of discipline or convenience, intimidation, exploitation, misappropriation of resident property, mistreatment, and injuries of unknown source or punishment with resulting physical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the implementation of their P&P for abuse prevention program for two of seven sampled residents (Residents 4 and 9) when CNA 4 received a report of physical abuse from Resident 9 regarding CNA 5 hitting Resident 4. CNA 4 took CNA 5 to see Residents 4 and 9 to identify the alleged staff. This failure created the potential for not protecting the residents from the alleged staff. Findings: Review of the facility's P&P titled Abuse Prevention program dated 6/12/24, showed under the section for Immediate Actions, the Administrator or designated representative will provide for a safe environment for the resident as indicated by the situation. If the suspected perpetrator is an employee, remove the employee immediately from the care of the resident(s) and immediately suspend the employee pending the outcome of the investigation in accordance with the facility policies. Medical record review of Resident 4 was initiated 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, medical record review, facility document review, and facility P&P review, the facility failed to protect Resident 1's rights to be free from the physical abuse by Resident 2. This failure had the potential to result in the serious injury and/or psychosocial harm to Resident 1. Findings: Review of the facility's P&P titled P-AN01 Abuse Prevention and management, Operation Manual Abuse & Neglect revised 5/30/24, showed abuse is defined as the willful, deliberate infliction of injury, unreasonable confinement, involuntary seclusion, and physical or chemical restraint not required to treat symptoms, and/or imposed for the purposes of discipline or convenience, intimidation, exploitation, misappropriation of resident property, mistreatment, and injuries of unknown source or punishment with resulting physical harm, pain, or mental anguish. Abuse includes the neglect and deprivation of goods and services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Abuse…

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, facility document review, and facility P&P review, the facility failed to provide a homelike environment for one of 21 sampled residents (Resident 20). * Resident 20's room (Room A) had a hole on the dry wall, exposed drywall, and multiple areas of dark stains on the walls. * Room A's restroom had a crack behind the sink, large unpainted area above the sink, crack on the door connecting the restroom to the adjacent room and dark stains on the floor and walls near the toilet. These failures had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Resident Rooms and Environment revised 1/1/12, under the Policy section, showed the facility provides the residents with a safe, clean, comfortable, and home like environment; and the facility staff will provide residents with a pleasant environment and person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences. On 5/23/24 at 1015 hours, an observation and concurrent interview was conducted with Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility document review, the facility failed to ensure one of 21sampled residents (Resident 18) was free from the physical abuse when Resident 19 hit Resident 18 with an open hands. This failure had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Abuse-Prevention, Screening, & Training Program revised July 2018 showed the facility does not condone any form of resident abuse, neglect, misappropriation of resident's property, exploitation, and or/mistreatment and develops facility policies, procedures, training programs, and screening and prevention systems to promote an environment free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment. Under the section for Definitions showed the following: - abuse is defined as the willful, deliberate infliction of injury, unreasonable confinement, involuntary seclusion, physical or chemical restraint, not required to treat…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of 21 sampled residents (Resident 13) attained and maintained their highest practicable well-being. * The facility failed to ensure Resident 13 was assessed and offered the pain medication as per the physician's order after complaining of the severe left knee pain. This failure posed the risk of not providing appropriate and consistent care to Resident 13. Findings: Review of the facility's P&P titled Change of Condition Notification revised 4/1/2025, showed the licensed nurse will assess the change of condition and determine what nursing interventions are appropriate. Before notifying the Attending Physician, the Licensed Nurse must observe and assess the overall condition utilizing a physical assessment and chart review. Notification to the Attending Physician will include a summary of the condition change and an assessment of the resident's vital signs and system…

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, medical record review, and facility record review, the facility failed to ensure one of 21 final sampled residents (Resident 10) remained free from the accident hazards. * The facility failed to provide the bilateralfloor mats as per the physician's order for Resident 10. This failure had the potential to place the resident at risk for serious injury. Findings: Review of the facility's P&P titled Fall Management Program revised 3/13/21,showed the purpose is to provide the residents a safe environment that minimizes complications associated with falls. Medical record review for Resident 10 was initiated on 6/4/24. Resident 20 was admitted to the facility on [DATE]. Review of Resident 10's IDT note dated 3/31/23 at 1232 hours, showed Resident 10 [NAME] fall while attempting to self-transfer to thecommode on 3/29/24. Review of Resident 10's IDT note dated 8/14/23 at 1827 hours, showed Resident 10 [NAME] fall while self-transferring from the commode to her bed on 8/13/24. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the needs of two of 21 sampled residents (Residents 8 and 9). * The facility failed to administer citalopram hydrobromide (antidepressant medication) to Resident 8 as ordered by the physician. * The facility failed to administer Austedo XR (medication used to treat tardive dyskinesia) to Resident 9 as ordered by the physician. These failures had the potential to negatively affects the residents' well-being. Findings: Review of the facility's P&P titled Medication Administration revised 1/1/12,showed medication will be administered upon the order of a physician or licensed independent practitioner. Medications and treatments will be administered as prescribed to ensure compliance with dose guidelines. 1. On 6/3/24 at 0940 hours, a medication administration observation was conducted with LVN 7. During the medication administration observation, LVN 7 administered the following…

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 facility P&P review, the facility failed to ensure the medications were safely stored. * The facility failed to ensure Medication Cart A was locked when left unattended. This failure had the potential for unauthorized person to have access to the medications and drug diversion in the facility. Findings: Review of the facility's P&P titled Medication Storage in the Facility effective 04/2008 showed under the Procedures Section B, only licensed nurses, pharmacy personnel, and those lawfully authorized are allowed access to medications. Medications rooms, carts, and medications supplies are locked or attended by persons with authorized access. On 5/23/24 at 0946 and 0952 hours, Medication Cart A was observed parked in the hallway near Station 2. Medication Cart A was observed unlocked and unattended. The Medication Cart A drawer was opened and observed to have multiple prescription medications. Multiple residents were observed ambulating in the hallway near the unlocked medicationcart. On 5/23/24 at 0952 hours, a concurrent observation and interview…

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, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the heavy-duty blender used for puree preparation was air dried prior to use. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and were in good conditions. * The facility failed to ensure the kitchen utensils were clean and free of food particle or residue. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. These failures had the potential to cause foodborne illnesses for the residents in the facility. Findings: Review of the facility's Resident Assessment Report (CMS-802) dated 4/29/24, showed 133 of 137 residents residing in the facility received food prepared in the kitchen. 1. Review of the facility's P&P titled Blender Use and Cleaning revised 10/2014 showed to allow the container and lid to air dry. According to the USDA Food Code 2022, 4-901.11, Equipment and Utensils, Air-Drying…

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, medical record review, facility document review, and facility P&P review, the facility failed to implement their infection control surveillance program in accordance with the facility's P&P. * The facility failed to implement their infection control surveillance program from February 2024 through April 2024. The IP was unable to show documentation for the facility's monthly resident infection surveillance from of February 2024 through April 2024. The IP stated she did not complete the facility mapping of resident infections nor did she complete the Infection Control Monthly Summary Report from February 2024 through April 2024. Additionally, the facility conducted surveillance of resident infections based on whether the residents were prescribed antimicrobial medications. The facility failed to determine whether the residents who exhibited signs and/or symptoms of infections and were not prescribed antimicrobial medications met the facility's criteria for infection (McGeer'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, medical record review, and facility document review, the facility failed to provide the shower as per the resident's request for one of three final sampled residents (Resident 87). This failure had the potential for the resident's need to not be met promptly. Findings: Review of the facility's P&P titled Showering and Bathing dated 1/2012, showed a tub or shower bath is given to the residents to provide cleanliness, comfort and to prevent body odors. Medical record review for Resident 87 was initiated on 4/29/24. Resident 87 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 87's care plan dated 11/1/23, showed a care plan problem addressing the resident at risk or a self-care deficit bathing, dressing, and feeding related to dementia with behavioral disturbance, psychosis, major depressive disorder, anxiety disorder, insomnia, fatigues, impaired physical mobility and benign prostatic hyperplasia (a medical condition in men which the prostate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to follow up on the grievance for four of six nonsampled residents (Residents 6, 60, 77, 80, 94, and 123). This failure had the potential for the residents to not be fully informed about the resolution to the grievances. Findings: Review of the facility's P&P titled Grievance and Complaints dated 12/2017, showed the facility ensures there is no retaliation for filling a grievance or complaint and ensures that there is a prompt review, investigation and response to and resolution of grievances and complaints. Under section Grievance investigation, the facility will inform the resident or his or her representative of findings of the investigation and any corrective actions recommended in a timely manner 1. Medical record review for Resident 6 was initiated on 4/29/24. Resident 6 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 6's H&P examination dated 7/13/23, showed…

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, medical record review, and facility P&P review, the facility failed to ensure the physician was informed of a change of condition for one or three final sampled residents reviewed for weight loss (Resident 332). The facility failed to notify the physician of Resident 332's six-pound weight loss. This failure had the potential for Resident 332 to have a delay in care and treatment. Findings: Review of the facility's P&P titled Change of Condition Notification revised 4/2015 showed the facility will promptly inform the resident, consult with the resident's Attending Physician, and notify the resident's legal representative or an interested family member, if known, when the resident endures a significant change in their condition caused by, but not limited to a significant change in the resident's physical, mental, or psychosocial status. A licensed nurse will document the following: date, time, and pertinent details of the incident and the subsequent assessment in the Nursing Notes, the time the Attending Physician was contacted, the method by which he 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 observation and interview, the facility failed to maintain a clean and homelike environment for two of 27 final sampled residents (Residents 8 and 115) and six nonsampled residents (Residents 9, 26, 30, 582, 22, and 94) reviewed for environment. * Resident 9 resided in Room D. Room D was observed with several unpainted patched areas on the walls throughout the room. * Residents 26 and 582 were roommates who resided in Room B. Room B was observed with bed linens and beverage cups on the floor. The residents' trash can was observed overflowing with trash. The room walls were observed with several unpainted patched areas. * Residents 8 and 30 were roommates who resident in Room C. Room C was observed with cereal lying on the floor adjacent to Resident 30's bed. * Residents 22 and 94 resided together in Room A. Room A was observed with incontinence briefs and chucks stored underneath Resident 22's bed. Room A was observed with unfinished patched walls. * Resident 115 resided in Room E. Room E was observed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to develop/implement the comprehensive plans of care to reflect the individual care needs for three of 27 final sampled residents (Residents 23, 69, and 115) and one nonsampled resident (Resident 29) reviewed for care plans. * The facility failed to develop the comprehensive person-centered care plan to address the use of PICC (peripherally inserted central catheter- intravenous access used for a prolonged period of time) line for Resident 115. * The facility failed to implement care plan interventions per Resident 29's plan of care addressing Resident 29's swallowing problem. * The facility failed to develop a care plan to address Resident 69's pain and use of bed rails. * The facility failed to ensure a care plan was developed to address Resident 23's need for one-to-one supervision. These failures had the potential risk of not providing appropriate, consistent, and individualized care to the residents.…

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, medical record review, and facility document review, the facility failed to provide the necessary care and services to ensure one of four final sampled residents (Resident 71) attained and maintained their highest practical well-being. * The facility failed to ensure Resident 71's right leg fracture with the immobilizer was assessed and monitored. This failure had the potential for the resident to not receive appropriate care and treatment. Findings: On 4/29/24 at 1101 hours, an observation and concurrent interview was conducted with Resident 71. Resident 71 stated he fell and broke his bone on the right leg. Resident 71 stated he was wearing a leg immobilizer which came from the acute care hospital. Resident 71 was asked regarding the care of the leg immobilizer. Resident 71 stated the nurses were not taking care of the right leg immobilizer. Resident 71 added, there were no staff who opened and looked at the leg immobilizer including the bone doctor. Medical record review for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure two of two final sampled residents (Residents 32 and 41) and one nonsampled resident (Resident 582) remained free from accident hazards. * The facility failed to implement the floor mats as per the physician's order for Residents 582, 32, and 41. This failure had the potential to place the residents at risk for serious injury. Findings: 1. Medical record review for Resident 582 was initiated on 4/29/24. Resident 582 was admitted to the facility on [DATE]. Review of Resident 582's care plan titled At Risk for Falls developed on 2/28/24, showed Resident 582 was at risk for falls related to osteoarthritis, depression, neuropathy, and dementia. The care plan showed a goal of Resident 582 remaining free of falls. Review of Resident 582's care plan titled Actual Fall developed on 3/8/24, showed Resident 582 sustained an actual fall having sustained a skin tear on her right knee. Review of Resident 582's care plan titled…

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 facility P&P review, the facility failed to ensure one of one final sampled resident reviewed for GT care (Resident 23) received the appropriate GT care. This failure posed the risk of the resident's GT not being kept patent. Findings: Review of the facility's P&P titled Feeding Tube - Administration of Medication revised 11/2018 showed when administering the medications via GT, the placement and residual were to be checked prior to administering the medications. The P&P showed the medications were to be administered by the syringe via gravity into the feeding tube and flushing after each medication administration. On 4/30/24 at 0839 hours, a medication administration observation was conducted with LVN 4. During the medication administration pass, LVN 4 was observed not checking Resident 23's GT for placement or residual prior to administering Resident 23's medications. LVN 4 was observed administering the medications into Resident 23's GT, without waiting for each medication to flow into Resident 23's GT by gravity before flushing the tube with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the IV access for one of one final sampled resident reviewed for IV therapy(Resident 115). * The facility failed to ensure the PICC (peripherally inserted central catheter- intravenous access used for a prolonged period of time) line external catheter and arm circumference measurements were completed and documented in the medical record for Resident 115. This failure had the potential to delay the identification of catheter related complications for the residents. * The facility failed to label Resident 115's IV medication tubing with the date and time when it was hung. This failure posed the potential risk for infection or phlebitis (inflammation of a vein) for Resident 115. Findings: Review of the facility's P&P titled PICC Dressing Change dated 6/2018 showed the length of the external catheter is obtained: upon admission, during dressing changes, and if…

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, medical record review, and facility P&P review, the facility failed to ensure the oxygen therapy equipment was stored in a sanitary manner for two of three final sampled residents reviewed for respiratory care (Residents 8 and 36). * The facility failed to ensure Resident 8's nasal cannula and oxygen mask were stored in a sanitary manner. * The facility failed to ensure the administration of oxygen therapy had a physician's order, and the care plan for respiratory problem was updated for the use of oxygen for Resident 36. In addition, the oxygen tubing was labeled and not in the floor for Resident 36. These failures posed the risk for equipment contamination and associated respiratory complications. Findings: Review of the facility's P&P titled Oxygen Therapy revised 11/2017 showed oxygen is administered under safe and sanitary conditions to meet the residents' needs. 1. Medical record review for Resident 8 was initiated on 4/29/24. Resident 8 was admitted to the facility 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 observation, interview, medical record review, and facility P&P review, the facility failed to offer or provide adequate and appropriate pain management for one of two final sampled residents reviewed for pain (Resident 69). This failure had the potential to cause the resident unnecessary pain and complications from worsened pain. Findings: Review of the facility's P&P titled P-PA01 Pain Management revised 5/25/23, showed the licensed nurse will administer pain medication as ordered and document the medication administered on the Medication Administration Record (MAR) and after medications/interventions were implemented, the licensed nurse will reevaluate the resident's level of pain within one hour. Review of the facility's P&P titled Administration of Pain Medication revised 11/2016, showed to document if the resident refuses pain medication. On 4/29/24 at 0828 hours, an observation and concurrent interview was conducted with Resident 69. Resident 69 was observed lying in bed rubbing her abdomen.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, medical record review, and facility P&P review, the facility failed to ensure the proper monitoring, documentation, initiation of a plan of care addressing the dialysis site, and reporting to the physician of the weight variances for one of two final sampled residents reviewed for dialysis services (Resident 49). These failures had the potential to delay identifying and responding to dialysis access site issues, and delay of care and treatment for Resident 49. Findings: Review of the facility's P&P titled Dialysis Management revised 1/2024 showed the facility will initiate a plan of care based on the resident's needs. Under the section Vascular Access Site showed the facility will assess, observe and document care of the access sites daily, as applicable, such as auscultation/palpation of the AV fistula (pulse, bruit and thrill) to assure adequate blood flow. All documentation concerning dialysis services and care of the dialysis resident will be maintained in the resident'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, medical record review, and facility P&P review, the facility failed to obtain a physician's order and an informed consents prior to the use of elevated side rails for one of one final sampled resident (Resident 69) and one nonsampled resident (Resident 582) reviewed for use of bed rails. This failure had the potential to put the residents at risk for serious injuries. Findings: The FDA issued a Safety Alert entitled Entrapment Hazards with Hospital Bed Side Rails. Residents most at risk for entrapment are those who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain, uncontrolled body movement, hypoxia, fecal impaction, acute urinary retention, etc., that may cause them to move about the bed or try to exit from the bed. Entrapment may occur when a resident is caught between the mattress and bed rail or in the bed rail itself. Inappropriate positioning or other care related activities could contribute to the risk of entrapment. 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 observation, interview, and medical record review, the facility failed to ensure the individualized behavioral health care needs and services for one of one final sampled resident reviewed for behavioral management (Resident 23) were met. * Resident 23 was diagnosed with schizophrenia (a severe brain disorder in which people interpret reality abnormally) with a thorough clinical assessment and was prescribed a risperidone (antipsychotic medication). However, the facility failed to ensure a physician's order was obtained for one-to-one supervision and the IDT or Bioethics Committee meeting was conducted where a possible psychotropic medications and behavior management of Resident 23 were discussed and recorded. This failure had the potential for the resident not able to attain the highest practicable wellbeing. Findings: On 4/29/24 at 1057 hours and 4/30/24 at 1358 hours, Resident 23 was observed with one-to-one supervision with the private caregiver. Medical record review for Resident 23 was initiated…

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 medical record review, the facility failed to ensure the pharmacy services were provided as evidenced by: * The medications for two of two final sampled residents (Residents 6 and 23) and two nonsampled residents (Residents 77 and 80) reviewed for medication administration were not acquired in a timely manner. This failure had the potential for the residents to not consistently receive their medications as ordered. *The staff's personal items were stored inside a medication room. This failure posed the risk of not keeping an accurate account of medications stored inside the medication room. Findings: 1.a. Medical record review for Resident 23 was initiated on 4/30/24. Resident 23 was readmitted to the facility on [DATE]. Review of Resident 23's H&P examination dated 12/22/23, showed Resident 23 had no capacity to make decisions. On 4/30/24 at 0839 hours, a medication administration observation for Resident 23, was conducted with LVN 4. Review of Resident 23's MAR for March…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure seven out of seven final sampled residents reviewed for unnecessary psychotropic drugs (Residents 23, 36, 49, 105, 112, 124, and 332) were free from unnecessary psychotropic drugs (any drug that affects brain activity associated with mental process and behavior). * The facility failed to ensure Resident 49's monitoring for orthostatic blood pressure (blood pressure obtained when sitting or lying down, and after standing; used when monitoring for potential side effects from antipsychotropic use), for the use of clozapine (antipsychotic) and aripiprazole (antipsychotic) was accurate. * The facility failed to ensure Resident 332's monitoring of orthostatic blood pressure, for the use of quetiapine fumarate (antipsychotic) was accurate. * The facility failed to ensure Resident 23's episodes of behavior for the use of psychotropic medications were made available to the prescriber on a monthly basis to serve as 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 observation, interview, and medical record review, the facility failed to ensure the medication error rate was lower than five percent. This failure posed the risk of the residents not receiving appropriate care. Findings: The facility's total medication error rate was 11.54%. 1a. On 4/30/24 at 0839 hours, a medication administration observation for Resident 23 was conducted with LVN 4. Medical record review for Resident 23 was initiated on 4/30/24. Resident 23 was readmitted to the facility on [DATE]. Review of Resident 23's H&P examination dated 12/22/23, showed Resident 23's diagnoses included paralysis and adrenal insufficiency. Review of Resident 23's March 2024 MAR showed Resident 23 was to be administered with Calcium Oyster Shell (vitamin supplement) 1250 mg daily at 0900 hours and docusate sodium (stool softener) 100 mg daily at 0800 hours. On 4/30/24 at 1432 hours, a post medication administration observation interview was conducted with LVN 4. LVN 4 verified he did not administer 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 medical record review, the facility failed to ensure one nonsampled resident (Resident 29) received the appropriate mechanically altered diet (the texture of the diet is altered) as ordered by the physician. This failure had the potential for the resident to choke and/or aspirate (inhalation of foreign object into the airway and/or lungs). Findings: On 4/29/24 at 1408 hours, Resident 29 was observed eating lunch in his room. Review of Resident 29's meal ticket (used to identify the resident's diet and food preferences for meal service) showed Resident 29 required a pureed consistency diet (the food is put in a blender and blended into a puree consistency). Resident 29 had a cup of coleslaw (shredded raw cabbage and carrots), which was not pureed. On 4/29/24 at 1410 hours, an interview was conducted with LVN 2. LVN 2 reviewed Resident 29's meal ticket and stated Resident 29 should receive a pureed consistency diet. LVN 2 verified the coleslaw on Resident 29's meal tray, 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 and interview, the facility failed to ensure one of two medication rooms' refrigerator freezer compartment was free of ice buildup. This failure posed the risk of the medication room refrigerator not maintained in safe operating temperature and condition. Findings: On 4/30/24, at 1432 hours, a Medication Room A inspection and concurrent interview was conducted with LVN 4. A refrigerator containing the facility's emergency medications, tuberculin and insulin vials were observed inside the Medication Room A. However, the refrigerator freezer compartment was observed with ice buildup. LVN 4 verified the freezer compartment of the refrigerator used for resident's medications was observed with ice buildup. LVN 4 stated the refrigerator's daily temperature log showed the last time the refrigerator including the freezer compartment was checked was on 4/30/24. LVN 4 further stated the nursing staff were responsible for ensuring the refrigerator was free of ice buildup. When asked if the ice buildup was reported, LVN 4 acknowledged it should have been reported 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, medical record review, facility document review, and facility P&P review, the facility failed to ensure the resident's bed was inspected and with the record of the bed inspection when identifying areas of possible entrapment with the use of bed rails for one of two final sampled residents reviewed for bed siderail use (Resident 69). This failure had the potential to negatively impact the residents for possible entrapment, serious injury, and death. Findings: According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the physician was notified when one of seven sampled residents (Resident 1) refused to take the antipsychotic medications (medication use to treat psychosis) as ordered. This failure had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Medication – Administration revised 1/1/12, showed under the section for Refusing Medication, if the resident is refusing to take medication, time of refusal must be circled in the Medication Administration Record (MAR) and initialed by the Licensed Nurse who is passing meds and documentation will be entered on the back of the MAR stating the reason for the refusal. The Licensed Nurse will attempt to give the medications several times, but if resident continues to refuse after one hour, the refused medications will be destroyed. Licensed Nurse will notify physician and document in the medical record. Medical record review for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure lunch was provided at the facility's established mealtime. This failure had the potential for not meeting the residents' needs. Findings: Review of the facility's P&P titled Meal Services Times revised 7/1/14, showed: - Meals are served in a regularly scheduled hour. - The dietary manager is responsible for monitoring meal service time daily to ensure the facility meets posted mealtimes. - Meal times are typically at 0700, 1200, and 1700 hours. Review of the facility's document titled Meal Times posted in the dining area bulletin board showed the following: - Breakfast is served at 0700 to 0800 hours; - Lunch is served at 1200 to 1300 hours; - Dinner is served at 1700 to 1800 hours, and - Snacks are served at 1000, 1400, and 2000 hours. Review of the facility's document titled Midnight Census dated 4/24/24, showed there were 24 residents from room [ROOM NUMBER] to Room56. On 4/23/24 at 1000 hours, an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 1) was free from the physical restraints. * The facility utilized a seat belt on Resident 1 while she was sitting in a wheelchair. The facility failed to complete the comprehensive assessment, obtain the informed consent prior to applying the seat belt, determine the least restrictive interventions before the seat belt was utilized, and develop and implement the interventions to prevent and address any risks related to the use of the seat belt. These failures had the potential for increased risk of physical harm to the resident. Findings: Review of the facility's P&P titled Restraints dated 1/1/12, showed all restraints are used properly and only when necessary on the residents at the Facility. The facility honors the resident's rights to be free from any restraints that are imposed for the reasons other than that of the treatment for the resident's medical symptoms. Restraints…

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, medical record review, and facility P&P review, the facility failed to promote dignity and respect for three of seven sampled residents (Residents 5, 6, and 7) and three nonsampledresidents (Residents A, B, and C). * The facility failed to ensure the call lights were answered in a timely manner for Residents 5, 6, 7, A, B, and C. * The facility failed to ensure the hair cut was provided for Residents 5 and B. These failures posed the risk to negatively affect the residents' physical and emotional well-being. Findings: 1. Review of the facility's P&P titled Communication - Call Light System revised 1/1/12, showed the following: - Nursing staff will answer call bells, promptly in a courteous manner. - Upon responding to request, if item requested is questionable, assistance will be obtained from the charge nurse. - In answering to request, nursing staff will return to resident with the item or reply promptly, and assistance will be offered before leaving. Review of the facility's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the copy of the resident's medical record was provided upon request within two working days as per the facility's P&P for one of eight sampled residents (Resident 2). This failure had the potential for violating Resident 2 and their representative rights to access their medical health information. Findings: Review of the facility's P&P titled Resident Access to PHI revised 11/2015 showed if the resident and/or their personal representative requests a copy of the resident's medical record, the HIPAA Privacy Officer will provide the resident and/or their personal representative with a copy of the medical record within two working days after receiving the written request. Closed medical record review for Resident 2 was initiated on [DATE]. Resident 2 was admitted to the facility on [DATE],and expired at the facility on [DATE]. Review of Resident 2's admission MDS dated [DATE], showed Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the nursing staff completed the 72-hour neurological checks as per the order and facility P&P for one of eight final sampled residents (Resident 1). This failure posed the risk for changes in Resident 1's health condition not being identified, delay in necessary care and treatment, and negative health outcomes to Resident 1. Findings: Review of the facility's P&P titled Fall Management Program revised 3/2021 showed neurological checks are performed at the ordered frequency or as the listed below equaling 72 hours: a. Every 15 minutes x 1 hour, then b. Every 30 minutes x 1 hour, then c. Every hour x 4 hours, then d. Every 4 hours x 66 hours or until the physician states it is no longer necessary or after 72 hours if the Resident's condition is stable and not showing signs or symptoms of neurological injury. Review of Resident 1's medical record review was initiated on 2/23/24. Resident 1 was admitted to the 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 interview and medical record review, the facility failed to protect Resident 1's rights to be free from physical abuse by Resident 2. Resident 2 struck Resident 1 in the face, and Resident 1 fought back and sustained a skin abrasion to his forearm. This failure had the potential to negatively affect Resident 1's psychological and physical well-being. Findings: Review of the SOC 341 Report of Suspected Dependent Adult/Elder Abuse dated 1/19/24, showed Resident 1's right arm was bleeding. On investigation, Resident 1 stated he and Resident 2 got in a fist fight, and his arm got scratched. a. Medical record review for Resident 1 was initiated on 1/25/24. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's MDS dated [DATE], showed Resident 1 had moderate cognitive impairment. Review of Resident 1's Change in Condition Evaluation dated 1/19/24 at 1435 hours, showed Resident 1 was involved in a resident-to-resident altercation that resulted in a skin abrasion 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 observation, interview, medical record review, and facility document review, the facility failed to ensure the food for one of five sampled residents (Resident 4) was consistent with the resident's need and preference. This failure had the potential to negatively impact the resident's well-being. Findings: During a concurrent lunch observation and interview with Resident 4 on 1/25/24 at 1320 hours, Resident 4 was observed having lunch in the hallway in Station 2. Resident 4 stated she had a concern with the foods not given correctly. Resident 4 stated she was allergic to apple juice and was given apple juice. Resident 4's lunch tray was observed with a glass of apple juice. Resident 4 stated her throat got inflamed when she drank apple juice. Resident 4's lunch ticket showed the food allergies/dislikes were beans, bread, apple juice, and fish. On 1/25/24 at 1320 hours, an interview was conducted with CNA 2. CNA 2 confirmed the findings and stated the LVN was supposed to check the meal trays before giving to the residents. On 1/25/24 at 1615 hours, an interview was conducted…

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, medical record review, and facility document review, the facility failed to protect two of 11 sampled residents' (Residents 4 and 9) rights to be free from the physical abuse by other residents (Residents 10 and 11). This failure posed the risk for injuries and psychological harm for Residents 4 and 9. Findings: Review of the facility's P&P titled Abuse and Neglect dated 11/18/21, showed the facility will protect the health, safety, and welfare of Facility Residents by ensuring that all reports of Resident abuse, mistreatment, neglect, exploitation, injuries of an unknown source and suspicion crimes are promptly reported and thoroughly investigated. 1. Review of the SOC 341 Report of Suspected Dependent Adult/Elder Abuse dated 12/29/23, showed Resident 9 was hit on his face with a cane by Resident 10. a. Medical record review for Resident 9 was initiated on 1/8/24. Resident 9 was originally admitted to the facility on [DATE]. Resident 9 was transferred to the acute care hospital…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility document review, the facility failed to implement their P&Ps to ensure the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when the allegations of abuse were not reported to the CDPH, L&C program and other agencies in a timely manner for two sampled residents (Resident 4 and 7). * The facility failed to ensure the staff reported Resident 7's allegation of being hit in the face by Resident 8 in a timely manner. * The facility failed to ensure the staff reported an incident involving Resident 11 exposing his genitalia to Resident 4 in a timely manner. These failures had the potential of placing the residents at risk for abuse and delayed conducting an investigation to determine the cause and rule out abuse. Findings: Review of the facility's P&P titled Abuse and Neglect dated 11/18/21, showed the facility promptly reports and thoroughly investigates allegations of resident abuse, mistreatment, neglect, exploitation,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility document review, the facility failed to provide the necessary care and services to ensure three of 11 sampled residents (Residents 2, 7, and 11) maintained their highest practicable physical well-being. * The facility failed to ensure Resident 2's clozapine (an antipsychotic medication that treats medical health condition like schizophrenia, a severe brain disorder in which people interpret reality abnormally) medication was administered as prescribed by the physician. In addition, the facility failed to send a request to the pharmacy to refill the clozapine medication for Resident 2. * The facility failed to assess Resident 7 every shift for 72 hours after an alleged resident to resident altercation. * The facility failed to monitor the behavior of Resident 11 after he was witnessed exposing himself to another resident. These failures had the potential to affect residents' mental and physical wellbeing. Findings: Review of the facility's P&P titled Change…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, pharmacy document review, and facility P&P review, the facility failed to ensure the availability of a prescribed medication for one of 11 sampled residents (Resident 2). * Resident 2 had a physician's order for clozapine for schizoaffective disorder; however, the licensed nurses were unable to administer clozapine as ordered due to the unavailability of the medication. This failure posed the risk for inhibiting the therapeutic effects of the medication and had the potential to negatively affect the resident's health. Findings: Review of the facility's P&P titled Medication Ordering and Receiving from Pharmacy dated 4/2008 showed the medications and related products are received from the dispensing pharmacy on a timely basis. The facility maintains accurate records of medication order and receipt. For new admission or readmission orders: a. When calling/faxing medication orders for a newly admitted resident, the pharmacy is also given all ancillary orders, allergies,…

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, medical record review, and facility P&P review, the facility failed to ensure the nursing staff provided the nursing care to one of five sampled residents (Resident 1) status post an unwitnessed fall as evidenced by: * The facility failed to complete a 72-hour neurological check for Resident 1 after a fall as per facility P&P. * The facility failed to complete a Fall Risk Evaluation for Resident 1 after a fall as per facility P&P. These failures had the potential for the resident to not receive adequate care and risk for adverse complications post falls. Findings: Review of the facility ' s P&P titled Fall Management Program revised 3/2021 showed a licensed nurse will conduct a new fall risk evaluation quarterly, annually, upon identification of a significant change of condition, post falls, and as needed. The P&P further showed for an unwitnessed fall or a witnessed fall with suspected or known head injury, the licensed nurse will complete the neurological checks for 72 hours…

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 medical record review, the failed to protect one of four residents ' (Resident 3) rights to be free from the sexual abuse by Resident 4. This failure had the potential to negatively impact Resident 3 ' s mental and emotional well-being. Findings: 1. Medical record review of Resident 3 was initiated on 12/11/23. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3 ' s IDT notes dated 12/7/23, showed the IDT had met to discuss an unwitnessed sexual allegation involving Resident 3. Resident 3 alleged Resident 4 came to her room sometime last week and offered her money in exchange for physical contact. Resident 3 stated she declined; however, Resident 4 still attempted to expose himself to Resident 3. Resident 3 ' s allegations were denied by Resident 4. On 12/7/23 at 1640 hours, an interview was conducted with Resident 3. Resident 3 was asked regarding the incident that took place involving Resident 4. Resident 3, unable to recall the exact date, stated one afternoon from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to report the allegations of abuse to the CDPH in a timely manner when: * Resident 4 exposed his penis to Resident 3 who was also alleged Resident 4 of verbal abuse when he made racial remarks. This failure had the potential for Resident 3 and other residents to be exposed to further abuse. Findings: Review of facility's P&P titled Abuse- Reporting and Investigation dated March 2018 showed the Administrator or designated representative will notify within two hours by telephone to the CDPH, Ombudsman office, and law enforcement agency regarding any allegations of abuse with no serious bodily injury. The Administrator or designated representative will send a written SOC 341 report to the Ombudsman office, and law enforcement agency, and CDPH within two hours. Medical record review of Resident 3 was initiated on 12/11/23. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's Progress Notes dated 12/7/23 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, facility document review, and facility P&P review, the facility failed to ensure the abuse allegations were thoroughly investigated for two of five sampled residents (Residents 1 and 2). This failure had the potential for the residents to be vulnerable for further abuse, mistreatment, and injury. Findings: Review of the facility's P&P title Abuse-Reporting Investigations dated 9/2017 showed all reports of resident abuse, mistreatment, neglect, exploitation or injuries of an unknown source are promptly and thoroughly investigated. The administrator or designated representative conducting the investigation will interview individuals who may have information relevant to the allegation. Individuals who may have information relevant to the incident are the resident, witnesses to the incident, other residents under the care of the staff member involved, roommates, family, visitors, etc. Review of the SOC 341 Report of Suspected Dependent Adult/Elder Abuse dated 11/19/23, showed Resident 2 hit…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of five sampled residents (Resident 2) was free from unnecessary psychotropic medications. *The facility failed to monitor the behavioral manifestations and side effects associated with the use of olanzapine (antipsychotic medication) and vortioxetine (antidepressant). This had the potential for Resident 2's physician to lack the necessary information to determine the effectiveness of the medications. Findings: Review of the facility's P&P titled Behavior/Psychoactive Drug Management dated 11/2018, under Procedure: III. Evaluation, section D, showed occurrences of behaviors for which psychoactive medications are in use will be entered with hash marks on the medication administration record every shift. Monthly the occurrence of behavior will be tallied and entered on the Monthly Psychoactive Drug Management Form in addition to any occurrence of adverse reaction. Medical record review for Resident 2 was initiated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the responsible party was informed in advance of the risks and benefits of their proposed treatment for one of five sampled residents (Resident 5). * The facility failed to ensure the informed consent was obtained from Resident 5's responsible party for the use of Remeron (an antidepressant drug which can be taken as an appetite stimulant) and Cogentin (a drug used to help control movement dysfunction, extrapyramidal symptoms). This failure had the potential for Resident 5 and their responsible party to not make informed medical decisions regarding Resident 5's care. Findings: Review of the facility's P&P titled Informed Consent revised 7/2020 showed the facility will not administer any medical interventions unless the resident or the resident'ssurrogate decisionmaker has consented to the intervention. If the physician determines that the resident lacks capacity to provide informed consent and has documented 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, medical record review, and facility P&P review, the facility failed to notify the Long-Term Care Ombudsman of a transfer for two of five sampled residents (Residents 1 and 2). This posed the risk of the Long-Term Care Ombudsman not being aware of the circumstances should an appeal be filed by the resident or their representative regarding the transfer. Findings: Review of the facility's P&P titled, Notice of Transfer/Discharge revised 10/2017 showed before the transfer or discharge occurs, the facility must notify the resident, and if known, the responsible party, and the Ombudsman of the transfer and reasons for the transfer, and document in the resident's clinical record. If the resident is transferring to the acute hospital, the nurse will complete the Notice of Proposed Transfer and Discharge form. 1. Medical record review of Resident 1 was initiated on 11/8/23. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's Change in Condition Evaluation dated 11/6/23, showed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility document review, the facility failed to ensure one of five sampled residents (Resident 3) wasprovided sufficient supervision to prevent wandering and elopement from the secured unit (a locked unit in the facility). * The facility failed to provide sufficient supervision and monitoring for Resident 3 who had a known history of elopement prior to admission and during admission in the facility. Resident 3 had a 1:1 sitter; however, the 1:1 sitter did not stay with Resident 3 all the time. As a result, Resident 3 eloped undetected through another resident's window on 11/1/23, and went missing until 11/3/23. Findings: Review of the SOC-341 (Report of Suspected Dependent Adult/Elder Abuse) dated 11/1/23, showed Resident 3 eloped at approximately 1900 hours. The staff went out to look for the resident, but the resident was unable to be found. Closed medical record review of Resident 3 was initiated on 11/8/23. Resident 3 was readmitted to the facility on [DATE].…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to protect one of five sampled resident's (Resident 1) rights to be free from the physical abuse by Resident 2. This had the potential for Resident 1 to be injured and have psychological harm. Findings: Review of the facility's P&P titled Resident to Resident Altercations showed the facility will make any necessary changes in the care plan for any and or all of the involved residents as necessary. Review of the SOC 341 Report of Suspected Dependent Adult/Elder Abuse dated 10/3/23, showed Resident 1 was hit on his face by Resident 2. a. Medical record review for Resident 2 was initiated on 10/5/23. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's H&P examination dated 1/26/23, showed Resident 2 did not have the mental capacity to make informed decisions. Review of Resident 2's MDS dated [DATE], showed Resident 2 had severe cognitive impairment. Review of Resident 2's progress notes dated 10/3/23,…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to provide the necessary care and services for two of four sampled residents (Residents 1 and 2) and 25 of 35 nonsampled residents (Residents 5, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, and 39) to maintain their highest physical well-being. * The facility failed to follow the physician's orders to administer Tea Tree oil to Residents 1, 5, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, and 39. * The facility failed to follow the physician's order to call for dermatology consult for Resident 5. * The facility failed to ensure Resident 2 had an adequate supply of Triamcinolone (triamcinolone acetonide), a medication used for temporary relief of symptoms of mouth sores, dental paste 0.1% to treat Resident 2's oral lesions (mouth sores). These failures had the potential to affect the residents' mental and physical wellbeing. Findings: 1.…

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, medical record review, facility document review and facility P&P review, the facility failed to implement their infection control practices designed to provide a safe and sanitary environment; and help prevent the development and transmission of diseases and infections as evidenced by: * The facility failed to implement their P&P to identify, isolate, and prevent the transmission of undiagnosed rashes, suspected scabies, and other opportunistic pathogens for the residents in the facility. * Residents 1 and 2 had history of scabies. The facility failed to place these residents on contact isolation precaution when the undiagnosed rashes or suspected to have scabies appeared to these residents. These failures caused the cross-contamination and spread of infectious organisms in the facility. Findings: According to the Prevention and Control of Scabies in California Healthcare Settings dated 8/2020, all HCF (Health care facilities) should develop, implement, and periodically evaluate…

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 medical record review, the facility failed to ensure the plan of care was developed to address the residents' specific care needs related to rashes, scabies, oral lesion, and UTI for one of four sampled residents (Resident 2). This failure posed the risks for Resident 2 not receive the person-centered care and services required to attain or maintain her highest level of physical and mental well-being. Findings: Review of the facility's P&P titled Change of Condition dated 4/2012 showed Change of Condition related to the attending physician's notification is defined as when the attending physician must be notified when any sudden and marked adverse change in the resident's condition which is manifested by signs and symptoms different than usual denote a new problem, complication or permanent change in status and require a medical assessment, coordination and consultation with the Attending Physician and a change in the treatment plan . Medical record review for Resident 2 was initiated 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 medical record review, the facility failed to provide the necessary care and services to maintain their highest physical well-being for one of 35 nonsampled residents (Resident 7). Resident 7 was admitted from the acute care hospital with history of right lower extremity diabetic ulcer and left lower extremity dry gangrene (death of body tissue due to lack of blood flow or serious bacterial infection). * The facility failed to conduct the skin and pain assessments, and pain monitoring for Resident 7's neck abscess and lower extremities with multiple wounds on admission 7/8/23. The wound care plan was not developed until seven days after admitting with the wounds. * The facility failed to follow the physician's orders for wound care treatment from 7/10 to 7/15/23, for Resident 7. * The facility failed to ensure to arrange for vascular surgery consult and follow-up appointment with the podiatrist as ordered. * The facility failed to provide the wound care treatments on multiple days for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of four sampled residents (Resident 3) was free from unnecessary psychotropic medications. The facility failed to monitor behavioral manifestations associated with the use of quetiapine (antipsychotic medication) and divalproex (antiseizure medication used to treat bipolar disorder) and failed to monitor episodes of inability to sleep associated with use of trazadone (antidepressant medication) for Resident 3. This had the potential for Resident 3's physician not having necessary information to determine the effectiveness of the medications. Findings: Review of the facility's P&P titled Behavior/Psychoactive Drug Management dated 11/2018, under Procedure: III. Evaluation, section D, showed occurrences of behaviors for which psychoactive medications are in use will be entered with hash marks (#) on the medication administration record every shift. Review of Resident 3's medical record was initiated on 9/5/23.…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to maintain the complete and accurate medical records for two of four sampled residents (Residents 2 and 3). * The facility failed to ensure Resident 2's Triamcinolone (triamcinolone acetonide) treatment to oral lesions (mouth sores which may be painful) were accurately documented in Resident 2's TAR. * The staff failed to document care provided and percentage dinner intake on the Activities of Daily Living (ADL) Flowsheet on 8/19 and 8/20/23, for Resident 3. These failures had the potential for care needs for these residents not being met. Findings: Review of the facility's P&P titled Medication - Administration dated 1/2012 showed medication will be administered directed by a Licensed Nurse and upon the order of a physician or licensed independent practitioner. Documentation: The time and dose of the drug or treatment administered to the patient will be recorded in the patient's individual medication record by the person who administers the drug…

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 facility P&P review, the facility failed to maintain two of four shower stalls in the female shower room. This failure had the potential to pose risk of affecting the residents' health risk. Findings: Review of the facility's P&P titled The Maintenance Department dated 1/2012 showed the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Providing routinely scheduled maintenance service to all areas. The Director of Maintenance is responsible for maintaining the following records/reports: work order requests. On 9/5/23 at 0915 hours, an interview was conducted with Resident 2. Resident 2 stated the showers were broken for weeks. Resident 2 stated she could not bathe regularly, which made her rashes get worse. Resident 2 stated she was itching all over and felt so miserable without taking regular showers. On 9/5/23 at 1015 hours, an observation of the female shower room and concurrent interview with CNA 2 was conducted. Two residents were being showered, and one…

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 medical record review, the facility failed to protect the resident's right to be free from physical abuse by other resident for two of 14 sampled residents (Residents 4 and 6). * Resident 4 was hit in the face by Resident 5 after looking at Resident 5 when Resident 5 bumped into Resident 4. Resident 4 sustained a cut on his lip. * Resident 6 was punched in the mouth by Resident 7 after confronting Resident 7 who was yelling at another resident. Resident 6 sustained a cut on his lip. * Reside 6 was hit in the head by Resident 8 after Resident 6 and his roommate (Resident Q) confronted Resident 8 for using their bathroom. Resident 6 had redness to his forehead and Resident Q verbalized of not feeling safe at the facility. These failures had the potential for Residents 4 and 6 to be injured or have psychosocial harm. Findings: Review of the facility's P&P titled Abuse-Prevention Program revised 9/2017 showed the facility does not condone any form of resident abuse and develops facility P&Ps,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their P&P for ensuring the reporting of a reasonable suspicion of a crime in accordance with Section 1150B of the Act to the facility's Administrator, local law enforcement, and CDPH for one of 14 sampled residents (Resident 9). * LVN 7 failed to report an allegation of abuse when Resident 9 made an allegation and reported to LVN 7 that he had punched Resident 7 in the face while defending LVN 10. There was no documentation showing the incident was reported timely as per the facility's P&P. This failure had the potential to result in delay in assessment for Resident injuries, providing the potential interventions, and investigation of alleged abuse. Resident 9 was diagnosed with acute (sudden onset) traumatic fractures (break in the bones) of the fourth metacarpal (hand) neck and fifth metacarpal head. Findings: Review of the facility's P&P titled Abuse-Reporting & Investigations revised…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P, the facility failed to implement their P&P to conduct a thorough investigation of an allegation of resident-to-resident physical altercation for one of 14 sampled residents (Resident 9). This created the risk for not protecting the residents from physical abuse. Findings: Review of the facility's P&P titled Abuse-Reporting & Investigations revised 9/2017 showed the facility will report all allegations of abuse as required by law and regulations to the appropriate agencies. The facility promptly and thoroughly investigates reports of resident abuse, mistreatment, neglect, exploitation, abuse facilitated or enabled by the use of technology, misappropriation of resident property, or injuries of an unknown source when appropriate. Medical record review for Resident 9 was initiated on 7/13/23. Resident was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 9's record showed Resident 9 was sent to Hospital A on 6/30/23 at 1159…

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 medical record review, the facility failed to provide the necessary care and services for two of 14 sampled residents (Residents 1 and 9) to maintain their highest physical well-being. * The facility failed to follow the physician's order to call for pain management consult for Resident 1. * The facility failed to send a request to pharmacy to refill the pain medication and eye drops for Resident 1. * The facility failed to ensure Resident 9's Methadone medication was refilled and available. * The facility failed to ensure Resident 9's Keflex medication order was clarified with the physician. These failures had the potential to affect Residents 1 and 9's mental and physical wellbeing. Findings: 1.a. Medical record review was initiated for Resident 1 on 8/1/23. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of chronic back pain. Review of Resident 1's Order Summary Report for February 2023 showed a physician's order dated 2/17/23,…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility document review, the facility failed to ensure the environment was free of pests for one sampled resident (Resident 1) and 16 nonsampled residents (Residents A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, and U). * During the resident council meeting, the residents reported the presence of cockroaches in residents' rooms, bathrooms, and shower rooms. The facility failed to follow up with the pest control company in order to schedule a service for the residents' room. This had the potential for pests to multiply and the presence of pest-associated germs. Findings: Medical record review was initiated for Resident 1 on 8/1/23. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. On 8/1/23 at 1035 hours, an interview was conducted with Resident 1 in her room with the present of LVN 1. Resident 1 stated cockroaches were everywhere, in her room and the bathroom. On 8/1/23 at 1130 hours, an interview was conducted with Resident A. When asked if…

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, facility P&P review, and facility document review, the facility failed to ensure the menu was followed as evidenced by: * [NAME] 1 failed to follow the recipe for the preparation of pureed Salisbury Steak. In addition, [NAME] 1 failed to ensure the correct portion sizes as shown in the recipe were provided the residents' meal tray. * [NAME] 2 failed to follow the recipe for nectar thick consistency in the preparation of the pureed salad. [NAME] 2 failed to ensure the correct portion sizes as shown in the recipe were provided to the residents' meal tray during tray line observation. In addition, [NAME] 2 added seasoned salt (not in the recipe) to the Fiesta Rice. * The facility failed to provide the appropriate portion size for Resident 637. Resident 637 had an order for a double portion of CCHO diet. These failures had the potential for the 130 residents receiving food prepared in the kitchen to not meet their nutritional needs which may lead to nutritional related health complications. Findings: Review of the CMS 672 Resident Census and Conditions…

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

Based on observation, interview and record review, the facility failed to ensure food safety and sanitation requirements were met in the kitchen as evidenced by: * The black and white residues were observed on the interior portion of the kitchen ice machine. An orange residue was observed inside the ice machine located in a room outside the kitchen. * A thawed, uncooked chicken dated from 3 days ago was observed in the refrigerator. * A moldy onion was found in a plastic bag inside the refrigerator. * [NAME] 2 failed to perform hand hygiene prior to food preparation. * Dietary Aide 1 scooped ice from the ice bin using a cup and did not perform hand hygiene. * [NAME] 2 failed to monitor the food temperature when she prepared the tuna salad. * The kitchen's cutting board surface was heavily marred. * The frying pan used for cooking had a black thick buildup. * Black residues were observed on the dish rack. * Food debris were observed on the drying rack. * A black dusty residue was observed on the knife rack. * A non-food grade plastic bag was used to store food. * The used meal trays…

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, facility document review, and facility P&P review, the facility failed to ensure the licensed nurses had specific competencies and skill sets needed to care for the residents. * The facility failed to ensure a program or system was in place to check the competencies and skill sets of the licensed nurses at the facility upon hiring and ongoing basis. * LVN 2 failed to properly check Resident 53's GT residual before providing a bolus feeding. * The ADON, RN 2, and LVNs 2 and 8 failed to demonstrate how to obtain the history of the volume of feeding and water flush via the enteral pump for Resident 49. These failures had the potential to put residents at risk for care not provided in a safe and competent manner. Findings: Review of the facility's P&P titled Staff Competency or Skills Checks dated 8/19 showed competency evaluations or skills checks will be performed upon hire during the 90-day probation period, annually, anytime a new procedure is introduced and as needed. 1. 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 observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their policies to provide pharmaceutical services to meet the needs of the residents. * The facility failed to ensure the Station 1 Medication Cart A glucometer was calibrated regularly. * The facility failed to ensure the disposition of non-controlled medications for discharged residents were accurately documented. * The facility failed to ensure the disposition of Residents 786's hydrocodone-apap (narcotic pain medication) was accurately documented. Thirty tablets of hydrocodone-apap were unaccounted for. * The facility failed to ensure the licensed nurses were accurately documented the narcotics administered to Resident 17 and 123 in the MARs. These failures had the potential for the inaccurate reconciliation, medication administration errors, and diversion of controlled medications. Findings: 1. Review of the facility's P&P titled Blood Glucose Monitoring dated 1/1/12, showed the licensed nurse on the night shift will document the blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility's P&P review, the facility failed to ensure 11 of 27 final sampled residents (Residents 4, 18, 55, 93, 111, 113, 114, 116, 120, 130, and 637) were free from unnecessary psychotropic medications. * The facility failed to provide documented rationale from the physician for increasing the dose of Ativan for Resident 120. * The facility failed to ensure Resident 4's episodes of behavior for the use of olanzapine (antipsychotic medication) were summarized on a monthly basis to serve as reference for gradual dose reduction. In addition, Resident 4 was not properly monitored for orthostatic blood pressure (measure the blood pressure while laying down or sitting and again upon standing up) as ordered by the physician for the use of an antipsychotic medication. * Resident 18 had an order for risperdal (antipsychotic medication) and haloperidol (antipsychotic medication) PRN. The facility failed to ensure Resident 18's haloperidol had a stop date and 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 facility document review, the facility failed to ensure the kitchen staff had the appropriate skill sets to safely perform the daily operations of the Dietary Department as evidenced by: - [NAME] 1 was unable to follow the recipe for Salisbury steak, provide correct portions sizes for the lunch meal service, verbalize the correct cool down procedure for time temperature control for safety foods, and state the correct final cooking temperature for reheating poultry. - [NAME] 2 was unable to follow the recipes for the puree fresh green salad and the fiesta rice, and verbalize the correct cool down procedure for time temperature control for safety foods. - Cooks 2 and 3, and Dietary Aide 1 were unable to accurately test the sanitizing solution used to sanitize food preparation surfaces in the kitchen. - Dietary Aide 1 was unable to scoop ice from an ice storage chest using appropriate sanitary measures. These failures had the potential for unsafe food practices which may lead to food borne illnesses and the potential to not meet the nutritional…

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 facility document review, the facility failed to employ a full-time qualified social worker in accordance with federal law as required for a facility licensed for 120 or more beds. This failure had the potential for the residents to not receive necessary treatment and health services provided by a qualified social worker. Findings: Review of the facility's license showed the facility was licensed for 145 beds. On 8/23/2021, the facility census was 137 residents. On 8/30/21 at 1619 hours, an interview was conducted with the SSA. The SSA stated the facility's social worker had not worked at the facility since June of 2021. The SSA stated she did not possess the proper qualifications to work as the facility's social worker. The SSA stated she did not possess a bachelor's degree in the social work or human services field. On 8/30/21 at 1639 hours, an interview was conducted with the Administrator. The Administrator stated from the end of June 2021 through the present time, the facility did not have a full-time qualified social worker. The Administrator stated in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility document review, the facility failed to maintain the infection control practices to help prevent the development and transmission of diseases and infections. * The facility failed to ensure Resident 436 who was quarantined for COVID-19 precautions did not leave the quarantine area to be potentially exposed to other residents in the facility. * The facility failed to show documentation of Legionella testing protocols. * CNA 9 failed to perform hand hygiene before and after providing care. * The facility failed to ensure Resident 116's TB testing was done as ordered by the physician. These failures posed the risk of infection and the transmission of disease-causing microorganisms. Findings: 1. Review of the OCHCA's Guidance on COVID-19 in SNFs (Skilled Nursing Facility) dated 8/5/21, showed the Yellow/Observation unit is for new admission who are not fully vaccinated for COVID-19. Residents in the Yellow/Observation unit should be kept in their…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure four of 27 final sampled residents (Residents 114, 116, 120, and 130) and one of five unnecessary medication sampled residents (Residents 104) were provided the rights to self-determination regarding the psychotropic medication (medication affecting brain activity) use. * The facility failed to ensure the informed consents were obtained prior to the use of risperidone (antipsychotic medication) , quetiapine (antipsychotic medication), sertraline (antidepressant medication), and buspirone (antianxiety) for Resident 116. * The facility failed to ensure the informed consents were obtained prior to the use of Ativan (antianxiety medication) for Residents 120 and 104. * The facility failed to ensure the informed consents were obtained from Residents 114 and 130's responsible party for the use of lorazepam (antianxiety medication). These failures had the potential for residents not being informed of their medications and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 27 final sampled residents (Resident 9) was assessed to determine if the resident was safe to self-administer the medications. * There were multiple bottles of supplements observed at Resident 9's bedside. This failure had the potential for medication interactions and inappropriate use of medications. Findings: Review of the facility's P&P titled Medication-Self-Administration dated 1/1/12, showed the facility will allow a resident to self-administer medications when determined capable to do so by the IDT and resident's attending physician. Medical record review for Resident 9 was initiated on 8/23/21. Resident 9 was admitted to the facility on [DATE]. Review of the H&P examination dated 8/18/20, showed Resident 9 had the capacity to understand and make decisions. Review of the care plans did not show a care plan problem to address Resident 9's ability to self-administer the medications. Further…

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 medical record review, the facility failed to ensure the advanced directives (written statement of a person's wishes regarding medical treatment) was obtained for one of 27 final sampled residents (Resident 85). This failure had to the potential for resident to receive inaccurate and delayed treatment compatible with the resident's wishes during an emergent situation. Findings: Medical record review for Resident 85 was initiated on 8/23/21. Resident 85 was admitted to the facility on [DATE]. Review of Resident 85's Advance Healthcare Directive Acknowledgment Form dated 3/26/21, showed Resident 85 had formulated an advance healthcare directive. Review of Resident 85's medical record failed to show a copy of Resident 85's advance healthcare directive was obtained, or an attempt was made to obtain Resident 85's advance healthcare directive. On 8/26/21 at 0848 hours, an interview and concurrent medical record review was conducted with the SSA. The SSA verified the findings and stated she would…

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, medical record review, and facility P&P review, the facility failed to notify the physician and responsible party of a change in condition for one of 27 final sampled residents (Resident 53). This failure had the potential for a delay in prescribed treatments and interventions which posed the risk of negative health outcomes for Resident 53. Findings: Review of the facility's P&P titled Change of Condition Notification revised on 1/15 showed the facility will promptly consult with the resident's Attending Physician and notify the resident's legal representative when a resident endures a significant change in their condition. On 8/23/21 at 1205 hours, an observation and concurrent interview was conducted with LVN 1. Resident 53 was observed in bed with a white fitted sheet tied in two knots around his lower legs. Resident 53 could not move his legs. LVN 1 was immediately called in Resident 53's room and verified the findings. Medical record review for Resident 53 was initiated 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 observation, interview and facility P&P review, the facility failed to provide a homelike environment for one nonsampled resident (Resident 103). * The facility used a white blanket to cover Resident 103's sliding patio door instead of a curtain. The white blanket did not cover the full length of the sliding patio door. This failure posed the risk for Resident 103 to develop emotional distress. Findings: Review of the facility's P&P titled Resident Rooms and Environment dated 1/12 showed the facility will provide the residents with a pleasant environment and person-centered care that emphasizes the resident's comfort and preferences. On 8/23/21 at 1236 hours, an observation and concurrent interview was conducted with Resident 103. Resident 103's room was observed with a sliding patio door covered with a white blanket screwed into the wall. The white blanket did not cover the full length of sliding patio door. Resident 103 stated it bothered him why all other resident rooms had regular curtains that reached the floor and his room did not have. Resident 103 stated the white…

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, medical record review and facility P&P review, the facility failed to ensure one of 27 final sampled residents (Resident 53) was free from abuse. * The facility failed to protect a vulnerable resident (Resident 53) from abuse when RN 1 failed to assess him timely when he was admitted to the facility. Resident 53 who had severe cognitive impairment was admitted to the facility on [DATE] at 1030 hours. One and a half hours later, Resident 53 was found lying in his bed with a white sheet covering his face and both of his lower legs were bound together with a white sheet tied in two knots. This prevented Resident 53 from moving of his lower extremities. This failure had the potential to cause serious injury and physical and/or psychosocial harm to the resident. Findings: Review of the facility's P&P titled Abuse-Prevention, Screening, and Training Program revised on 7/18 showed the facility does not condone any form of abuse, neglect and/or mistreatment. Medical record review for…

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

Based on observation, interview, medical record review, and facility P&P review, the facility failed to report an incident of abuse to the California Department of Public Health (CDPH) Licensing and Certification (L&C) Program, California Department of Aging, Long-Term Care Ombudsman Program, and law enforcement for one of 27 final sampled residents (Resident 53). * Resident 53 who had severe cognitive impairment and was totally dependent on staff for his ADL care, was found lying on his bed with both legs tied together with a fitted sheet on 8/23/21 at 1205 hours. The facility failed to report the abuse incident to the state agencies 29 hours after the incident had occurred. This failure had the potential for the resident to be vulnerable for further abuse. Findings: Review of the facility's P&P titled Abuse-Reporting and Investigations revised 3/18 showed the Administrator or designated representative will send a written SOC 341 (Report of Suspected Dependent Adult/Elder Abuse) to the CDPH L&C, Ombudsman, and law enforcement within two hours of an allegation of abuse with no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of three closed record sampled residents (Resident 137) was safely discharged from the facility. * The facility failed to follow their P&P for Resident 137's discharge AMA (Against Medical Advice) as evidenced by a failure to discuss with the resident the risks and consequences associated with his decision to discharge from the facility AMA, failure to document the resident's stated reasons for his desire to leave the facility, failure to obtain a physician's order for discharge AMA, and failure to document whether the facility attempted to arrange necessary safe transportation for the resident. These failures resulted in Resident 137 having not received the necessary information in which to make an informed decision regarding the potential risks and consequences associated with having discharged from the facility AMA. Findings: Review of the facility's P&P titled Discharge Against Medical Advice revised…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the level 1 PASRR (used to ensure residents with a mental disorder are evaluated and receive care in a setting appropriate to meet their needs) contained accurate information for two of 27 final sampled residents (Residents 37 and 71). * Resident 71 had a diagnosis of schizoaffective disorder and was prescribed quetiapine; however, the level 1 PASRR showed Resident 71 had no diagnosed mental illness and was not prescribed the psychotropic medications. * Resident 37 had a diagnosis of depressive disorder; however, the level 1 PASRR showed Resident 37 had no diagnosed mental illness. These failures posed the risk for the residens' inappropriate placement in a long-term care nursing home when a PASRR level 2 (used to determine if residents with a mental disorder are placed in a appropriate setting and receive necessary recommendations for specialized services) evaluation was not done. Findings: Review of the facility's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of 27 final sampled residents (Resident 104) to meet the resident's medical and nursing needs. The facility failed to ensure a care plan was developed to address Resident 104's anxiety problem and the use of Ativan. This failure could potentially negatively impact the care needed for the resident. Findings: Medical record review for Resident 104 was initiated on 8/30/21. Resident 104 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], showed Resident 104 had severe cognitive impairment. Review of Resident 104's physician orders for the month of September 2021 showed a physician's order dated 8/18/21, to administer Ativan 1 mg one tablet by mouth every 12 hours as needed for anxiety manifested by restlessness, and monitor episodes of anxiety manifested by inability to relax every shift and the adverse side effects of Ativan. Review of Resident 104's plan…

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 medical record review, the facility failed to ensure the plans of care for two of 27 final sampled residents (Residents 49 and 120) were revised to address the residents' specific care needs. * Resident 49's care plan addressing risk for dehydration was not revised when the resident was diagnosed with dehydration. * The facility failed to ensure Resident 120's care plan was revised to address the use of wanderguard. These posed the risks for the residents to not receive the care and services required to attain or maintain their highest level of physical and mental well-being. Findings: Review of the facility's P&P titled Comprehensive Person-Centered Care Planning revised November 2018 showed additional changes or updates to the resident's comprehensive care plan will be made based on the assessed needs of the residents. The comprehensive care plan will be periodically reviewed and revised by the IDT after each assessment which means after each MDS assessment as required, except discharge…

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 medical record review, the facility failed to provide the necessary care and services for two of 27 final sampled residents (Residents 49 and 59) to maintain their highest physical well-being. * The facility failed to complete the CBC and CMP laboratory tests for Resident 59 as per the physician's order. * The facility failed to ensure the abdominal binder was applied to Resident 49 as per the physician's order. These failures had the potential to affect Residents 49 and 59's well being. Findings: 1. Medical record review was initiated for Resident 59 on 8/23/21. Resident 59 was admitted to the facility on [DATE], with a diagnosis of anemia Review of Resident 59's recapitulated Physician Orders for the month of August 2021 showed a physician's order dated 8/24/21, to complete CBC and CMP laboratory tests. However, further review of the medical record failed to show documented evidence the CBC and CMP laboratory tests were completed as per the physician's order. On 8/31/21 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure the residents were free from accidents and hazards. * The facility failed to provide adequate supervision to one nonsampled resident (Resident 436) who had behaviors of wandering and entering other resident rooms. * A metal drain grate missing one of nine slats was observed on the outdoor resident patio, which created a gap large enough for the front wheel of a resident's wheelchair to become entrapped. These failures had the potential to place the residents at risk for serious injury. Findings: 1. Review of the facility's P&P titled Wandering and Elopement revised on 7/17 showed the licensed nurse and in collaboration with the Interdisciplinary Team will assess residents upon admission to determine their risk of wandering/elopement. The resident's risk for elopement and preventative interventions will be documented in the resident's medical record and will be…

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, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of 27 final sampled residents (Resident 49), to ensure the resident maintained an acceptable nutritional status. The facility failed to administer the enteral feeding via GT as ordered by the physician. This failure had the potential for not meeting the resident's nutritional needs. Findings: Review of the facility's P&P titled Enteral Feeding-Open revised 1/1/12, showed enteral feeding will be administered via pump as ordered by the attending physician. Medical record review for Resident 49 was initiated on 8/23/21. Resident 49 was readmitted to the facility on [DATE]. Review of the Physician's Orders List showed an order dated 7/8/21, to flush the GT with 45 ml/hr for 20 hours of water to provide 900 ml/day via pump for hydration starting when the pump was initiated. In addition, there was an order dated 7/21/21, to start on 7/22/21, for Glucerna 1.2 at 80…

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, medical record review, and facility P&P review, the facility failed to ensure proper GT care for one of 27 final sampled residents (Resident 53) as evidenced by: * The facility failed to ensure Resident 53 was not lying flat when administering a bolus (a single dose of medication or other substance given over a short period of time) and enteral (refers to the intake of food through a gastrostomy tube) feeding to Resident 53. In addition, the facility failed to properly check the gastric residual volume (volume of fluid remaining in the stomach) before providing a bolus enteral feeding to Resident 53. These failures posed the potential risk for Resident 53 to have aspiration during feeding and medication administration. Findings: Review of the facility's P&P titled Enteral Feeding - Open dated 01/2012 showed the head of bed should be elevated 30 degrees during feedings. Medical record review was initiated for Resident 53 on 8/23/21. Resident 53 was readmitted to the facility 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 observation, interview, medical record review, and the facility P&P, the facility failed to ensure one of 27 final sampled residents (Resident 113) received the proper care of the peripheral catheter. * The licensed nurse failed to ensure the peripheral catheter dressing was labeled with the date and time when it was changed or applied on the peripheral catheter. This posed the risk for the resident to develop complications such as catheter- related infection or catheter-associated venous thrombosis (blood clot inside the vein). Findings: Review of the facility's P&P titled Peripheral Catheter Dressing Change dated January 2018 showed the licensed nurses should label the dressing with the date, time, and initials of person performing dressing change when they apply transparent dressing to the insertion site. On 8/23/21 at 0800 and 1000 hours, Resident 113 was observed in bed with an intravenous peripheral catheter on the right forearm with no labels showing the date and time when it was changed or…

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, medical record review, and facility's P&P review, the facility failed to ensure one of 27 final sampled residents (Resident 4) was assessed for pain and provided non-pharmacological interventions to ensure adequate pain management. This had the potential for Resident 4's pain not being managed effectively. Findings: According to the facility's P&P titled Pain Management dated 11/2016, the nursing staff will utilize non-pharmacological interventions to address possible issues contributing to pain. Interventions includes diversion activities, remake bed, breathing technique to reduce anxiety and etc. On 8/24/21 at 0824 hours, an interview was conducted with Resident 4. Resident 4 stated she had pain all over her body specially on her left side where she broke her hip. Resident 4 stated she received pain medication routinely and could ask the nurse if she needed. Medical record review for Resident 4 was initiated on 8/24/21. Resident 4 was admitted to the facility on [DATE]. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to implement fluid restriction for one of 27 sampled residents (Resident 96) as per the physician's order by monitoring the fluid intake. This failure had the potential for Resident 96 to experience life threatening conditions associated with fluid deficit/overload. Findings: Review of the facility's P&P titled Fluid Restrictions revised 1/1/12, showed to record any fluids given to the resident on the facility's intake and output record, total the amount of fluid each 24 hours and compare it against the fluid restriction guidelines, review intake and output summary weekly and address the adequacy of fluids and accuracy of documentation, and monitor the resident for signs of edema and dehydration. Medical record review for Resident 96 was initiated on 8/23/2021. Resident 96 was admitted to the facility on [DATE]. Resident 96 had a diagnosis of end stage renal disease (kidneys no longer function) and required dialysis three…

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 medical record review, the facility failed to ensure two of 27 final sampled residents (Resident 129 and 93) remained free from accident hazards due to the use of elevated side rails. *The facility failed to conduct the assessments for the risk of entrapment from side rails for Residents 116 and 129 and failed to attempt other interventions for Resident 116 prior to installing the side rails. These had the potential to put the residents at risk for entrapment and serious injury. Findings: The FDA issued a Safety Alert titled Entrapment Hazards with Hospital Bed Side Rails. Residents most at risk for entrapment are those who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain, uncontrolled body movement, hypoxia, fecal impaction, acute urinary retention, etc., that may cause them to move about the bed or try to exit from the bed. Entrapment may occur when a resident is caught between the mattress and bed rail or in the bed rail…

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 medical record review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 6.89 %. One of two licensed nurses (LVN 9) was found to have made errors during the medication administration observation. This had the potential to negatively impact the residents' health outcomes. Findings: Review of the facility's P&P titled Medication - Administration revised 1/1/12, showed medications will be administered directed by a Licensed Nurse and upon the order of a physician or licensed independent practitioner. Medications and treatments will be administered as prescribed to ensure compliance with dose guidelines. On 8/26/21 at 0853 hours, a medication administration observation for Resident 41 was conducted with LVN 9. LVN 9 prepared and administered Resident 41's medications which included the following: - two tablets of vitamin D 125 mcg (supplement), - two tablets of divalproex Sodium DR 500 mg (anticonvulsant), - one tablet of calcium carbonate 500 mg chewable (supplement), - one tablet of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility P&P review, the facility failed to ensure the medications were safely and securely stored. * Medication Cart A contained the prescription drugs, was left unlocked, and unattended in the hallway. * Multiple bottles of medications were observed at Resident 9's bedside. These failures posed the risk of unauthorized access to the medications and drug diversion. Findings: 1. Review of the facility's P&P titled Medication Storage in the Facility (undated) showed medication carts are locked or attended by persons with authorized access. On 8/26/21 at 0800 hours, an observation and concurrent interview was conducted with RN 2. Medication Cart A was observed to be unlocked and unattended in Nursing Station A's hallway. Medication Cart A was observed to have the prescription medications stored inside. Multiple residents and unlicensed staff were observed passing by Medication Cart A while it was unattended. RN 2 verified the findings. 2. On 8/23/21 at 1215 hours, 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 observation and interview, the facility failed to ensure 18 of 136 residents received pureed foods that were prepared by methods to conserve nutritive value. This failure placed residents receiving a pureed diet at risk for nutritional impairment. Findings: The nutritional value of pureed foods, in particular pureed vegetables, which are heated multiple times compromises both the palatability and nutritional value of foods (Nutrition.gov). Review of the facility's document showed 18 of 136 residents recieved pureed foods. On 8/23/21 at 1020 hours, an observation of the puree meal preparation was conducted with [NAME] 1. Upon pureeing corn for the lunch meal, [NAME] 1 transferred the pureed corn into a pan, covered it with foil, then put it in the oven. [NAME] 1 stated the oven was 350 degrees F and she held the puree food in the oven until lunch meal service for more than one hour. On 8/26/21 at 1307 hours, an interview was conducted with the RD. The RD confirmed holding puree vegetables in a heated oven for more than an hour prior to meal service would compromise the…

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

Based on observation, interview, and record review, the facility failed to serve food to meet the individual need for one of 27 final sampled resident (Resident 113). * Resident 113 was served a regular texture broth during lunch. Resident 113 had an order for puree honey thick liquid ( thickened liquid to prevent from going into the lungs). This failure had the potential to result in Resident 113 to develop aspiration and choking emergency. Findings: Review of the facility's P&P titled Menus undated showed, food served should adhere to the written menu. During the lunch meal service observation on 8/23/21 at 1213 hours, RNA 1 was observed assisting Resident 113 with her meal. Resident 113's meal tray contained a bowl of a broth type soup that was regular texture. Resident 113's meal ticket showed NAS (no added salt) L1/puree honey thick. RNA 1 was asked if the regular soup was appropriate for a puree honey thick diet texture. RNA 1 stated it was not and she would get a puree honey thick soup. On 8/26/21 1307 hours, a telephone interview was conducted with the RD. The RD verified…

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 facility P&P review, the facility failed to ensure the food items brought to the residents from the outside were handled to ensure safe storage, preparation and consumption. This failure posed the risk of resident food brought to the facility from the outside not being handled in a safe and sanitary manner which posed the risk of food borne illnesses. Findings: According to the facility's P&P titled Food Brought in by Visitors dated June 2018 showed, .the nursing home is responsible for ensuring that the food container is clearly labeled with the resident's name and date received and stored in a refrigerator designated for this purpose . B. Ensuring safe food handling once the food is brought to the facility, including safe reheating and hot/cold holding, and handling of leftovers. On 8/24/21 at 0809 hours, a concurrent observation and interview regarding food items brought to the residents from the outside was conducted with RN 1. RN 1 stated the food items brought into the facility for a resident had to be checked first to ensure it 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 medical record review, the facility failed to maintain the accurate medical records for three of 27 final sampled residents (Residents 85, 114, and 116). * Resident 85 had conflicting information documented in the medical record as to whether Resident 85 had formulated an advance directive for health care. * The facility failed to ensure the licensed nurses documented their inititals in the MARs when the medications were administered to Residents 114 and 116. These failures had the potential for the resident's care needs not being met as their medical information was inaccurate. Findings: 1. Medical record review for Resident 85 was initiated on 8/23/2021. Resident 85 was admitted to the facility on [DATE]. Review of Resident 85's Physician Orders for Life-Sustaining Treatment (POLST) dated 3/26/21, showed Resident 85's had not formulated an advance directive for healthcare. However, review of Resident 85's Advance Healthcare Directive Acknowledgment Form dated 3/26/21, showed Resident 85…

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, facility document review, and CMS guidelines, the facility failed to follow the current COVID-19 routine testing guidelines of facility staff for two of five sampled unvaccinated facility staff (CNAs 3 and 10) during the COVID-19 pandemic. * CNAs 3 and 10 who were not vaccinated against the COVID 19 virus were not tested for COVID 19 when the county's positivity rate was at 8.3%. This failure posed the risk for the spread of the COVID-19 virus to residents and other facility staff. Findings: According to the CMS QSO 20-38 titled Interim Final Rule (IFC), CMS 3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirement and Revised COVID-19 Focused Survey Tool revised on 4/28/21, the facility staff should be tested a minimum once a week when the county positivity rate in the past week is between 5% to 10%. Review of the Orange County COVID-19 Dashboard dated 8/13/21, the average positivity rate for the county was 8.3%. 1. Review of the COVID-19 laboratory test…

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 call light system was functioned properly in a room occupied by two residents. The call ight indicator outside Room L did not lit up when pressed. This failure had the potential for the staff to not know when these residents needed assistance. Findings: On 8/25/21 at 1457 hours, a concurrent observation and interview was conducted with the Activity Director. The call light indicator outside Room L did not light up when pressed. The Activity Director was outside Room L and verified the call light indicator was not working. On 8/25/21 at 1455 hours, an interview was conducted with the Administrator. The Administrator verified the call light indicator outside Room L was not working. The Administrator stated the call light indicator outside residents' room had to be functional. On 8/25/21 at 1730 hours, an interview was conducted with the Maintenance Supervisor. The Maintenance Supervisor verified the findings.

Based on observation, interview, and facility document review, the facility failed to maintain an environment free of pests for one of 27 final sampled residents (Resident 127) and one nonsampled resident (Resident 95). * Resident 127 kept dead cockroaches inside a plastic bag when staff did not address her previous concerns about pests in her room. * Fruit flies were observed inside and flying around Resident 95 's bag of red grapes. These failures had the potential to cause the spread of infection throughout the facility. Findings: 1. Review of the facility's P&P titled Pest Control revised 1/1/12, showed the facility maintains an ongoing pest control program to ensure the building and grounds are kept free of insects, rodents, and other pests. On 8/23/21 at 0933 hours, during initial tour, Resident 127 was observed sitting on her bed. Resident 127 stated she had been living in the facility for a while. Resident 127 stated she had seen cockroaches in her room. Resident 127 showed two plastic bags with dead cockroaches inside. Resident 127 stated she saved the dead cockroaches from…

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.