Santa Rosa Post Acute

Based on observation, interview, and record review, the facility failed to ensure one out of twenty sampled residents (Resident 28) was provided the Restorative Nursing Assistant Program (RNA-P, a program which provides exercise and a range of motion activities to the residents), when Resident 28's physician's orders, person-centered care plan, and resident's choice to participate in the RNA-P was not being followed.This failure had the potential to result in Resident 28's decline in physical abilities and decreased muscle strength.Findings:A review of Resident 28's admission record indicated he was originally admitted to the facility in November 2023 with diagnoses including lung disease and the absence of right leg, below the knee. A review of Resident 28's Minimum Data Set (MDS- a federally mandated assessment tool), dated 8/22/25, indicated Resident 28 had an ability to express ideas and wants.A review of Resident 28's Care Plan Report, dated 12/8/23 with no resolved date, titled Restorative Nursing- Range of Motion indicated, RNA PROGRAM FOR AROM [active range of motion] BUE…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews and record reviews, the facility failed to ensure adequate pain relief for one out of 20 sampled residents (Resident 45), when using a numeric pain rating scale where 0 as no pain, 1 to 3 as mild pain, 4 to 6 as moderate pain, and 7 to 10 as severe pain, Resident 45 complained of moderate to severe pain daily.This failure resulted in Resident 45 feeling frustrated and complaining of lack of quality of life.Findings:A review of Resident 45's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated an admission date in June 2025 with a diagnosis of fracture of unspecified part of neck of left femur (a break in the part of the left thigh bone just below the hip joint) and pain due to internal orthopedic prosthetic devices (an artificial replacement part for the body), implants (devices or tissues that are placed inside or in the body) and grafts (skin or bone cut from one part of a person's body or other source and used to repair a damaged part).A review of Resident 45's Brief Interview for Mental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews and record review, the facility failed to ensure one resident out of 20 sampled residents (Resident 87) was provided with a safe and sanitary environment when the commode (portable toilet designed for individuals with limited mobility) was covered with a blanket.This failure has the potential to spread germs and cause illness among residents.Findings:A review of Resident 87's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated an admission date to the facility in July 2025 with a diagnoses of muscle weakness and difficulty walking.During a concurrent observation and interview on 09/09/2025 at 12:34 PM, in Resident 87's room, a commode was covered with a blanket. Resident 87 stated staff have used a blanket to cover the commode for about two months.During a concurrent observation and interview on 09/09/2025 at 1:18 PM, Licensed Nurse (LN) C verified Resident 87's commode bucket was covered with a blanket. LN C verified the commode had always been covered that way. LN C stated it was not…

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

Based on observation, interviews and record reviews, the facility failed to ensure the call light (a communication tool used in healthcare settings to allow patients to request assistance from staff) was within reach for one out of five sampled residents (Resident 102), when her call light was found coiled around her lower bed post away from her reach.This failure put Resident 102 at risk for delayed provision of care and accidents.Findings:A review of Resident 102's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated an admission to the facility in April 2020 with a diagnosis of hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body).During a concurrent observation and interview on 09/09/2025 at 11:47 AM, in Resident 102's room, Resident 102's stated she had been using the pressure pad to call for help and no staff responded because she believed it was not working. Resident 102 stated earlier in the morning her normal call light had been changed to the pressure pad call button. Resident 102…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain the kitchen's drain in working order when the sewage drainpipe was observed disconnected and leaking outside the kitchen. This decreased the facility's potential to maintain sewer lines in proper working order and containment.Findings:During a concurrent observation and interview on 9/9/25 at 11:27 a.m. with the Maintenance Director (Maint Dir) outside the kitchen near the wall corresponding to the kitchen's food preparation sink. A black plastic sewer pipe was observed coming off the wall down to the top of the ground. The pipe was observed disconnected at one of the joints with light-colored solid particles scattered in the direction of the slope of the ground from the pipe's opening. Maint Dir confirmed that the pipe is not supposed to be disconnected. During an interview on 9/12/25 at 1:47 p.m. with the Dietary Supervisor (DS), DS acknowledged that a leaky drainpipe could attract pests, and it should have been fixed. During a review of the facility's policy and procedure (P&P) titled, Maintenance Service,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure services provided by the facility met professional standards of practice for administering medications as ordered by the physician (MD) for three residents (Resident 1, Resident 2, and Resident 3) of three sampled residents when: 1. Resident 1 did not receive her heart failure medication, antidepressant medication, and ointment for skin redness;2. Resident 2 did not receive a dose of his anti-fungal powder; and,3. Resident 3 did not receive her medication to alleviate pain and itching and medication for her thyroid. These failures decreased the facility's potential to ensure residents received medications that prevented a decline in their health status or prolonged discomfort due to their health diagnoses. Findings:1. A review of Resident 1's admission record indicated she was admitted on [DATE] with a diagnosis of congestive heart failure (CHF - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect a census of 94 residents from sexual abuse when the facility allowed an alleged perpetrator, Certified Nursing Assistant 1 (CNA 1), to enter the facility on 4/4/25 after conducting an incomplete investigation per facility policy for a census of 94 residents. This failure granted CNA 1 access to Resident 1 and had the potential to place Resident 1 and other residents at risk for further harm. Cross-reference F610. Findings A review of an admission record indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of cardiomegaly (a condition when the heart becomes larger than normal) and dementia (a progressive state of mental decline). A review of Resident 1's progress note dated 4/4/25 at 9:38 p.m. indicated, Spoke to this [Resident 1] at approximately 12:40 p.m. today due to .reporting to a CNA that [Resident 1] experienced sexual abuse at the facility .This [Resident 1] reported that a male cleaned her in her room after a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to thoroughly investigate an allegation of sexual abuse for one resident (Resident 1) of eight sampled residents when Resident 1 alleged a male Certified Nursing Assistant (CNA) matching the identity of CNA 1 exposed himself to Resident 1 and forced Resident 1 to touch his genitals. This failure decreased the facility's potential to protect Resident 1 and a facility census of 94 residents at the facility from harm. Findings: A review of CNA 1's employee file indicated he was hired at the facility on 8/31/21. A review of Resident 1's admission record indicated admission to the facility on 2/24/25 with a diagnosis of cardiomegaly (a condition when the heart becomes larger than normal), dementia (a progressive state of mental decline), delirium due to known physiological condition, adult failure to thrive (a condition where older adults experience a significant decline in their overall health and well-being, often due to a combination of 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.

Based on interview and record review, the facility failed to implement its abuse and change of condition policy for two residents (Resident 1 and Resident 2) of four sampled residents when the facility staff did not: Notify the residents' family representatives and physicians, Document an Interdisciplinary Team (IDT- a multidisciplinary team who ensures a comprehensive and coordinated approach to patient care) note, and Initiate care plans to provide person-centered care for both residents for an allegation of resident-to-resident abuse. This failure decreased the facility's potential to prevent recurrence of abuse between Resident 1 and Resident 2. Findings: A review of a investigation summary report sent to the California Department of Public Health (CDPH) on 4/14/25 indicated, On 4/9/25, the [Resident 1] reported to the staff that her roommate [Resident 2], came to her bed around midnight, tore the blankets off the bed, began commanding that she go to the bathroom, and then struck her on the face and chest several times. During an interview on 4/25/25 at 9:10 a.m., the…

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

Based on interview and record review, the facility failed to ensure an allegation of abuse was reported within the required timeframe for two residents (Resident 1 & Resident 2) of four sampled residents when an allegation of resident-to-resident abuse was reported to the California Department of Public Health (Department) five days later. This failure of timely reporting had the potential to cause a delayed response by enforcement agencies to ensure resident safety. Findings: A review of a facility document dated and received by the Department on 4/14/25, indicated an allegation of suspected dependent adult/elder abuse had been made on 4/09/25 related to a resident-to-resident altercation between Resident 1 and Resident 2. During an interview on 4/25/25 at 11:28 a.m., the Administrator stated the facility had mistakenly sent the five-day abuse investigation summary to the Department since the facility was not required to report abuse at all when the residents involved had dementia (memory loss), and the incident had not resulted in serious bodily injury. The Administrator confirmed…

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

Based on interviews and record reviews, the facility failed to implement their abuse policy, for one resident out of three sampled residents (Resident 1) when: 1. Resident 1 made an abuse allegation on 3/26/25 but the facility did not report the allegation within two hours to the State (licensing agency), the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and law enforcement, and 2.six out of six facility staff did not know the expectation to report any allegation of abuse within two hours to the State, the Ombudsman, and the law enforcement. These failures could put the resident ' s safety at risk due to delayed intervention. Findings: During an interview on 4/9/25 at 9:45 a.m., Licensed Nurse A (LN A) stated abuse allegations should be reported to the State, Ombudsman and the Police (law enforcement), within 24 hours if there was no injury but within 2 hours if there was injury. LN A stated that late reporting of abuse might put residents at risk for abuse to continue and could put the residents at risk for emotional…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure three out of five sampled residents (Resident 2, Resident 3, and Resident 4) were provided with a homelike environment when Resident 1 would wander into their rooms, rummage through their personal belongings and take them. This failure caused emotional distress and feelings of anger for Resident 2, Resident 3, and Resident 4. Findings: A review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of polyneuropathy (a condition in which multiple nerves throughout the body are damaged), vascular dementia (type of brain damage caused by reduced blood flow to the brain causing a progressive state of decline in mental abilities), and Alzheimer ' s Disease (a disease characterized by a progressive state of decline in mental abilities). A review of a facility document titled Order Summary Report, dated 2/20/25, indicated a Psych Referral PRN [as needed]. A review of a 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.

Based on interview and record review, the facility failed to provide residents a copy of their medical records upon request for six of 15 sampled residents. This failure resulted in the obstruction of the residents' right to access their own medical record. Findings: A review of Resident 1's admission record indicated admission to the facility on 2/9/24 with diagnosis of Central Cord Syndrome (a spinal cord injury that affects arms and hands more than the legs), fusion of the spine surgical procedure permanently joining two or more bones in the spine), and Spinal Stenosis (a condition where the space surrounding the spinal cord becomes narrowed). A review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 5/17/24, indicated a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 13 which indicated no cognitive (relating to processes of thinking and reasoning) impairment. A review of a document titled Authorization Form for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to appropriately respond to a scabies (a burrowing mite that causes an itchy rash; it can spread from person to person in crowded living situations such as nursing homes) outbreak that resulted in 41 out of 95 residents developing an itchy rash when the infection preventionist did not implement surveillance for potential cases of scabies when rashes began appearing, did not identify the scabies outbreak, and did not report the scabies outbreak to the local health department (LHD) per Centers for Disease Control and Prevention (CDC) guidance. This failure potentially delayed additional resources and assistance from the local health department to prevent scabies from spreading to all 95 residents and delayed the LHD from investigating potential exposures and further spread in the community. Findings: During an interview on 11/14/24 at 1:35 p.m. with Director of Nursing (DON) and Infection Preventionist (IP), DON stated that during a heat wave…

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

Based on observation, interview and record review, the facility failed to provide a reliable communication channel to one of three sampled residents (Resident 1), when phone calls to the facility were not picked up in a timely manner. These multiple unanswered phone calls resulted in difficulties in establishing communication between Resident 1 and her family, causing frustration and distrust. Findings: During an interview on 8/29/24 at 10 a.m., Family Member (FM) stated phone calls to the facility were not always answered. FM stated she did not live in the area, and calling the facility was the only way to contact her mother, Resident 1. FM stated she tried to call the facility in the evenings after her work, and added it was very frustrating when she was unable to get ahold of any staff for any updates or to answer questions. FM stated one phone call was even picked up by a very confused lady, most likely another resident there. FM stated it was pointless for the facility to post their phone number as their contact information, if no one would be answering the calls. An internet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed provide pharmaceutical services that meet the needs of the residents when one of four sampled residents (Resident 1) did not receive Lyrica (a medication used to treat It is used to treat painful nerve diseases) twice, over a seven-day period, contrary to the physician ' s orders. This failure was not in alignment with facility policy and procedures and resulted in Resident 1 to experience unrelieved pain which prompted her subsequent transfer to the emergency room. Findings: During an interview on 8/29/24 at 10 a.m., FM (Family Member stated Resident 1 was not given several doses of Lyrica. FM stated Resident 1 had been on Lyrica for a long time to control her pain and her suddenly missing several doses would increase her risk for withdrawal. FM stated Resident 1 ' s pain got so severe that she requested to be sent out to the emergency room. Record review revealed Resident 1 was admitted to the facility with diagnoses including acute transverse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews and record reviews, the facility failed to: Ensure residents were consistently able to communicate with their Responsible party (RP, the individual who directs someone else's care) and loved ones via the facility phone after 5 p.m., and on the weekends, for two out of two sampled residents (Resident 4 and Anonymous Resident 5 (AR 5). In addition, two out of two Anonymous family members 6 and 7 (A FM 6 and 7) complained of staff not picking up the facility phone at the nursing station and not being able to talk to their loved ones after 5 p.m., at nighttime, and on the weekends, and Licensed Nurses (LNs) and Certified Nursing Assistants (CNAs) stated receiving complaints from family members and residents in general, about how they were not able to communicate with each other when they called the facility phone after 5 p.m., and on the weekends. These failures resulted in Resident 4 and AR 5 feeling frustrated and at risk for depression and self-isolation. Findings: A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide adequate nutrition and weight monitoring for (Resident 1) when (Resident 1) lost 7.8 pounds (5.3%) within the first week of the Resident's admission. This failure had the potential for Resident 1 to be at risk for malnutrition, dehydration, and electrolyte imbalance. Findings: During a record review of Resident 1's medical record, face sheet revealed Resident 1 is a [AGE] year old with multiple diagnoses with some being; Spastic Quadriplegic Cerebral Palsy, (impaired movements, due to brain damage at a very young age characterized by paralysis of both arms and both legs, with muscle stiffness in face and trunk of body), Epilepsy (seizure disorder), Dysphagia, (difficulty swallowing), and cognitive communication deficit (difficulty communicating). During a record review of Resident 1's medical record, Brief Interview for mental status (BIMS Score) (indicates thinking and reasoning capabilities. A score of 15 out of 15 is the highest…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure: 1. Staff were aware of what Baseline Care Plan (BCP, a plan that promotes continuity of care and communication among nursing home staff to increase resident safety) was, or its completion time frame. 2. BCP was completed timely for five out of five sampled residents (Residents 1, 2, 4, 7 and Anonymous 5). These failures had the potential to put residents' safety at risk and for residents not receiving the care that they need. Findings: A review of Resident 1's face sheet (demographics) indicated he was initially admitted to the facility on [DATE]. His diagnoses included Heart Failure (HF, occurs when the heart muscle doesn't pump blood as well as it should), Vitamin B12 deficiency Anemia (your body doesn't have enough healthy red blood cells because you're low in vitamin B12, a nutrient that helps keep your body's blood and nerve cells healthy) and Parkinson's Disease (PD, a movement disorder that causes tremors, stiffness, and slow…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure food served to seven out of seven sampled residents (Residents 1, 2, 4, 6, 7, Anonymous 3 and 5) were palatable, and at an appetizing temperature. These failures could lead to Gastrointestinal Disease such as Diarrhea and vomiting and could result in residents not eating their meal, feeling frustrated and upset. Findings: A review of Resident 1's face sheet (demographics) indicated he was initially admitted to the facility on [DATE]. His diagnoses included Heart Failure (HF, occurs when the heart muscle doesn't pump blood as well as it should), Vitamin B12 deficiency Anemia ( your body doesn't have enough healthy red blood cells because you're low in vitamin B12, a nutrient that helps keep your body's blood and nerve cells healthy) and Parkinson's Disease (PD, a movement disorder that causes tremors, stiffness, and slow movement). His Minimum Data Sheet Assessment (MDS, a federally mandated process for clinical assessment of all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to: 1. Ensure dietary staff were aware the facility had a vegan (strict vegetarian, vegan diet completely excludes anything that comes from an animal) menu. 2. Ensure one out of two sampled residents (Resident 1) was receiving a vegan meal per his and his responsible party (RP, someone who is able to act on behalf of the resident) preference. These failures led to Resident 1 to not receive a vegan meal per his preference. This failure also had the potential for Resident 1 to not meet the recommended daily intake (RDI, the average daily dietary intake level that is sufficient to meet the nutrient requirements of nearly all (97-98 per cent) healthy individuals in a particular life stage and gender group) for certain nutrients like protein or vitamins which could further compromise his medical status. Findings: A review of Resident 1's face sheet (demographics) indicated he was initially admitted to the facility on [DATE]. His diagnoses included Heart…

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

Based on interviews and record reviews, the facility failed to ensure there was a qualified staff with the appropriate competencies and skill sets to carry out food and nutrition services when a dietary manager (DM) who was not certified was put in place to oversee dietary services when the Registered Dietician (RD) was not employed full-time (staff that works 35 or more hours per week). Findings: During an interview on 4/11/24 8:44 a.m., the DM verified she was not a certified Dietary Manager but was currently enrolled to get her certification. The DM stated she also was not a certified food service manager. The DM stated she had no certification at this facility. The DM stated she was not done in school yet and had not gotten certified as a dietary manager. The DM stated RD came in 3 times a week. The DM stated she oversees the kitchen and dietary needs of the residents if the RD was not in the building. When asked what the facility's policy was with regard to hiring a DM, she was silent. When asked if she should have been certified prior to being hired as a dietary manager, she…

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

Based on observation, interview, and record review, the facility failed protect the residents ' right to be free from sexual abuse by a resident when one resident, Resident 1, who had a known history of touching a female resident inappropriately, did not have a plan in place to prevent further abuse. This failure resulted in sexual abuse of two additional residents. Findings: On 12/4/23, the Department received a report from the facility that staff witnessed Resident 1 touching female Resident 3 sexually and the local police department was notified. Review of Resident 1 ' s medical record revealed an admission date of 6/13/22 and medical diagnoses that included Parkinson ' s disease (a movement disorder of the brain that gets worse over time), Transient ischemic attack (TIA, a temporary blockage of blood flow in the brain), stimulant dependence, and kidney failure, among others. Resident 1 ' s most recent MDS (minimum data set, an assessment tool) indicated his BIMS score was 11 (Brief interview for mental status, a score of 11 indicates moderate cognitive impairment). Resident 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.

Based on interview and record review, the facility failed to initiate a care plan for the behavior of one of four sampled residents (Resident 1) when Resident 1 was witnessed touching a female resident inappropriately. This failure resulted in Resident 1 continuing to touch female residents inappropriately with no plan in place to manage or prevent the behavior. Finding: On 12/4/23, the Department received a report from the facility that staff witnessed Resident 1 touching female Resident 3 sexually and the local police department was notified. On 12/8/23, the Department received a report from the facility that staff witnessed Resident 1 touch Resident 4 ' s breast and the local police department was notified. During an interview on 12/12/23 at 3:17 p.m., Police Officer stated the first incident reported to their department involved Resident 1 and Resident 2 and was investigated on 11/17/23. Police Officer stated he was concerned about the pattern of Resident 1 ' s behavior and a lack of a safety plan for this guy who ' s just roaming around. Police Officer stated, This guy ' s name…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of six sampled certified nurse assistants (CNA [CNA 1]) had a valid nursing assistant certificate. This deficient practice placed all 94 residents at risk for receiving improper patient care. Findings: During a review of the California Department of Public Health Licensing & Certification (L&C) verification website, CNA 1 ' s certification was checked and was not found. The webpage indicated, Effective [DATE], the online Registry will only display active, denied, suspended and revoked statuses for CNA[s] . During a review of the employee files on [DATE] at 12:50 p.m., it was noted that CNA 1 was hired by the facility on [DATE] with an initial certification date of [DATE] and expiration date of [DATE]. CNA 1's employee file showed that CNA 1's nurse assistant certification expired on [DATE]. Review of the CNA staffing sheets dated [DATE], and as far back as [DATE], showed that CNA 1 worked the night shift with an expired certificate 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 record review, the facility failed to provide the care and services needed for one of two sampled residents (Resident 1) when: 1. Resident 1 ' s change in condition was not addressed timely, 2. Resident 1 missed his scheduled tube feedings, 3. Resident 1 ' s pressure injury was not documented according to nursing standards and Resident 1 was not placed on a low-air loss mattress, 4. Resident 1 missed multiple doses of his medications, and 5. Resident 1 was not weighed daily per physician ' s order. These multiple failures to carry out Resident 1 ' s physician orders resulted in care and services not provided to a vulnerable resident totally dependent on nursing staff to meet his needs. Findings: 1. During an interview on [DATE] at 3:18 p.m., FM 2 stated when she came to visit Resident 1 on [DATE] he was having trouble breathing, his blood pressure was 86/54, and his mouth was full of blood. FM 2 stated the OT (occupational therapist) found the low blood pressure, and the OT…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility ' s pharmacy failed to deliver timely the medications for one of two sampled residents (Resident 1). This failure resulted in Resident 1 missing doses of medications he needed for his multiple comorbidities. Findings: Review of Resident 1 ' s medical record revealed an admission date of 10/28/23 and a discharge date of 10/30/23. Resident 1 ' s medical diagnoses included cerebral infarction (stroke, a blockage of blood flow to the brain), dysphagia (difficulty swallowing), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following a cerebral infarction, atrial fibrillation (an irregular and often fast heart rhythm), Chronic Diastolic (Congestive) Heart Failure (left heart ventricle (the heart ' s main pumping chamber) becomes stiff and cannot fill properly), and primary hypertension (HTN, high blood pressure) among others. Resident 1 ' s nursing progress note, dated 10/28/23, indicated, Resident is a…

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

Based on observation, interview, and record review, the facility failed to follow policy and procedure on infection control practices during a COVID-19 outbreak when: 1) Two unlicensed staff were observed not wearing the correct Personal Protective Equipment (PPE - typically gown, mask, gloves) when entering a COVID positive room. 2) One unlicensed staff was observed in a room with no facemask or PPE that housed a resident on contact precautions (involves the use of PPE appropriately, including gloves, gown, mask to protect against exposure and cross contamination of certain illnesses) for Clostridioides difficile (C-difficile - a contagious bacteria that causes an infection of the colon, the longest part of the large intestine. Symptoms can range from diarrhea to life-threatening damage to the colon.) This deficient practice had the potential to cause cross contamination and spread germs and organisms to other vulnerable residents in the facility. Findings: The facility experienced a COVID-19 outbreak that started on October 26,2023. During an initial observation on 11/2/23 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 observations, and interviews the facility failed to maintain a consistently operable telephone communication system in operating condition that had an established answering system when it was observed there was no efficient communication system to contact the facility by calling the facility ' s main contact phone number during hours of operation and after hours when the front desk receptionist was not in the facility to answer phone calls. This failure caused stress, anxiety, and lack of communication between resident ' s responsible parties, and family members who were unable to contact staff members at the facility creating a safety concern that had the potential to result in delayed or non-delivery of care and services to its residents. Findings: During an interview on 11/7/23 at 9:20 a.m., Licensed Staff A was asked who answered the telephones at the front desk, she stated the facility had a receptionist from 8:00 a.m. to 5 p.m., and after hours, anyone sitting at the front desk can answer the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure nursing professional standards of practice were followed for one of three sampled residents (Resident 1) when: 1. Licensed Staff A, the admitting nurse, felt Resident 1 needed a higher level of care upon arrival to the facility based on her nursing assessment, but did not notify or share her concerns with the attending physician. In addition, she documented Resident 1's cognition was alert and oriented, when the discharging facility indicated he was nonresponsive and unable to follow commands due to a traumatic brain injury, 2. No baseline or comprehensive care plans were created for Resident 1 until after he passed away at the facility approximately 36 hours after admission, even though, according to the facility physician, he was a critically ill resident, 3. A physician order to provide Resident 1 a snack daily at 8:00 p.m., contradicted another physician order indicating Resident 1 was NPO (No meals/fluids were to be given by mouth), but…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure one out of three sampled residents (Resident 1) was provided the needed care, assessment and treatment in a timely manner and in accordance with professional standards of practice when Resident 1 A. did not receive a timely assessment for complaints of eye irritation and coughing. B. there were no nurse documentation for the eye infection and coughing C. did not receive the ophthalmic antibiotic order for the eye infection until 2 days later. 4. there were no care plan created for the eye infection or the coughing that would have guide staff on how to care for Resident 1 safely. These failures resulted to Resident 1 developing a fever, an infection on both eyes and right lung infiltrates (a pulmonary infiltrate is a substance denser than air, such as pus, blood, or protein, which lingers within the parenchyma of the lungs) in the facility. Resident 1 ' s status had worsened and she was then sent to the hospital for 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.

Based on interviews and record reviews, the facility failed to notify the Office of the State Long-Term Care Ombudsman (a public advocate [official] who is charged to provide valuable assistance to residents, their families and/or friends, in the resolution of quality of care and quality of life issues) when five of five sampled residents (Residents 74, 15, 45, 23 and 84) were transferred out, and eventually admitted to acute care. This failure had the potential for all five sampled residents to not have protection from being discharged or transferred inappropriately, and limit residents' access to an advocate who can inform them of their options and rights. Findings: During an interview on 4/19/21, at 9 a.m., Resident 74 stated he had recently come back from the hospital. A review of Resident 74's SBAR Communication Form and Progress Note for RNs/LPN/LVNs (SBAR: Situation-Background-Assessment-Recommendation, provides a framework for communication between members of the health care team about a patient's condition), dated 3/26/21, indicated seizures noted lasting 15-30 secs…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 treat each resident with dignity and respect when a staff member did not knock on the door before entering five of five residents' rooms (Resident 41, Resident 34, Resident 67, Resident 24 & Resident 66). This failure had the potential to cause residents to feel disrespected and an invasion of privacy when staff did not knock and request permission before entering resident rooms. Findings: During an observation on 4/19/2021, beginning at 8:30 a.m., Staff H entered each resident's room without knocking on the door while this surveyor conducted interviews with Resident 34, Resident 66, Resident 67, Resident 41 & Resident 24. During an interview on 4/19/2021 at 10:30 a.m., Resident 24 stated that she did not care anymore if a staff walked in her room without knocking on the door first because it happened all the time. During an interview on 4/19/2021 at 11:30 a.m., Resident 67 stated that she was used to housekeeping staff entering her room without knocking on the door. During an interview on 4/22/21 at 11:10…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 post the contact information for the Office of the State Long-Term Ombudsman (the Ombudsman) in a form and manner accessible to residents. This failure resulted in four of four residents (Residents 3, 4, 31 and 44) not knowing how to contact the Ombudsman. Findings: During a group interview on 4/20/21, at 10 a.m., Residents 3, 4, 31 and 44 stated they did not know how to contact the Ombudsman. During an interview on 4/20/21, at 11:05 a.m., Staff B was asked the location of the Ombudsman contact information sign. Staff B stated there were two signs displaying the Ombudsman contact information in the facility: one inside the staff breakroom and one at the entrance of Hall 2 (rooms 15-25). During an observation on 4/20/21, at 11:05 a.m., the Ombudsman contact information sign placed at the entrance of Hall 2 could only be seen by persons entering Hall 2. During a concurrent interview, Staff P confirmed the Ombudsman contact information sign at the entrance of Hall 2 was only visible to residents and family…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop a comprehensive care plan that met the needs of three of three residents (Residents 28, 35, and 232). For Resident 28, the facility did not create a care plan for use of supplemental oxygen. For Resident 232 the facility did not create a care plan for a PICC (Peripherally Inserted Central Catheter) line, an intravenous catheter. For Residents 35 and 232, the facility did not create a care for use of indwelling urinary catheters (drainage tubes for urine). These failures placed Residents 28, 35 and 232 at risk of not having their care needs met, including the prevention of urinary, respiratory, skin and blood infection. Findings: During an observation on 4/19/21, at noon, Resident 35 had a Foley catheter (a type of indwelling urinary catheter). A review of Resident 35's care plans indicated no care plans with interventions to care for Resident 35's Foley catheter. During an interview on 4/22/21, at 3 p.m., Staff B reviewed Resident 35's care plans and confirmed there was no Foley catheter care 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 observation, interview and record review, the facility failed to implement the activities care plan for one of two residents (Resident 35). This failure resulted in Resident 35 not enjoying his favorite activity of being outdoors for fresh air and sun. Findings: A review of Resident 35's facesheet (a resident demographic) indicated he was admitted on [DATE] with diagnoses including paraplegia (an impairment in motor or sensory function of the lower extremities), pressure ulcers (injuries to the skin and underlying tissue resulting from prolonged pressure on the skin), generalized muscle weakness and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). A review of Resident 35's activities care plan dated 3/1/21 indicated Resident 35 enjoyed being outdoors. A review of progress note dated 3/29/21, at 3:01 p.m., indicated SS [Social Services] met with patients [family] to address [family]'s concerns. [Family] is concerned about him not getting up and his…

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

Based on observation, interview and record review, the facility and their pharmacist failed to ensure that the instructions on the label of the medication (Prednisone - an anti-inflammatory) container were correct for one of three residents (Resident 80). The discrepancy in the instructions, on the medication container, the eMAR (electronic medication administration record), and the doctor's order for the administration of Resident 80's Prednisone included with lunch, at 8:30 a.m., and one time a day. This failure of uncorrected administration instructions for the Prednisone had the potential to cause a medication error when dispensing the Prednisone leading to possible adverse effects for Resident 80. Findings: During an observation on 4/21/21 at 8:30 a.m., Staff M prepared morning medications for Resident 80. Staff M handed the medication container of Prednisone to this Surveyor for review. The label on medication container, for Resident 80, revealed, Prednisone tablet 5mg (milligrams), give 1 tablet by mouth every day with lunch. A concurrent review of the eMAR for Resident 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.

Based on observation, interview and record review, the facility failed to ensure accurate labeling of medications for safe administration, for safe and proper storage of medication in the correct temperature, for discarding expired medication, and for labeling food items in the refrigerator located in the Medication Room. These failures had the potential to result in licensed nurses administering wrong medication or the wrong dose of medications which may have a significant adverse effect on residents that may lead to serious harm or death. Findings: Labeling: During an observation on 4/21/21 at 8:30 a.m., Staff M prepared morning medications for Resident 80. Staff M handed the medication container of Prednisone to this Surveyor for review. The label on medication container, for Resident 80, revealed, Prednisone tablet 5mg (milligrams), give 1 tablet by mouth every day with lunch. A concurrent review of the eMAR for Resident 80 revealed, 8:30 a.m. to give Prednisone tablet 5mg, Give 1 tablet by mouth one time a day for Hx (history) of kidney transplant. The second line of the eMAR…

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

Based on interviews and record reviews, the facility failed to maintain accurate medical records for one of 18 sampled residents (Resident 50) when her signature was entered on the wrong line in the medication consent form. This failure had the potential to misrepresent a resident's care experience, and assented plan of care goals and treatment. Findings: During an interview on 4/21/21, at 10 a.m., Resident 50 stated she is taking Cymbalta (a medication used to treat depression and anxiety) and Zyprexa (medication used to treat psychotic conditions such as schizophrenia and bipolar disorder). A review of Resident 50's admission Record indicated she was her own responsible party. During a concurrent interview and record review of Resident 50's PACS: Informed Consent - Psychoactive Medication form on 4/22/21 at 3:19 p.m., Staff E confirmed the Patient/Responsible Party Signature line was unsigned. Staff E stated, It looks like the resident signed on the physician signature line instead. I'm not sure who checks and reviews these consents, but someone should have caught that. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that all staff to practice infection control prevention when: A housekeeper did not change gloves after cleaning each resident's rooms, and, A housekeeper did not wash hands or use alcohol based hand rub (ABHR) after cleaning each resident's room, and, Licensed nurses did not change the dressing (bandage) on the PICC line (Peripheral Inserted Central Catheter - an intravenous line). These failures had the potential to spread infections (such as Covid19) to vulnerable residents, staff, and visitors, or skin and blood infections due to unchanged PICC line dressing. Findings: During an observation on 4/19/2021 at 8:30 a.m., Staff H entered room [ROOM NUMBER] with cleaning products in her hands with gloves. Staff H cleaned bathroom, wiped table top, handrails, mopped floors, wiped doorknobs. Staff H did not remove her dirty gloves (not heavy-duty) when exited the room. Staff H returned the cleaning products into housekeeping cart. Staff…

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