Stanford Court Skilled Nursing & Rehab Center

Based on observation, interview, and record review, the facility failed to ensure two kitchen staff (Cook 1 and cook assistant [CA]) were competent in taking final food temperatures and proper use of the thermometer.As a result of these deficient practices, there was the potential for residents' food to have been contaminated and unsafe to consume.Findings:On 12/3/25 at 10:46 A.M., an observation was conducted in the kitchen. [NAME] 1 was observed calibrating the facility's digital thermometer (orange in color) that would be used to take food temperatures. [NAME] 1 placed the thermometer into a full cup of ice water. The thermometer shut off at 33 degrees Fahrenheit ( F) and did not reach 32 F. The thermometer was turned back on, and it then read 34 F and continued to increase in temperature. [NAME] 1 stated the thermometer did not calibrate. The DM provided another digital thermometer (black in color) to [NAME] 1. The second thermometer reached 32 F and calibrated with no issues. On 12/3/25 at 10:50 A.M., [NAME] 1 began to take the temperatures of the food as it was placed on 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 follow the menu during lunch service.This deficient practice had the potential for residents to not be satisfied with the food which may lead to weight loss. Findings:A review of the facility's census dated 12/1/25 indicated there were 102 residents in the facility.On 12/2/25 at 10:04 A.M., a confidential group interview was conducted with eight residents. The facility's food was discussed. The confidential group residents stated sometimes they received food that was not on the menu. The confidential group residents stated they wanted the menu to be followed. A review of the facility's lunch menu for 12/3/25 indicated, Meat lasagna, marinara sauce, garlic bread, mixed vegetables, sorbet, and 2% milk. On 12/3/25 at 11:15 A.M., an observation in the kitchen was conducted during lunch tray line. Several residents' meals were observed plated and placed in the meal cart. The plated food was observed without mixed vegetables. [NAME] 1 stated the mixed vegetables were not on the menu. [NAME] 1 stated garden salad…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow appropriate infection prevention and control practices when a nurse did not clean the blood pressure cuff in between resident uses for three of three residents (Resident 20, 85, and 132). In addition, the facility failed to properly clean and disinfect a Purewick device (an external urinary catheter) according to the manufacturer's guidelines for one resident (Resident 124). As a result of these deficient practices, the residents were placed at risk for contracting infections. Findings: 1. A review of Resident 20's admission record indicated the resident was admitted on [DATE] with diagnosis including hypertensive heart disease (a collection of heart problems that develop over time because of long-term, untreated high blood pressure) and heart failure (the heart muscle doesn't pump blood as well as it should to meet the body's needs). A review of Resident 85's admission record indicated the resident was admitted on [DATE] 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, and record review, the facility failed to ensure current infection control practices were followed when the facility did not designate dedicated vital signs (VS) equipment (blood pressure cuff, stethoscope and thermometer) for two of two residents with clostridium difficile (C. diff- highly contagious bacteria in the large intestine causing diarrhea) infection reviewed for infection control. (Resident 1 and 4) This failure had the potential to spread infection throughout the facility. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses including sepsis (the body ' s extreme and life-threatening response to an infection) according to the admission Record. During an observation on 3/26/25 at 9:27 A.M., Resident 1 ' s room door was closed with two signs posted outside the room. One sign indicated, .ENTERIC (pertaining to the intestines) CONTACT . The other sign indicated, .STOP .CONTACT PRECAUTIONS (measure to prevent the spread of infections that are…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 current infection control practices were followed for two of five residents reviewed for infection control when: 1. Staff wore an N-95 (a fitted filtering mask) mask over a surgical mask, 2. Staff did not use a face shield upon entrance into a room with COVID-19 (a very contagious respiratory virus). This failure resulted in staff being exposed to COVID-19 and had the potential to spread infection to all residents residing in the facility. 1. Resident 1 was admitted to the facility on [DATE] according to the facility's admission Record. The change in condition progress note for Resident 1 dated 2/3/25 at 4:08 P.M. indicated, .Covid tested via rapid test with positive result . An observation of Resident 1's room on 2/6/25 at 9:02 A.M. was conducted. Resident 1's room had a sign on the wall outside which indicated, Special Droplet [spread of germs passed through speaking, sneezing or coughing] Contact [prevention of infection by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a resident-centered care plan for one of five residents (Resident 2) reviewed for care plan development. Resident 2 was identified to be at high risk for fall which was not reflected in the resident ' s care plan. This failure had the potential for staff to not be aware of Resident 2 ' s fall risk, which could potentially result in staff not providing the appropriate fall intervention to prevent fall incidents. Findings: Resident 2 was re-admitted to the facility on [DATE] with diagnoses that included abnormalities of gait (manner of walking) and mobility (ability to move) according to the admission Record. A review of Resident 2 ' s Fall Risk Evaluation, dated 5/3/24, indicated that Resident 2 was at High Risk for fall. A review of Resident 2 ' s care plan, dated 5/3/24, indicated a problem titled At Risk for Fall. An interview and joint record review was conducted with the Clinical Care Coordinator (CCC) on 8/16/24 at 12:55 P.M.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to revise one of five residents ' (Resident 3) care plan related to fall risk. This failure resulted in the miscommunication of Resident 3 ' s fall risk among the healthcare provider, which could potentially result in fall incidents. Findings: A review of Resident 3 ' s admission Record indicated that the resident was re-admitted to the facility on [DATE] with diagnoses that hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body). A review of Resident 3 ' s Fall Risk Assessment, dated 12/26/23, indicated the resident was at moderate risk for fall. A review of Resident 3 ' s Fall Risk Assessments, dated 2/20/24, 3/20/24, and 6/17/24, indicated the resident was at high risk for fall. A review of Resident 3 ' s care plan related to fall, dated 8/11/23, indicated Resident 3 was at Moderate Risk for Falls. An interview and joint record review of Resident 3 ' s medical record was conducted on 8/16/24 at 12:55 P.M. 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 interview and record review, the facility failed to ensure that one of five residents (Resident 21) was free from future falls when the facility failed to conduct a thorough investigation of Resident 21 ' s fall. This failure has the potential to cause a fall with injury to Resident 21 as the facility was not able to determine the cause of Resident 21 ' s fall and implement specific interventions to prevent future falls. Findings: During a review of Resident 21 ' s admission record, Resident 21 was admitted to the facility on [DATE] with a diagnosis of diverticulitis (inflammation or infection in one or more small pouches of the intestines), morbid obesity, other abnormalities of gait and mobility. Resident 21 ' s fall risk assessment dated [DATE], indicated Resident 21 was a high risk for falls. During a review of Resident 21 ' s progress notes, Resident 21 had a fall on 8/3/24. According the Interdisciplinary (IDT) note dated 8/5/24, .Per resident, she wanted to get up and tried to brace herself 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 observation, interview and record review, the facility failed to ensure food served to all residents was in a palatable, flavorful manner that maintained the nutritional value of the menu items served. This failure had the potential to decrease residents' meal intake and contribute to weight loss. The facility census was 90. Findings: During a dining observation and interview on 07/30/24 at 9:00 A.M. to 2:55 P.M., with residents in their rooms due to a coronavirus (COVID: a respiratory illness caused by a virus that is highly contagious) outbreak at the facility. Resident food concerns addressed included: Mostly chicken they serve here at the facility and I hate chicken so my wife brings me food. The food I don't like the food and I call [Dietary Supervisor (DS) Name]. The food is the same food every day, lots of chicken and the egg salad is bad. Sick of alternative menu, because it's always same PBJ [peanut butter and jelly] and ham sandwich. Sometimes cold. Eggs in am not hot. Lunch and dinner can…

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

Based on observation, interview and record review the facility did not maintain or perform the sanitary (free of bacteria and other germs that is can be hazardous to humans) practices according to their policies and procedures of using a low-temperature dishwasher. This failure had the potential to cause widespread food borne illness among all 90 residents who received food from the kitchen. Findings: On 8/1/24 at 10:00 A.M., an observation and interview was conducted with the Dietary Assistant (DA) 1, in the kitchen. A low-temperature dishwashing machine was being used by DA 1 to clean two crates of dishes that contained trays, cups, dishes and utensils used by the residents in the facility. DA 1 stated that the temperature gauge for the low-temperature dishwashing machine read 111°F and stated, Anything below 120°F I would report to my boss. DA 1 stated, It would need to be 120°F due to germs and bacteria that can still be on the dishes. DA 1 continued to use the low-temperature dishwashing machine to wash another crate of dirty dishes and did not notify her supervisor. DA 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, and record review, the facility failed to ensure one of three residents reviewed for dignity was provided care in a manner that promoted dignity and respect when resident was instructed to urinate (to excrete urine) on the diaper (Resident 178). As a result, the residents' self-esteem and self-worth was devalued. Findings: Resident 178 was admitted to the facility on [DATE] with diagnoses including need for assistance with personal care according to the facility's admission Record. During an observation and interview on 7/30/24, at 8:57 A.M., Resident 178 was in bed and stated the morning staff told her to, Go ahead and pee on the diaper and I'll change you. During another interview with Resident 178 on 8/1/24, at 9:32 A.M., Resident 178 stated she felt, Terrible when she was told to urinate in the diaper. Resident 178 further stated she did not know if the person was a certified nurse assistant (CNA) or a licensed nurse (LN). An interview was conducted on 8/1/24, at 9:43 A.M.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a homelike environment was provided for three out of 23 (14, 22,24) sampled residents, when resident's walls were not repaired after damaged by residents' beds. This deficient practice created an environment that was not homelike for three residents. Findings: Review of Resident 14's admission Record indicated she was admitted to the facility on [DATE]. Review of Resident 14's Minimum Data Set (MDS, a nursing assessment used in nursing homes) section C, Cognitive Patterns dated 7/3/24 indicated Resident 14 with a Brief Interview for Mental Status (BIMs, a test to determine cognitive levels in residents) score of 10, which indicates moderately impaired cognition. Review of Resident 22's admission Record indicated he was admitted to the facility on [DATE]. Review of Resident 22's MDS section C, Cognitive Patterns dated 6/26/24 indicated Resident 14 with a BIMs score of 13, which indicates intact cognition. Review of Resident 24'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 record review, the facility failed to re-evaluate one of three residents (Resident 23) reviewed for Pre-admission Screening and Resident Review (PASARR- a federal requirement to prevent individuals with mental illness [MI], developmental disability [DD], intellectual disability [ID], or related conditions from being inappropriately placed in nursing homes for long term care). This failure had the potential for Resident 23 to not receive necessary mental health care services in an appropriate healthcare setting. Findings: Resident 23 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder (a mental health disorder with combination of hallucinations or delusions and mood disorder symptoms, such as depression or mania) according to the facility's admission Record. An interview and joint record review was conducted on 8/1/24, at 2:30 P.M. with the case manager (CM). The CM stated the PASARR Level I was completed at the hospital prior to admission to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide services which met professional standards of practice for one of 23 sampled residents (Resident 47) when: 1. Resident 47 was using a left-hand splint (a device to help immobilize and prevent contractures) without a Medical Doctor's (MD) order. 2. Resident 47 did not have an MD order for triamcinolone ointment (a prescribed skin cream to treat skin associated irritation such as rash) and left open at Resident 47's nightstand table. Cross Reference F761 and F813 This failure had the potential for Resident 47 to suffer complications for an unmonitored left hand splint and potential for anaphylactic (life threatening allergy) reactions from triamcinolone side effects. Findings: 1. Review of Resident 47's clinical record indicated Resident 47 was re-admitted on [DATE] with diagnoses which included a history of hemiplegia (one sided muscle weakness) and hemiparesis (inability to move one side of the body) following cerebral infarction…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide the necessary care to maintain good grooming and personal hygiene for one of four residents (Resident 15) reviewed requiring dependent (helper does ALL the effort. Resident does none of the effort to complete the activity) assistance. This failure resulted to Resident 15 having long, and dirty fingernails. Cross Reference F684 Findings: Review of Resident 15's clinical record indicated Resident 15 was re-admitted on [DATE] with diagnoses which included a history of hemiplegia (one sided muscle weakness) and hemiparesis (inability to move one side of the body) following cerebral infarction affecting left dominant side (a brain attack known as a stroke that stops blood flow to the brain causing left sided weakness and movement to the body) per the facility's admission Record. A record review of Resident 15's minimum data set (MDS: a nursing assessment tool) dated 7/18/24 indicated a Brief Interview for Mental Status (BIMS-…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility did not ensure that a resident received needed care and services in accordance with professional standards of practice for one out of four residents reviewed requiring dependent (helper does all the effort. Resident does none of the effort to complete the activity) assistance. This failure had the potential to compromise Resident 15's health status. Cross Reference F677 Findings: Review of Resident 15's clinical record indicated Resident 15 was re-admitted on [DATE] with diagnoses which included a history of hemiplegia (one sided muscle weakness) and hemiparesis (inability to move one side of the body) following cerebral infarction affecting left dominant side (a brain attack known as a stroke that stops blood flow to the brain causing left sided weakness and movement to the body). A record review of Resident 15's minimum data set (MDS- a nursing assessment tool) dated 7/18/24 indicated a, Brief Interview for Mental Status (BIMS- developed by…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care for one of three residents' drainage tube reviewed for staff competency (Resident 177). This deficient practice had the potential for unresolved infection. Findings: Resident 177 was admitted to the facility on [DATE] with diagnoses including peritoneal abscess (collection of pus in the body below the abdomen between the hip bones) and sepsis (the body's extreme and life-threatening response to an infection) according to the facility's admission Record. During an observation and interview on 7/30/24, at 8:42 A.M. with Resident 177, Resident 177 was sitting on a wheelchair and showed a tube with an accordion bulb connected to a drainage bag. Resident 177 stated the drain was due to an abscess and the staff did not properly took care of it. Resident 177 stated it has been two days that the accordion bulb was not squeezed (squeezed - to apply suction to drain the fluid). The accordion bulb was observed with small amount 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 store medications in a secured location for two of three residents (Resident 47 and Resident 30) reviewed for medication storage when: 1. A discontinued order for triamcinolone ointment (a prescribed skin cream to treat skin associated irritation such as rash) was kept uncapped and unsecured on Resident 47's nightstand table. Cross Reference F658 and F813 2. A prescribed Salonpas (pain patches) was kept at Resident 30's bedside table. These failures had the potential for medication misuse, effectiveness and/or severe allergic complications. Findings: 1. Review of Resident 47's clinical record indicated Resident 47 was re-admitted on [DATE] with diagnoses which included a history of hemiplegia (one sided muscle weakness) and hemiparesis (inability to move one side of the body) following cerebral infarction affecting left non-dominant side (a brain attack known as a stroke that stops blood flow to the brain causing left sided weakness 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 observations, interviews and record reviews the facility failed to store foods in a safe and sanitary manner according to their facility's policies and procedure for outside foods brought by family and visitors for two out of seven residents (Resident 59 and Resident 47) reviewed for food preference and homelike environment when: 1. Resident 59 had a bag of unlabeled apples and oranges placed at the bedside for a week or more. Cross reference F880 2. Resident 47 had three unlabeled food items with a brownish yellow banana, placed on top of a cluttered emesis basin, plastic wrapped chocolate pastries on top of a plastic container and a sandwich in an open plastic container unsecured without a lid at the bedside. This failure had the potential to attract pests (insects and rodents that carry harmful bacteria or viruses that could be passed on to humans), spoilage (the process in which food or other substances stop being good enough to eat or use) of food and risks of foodborne illnesses from food…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a neutropenic (low white blood cell count- part of the body's immune system) precautions room for one reviewed resident (Resident 58), was free of potential infection from raw foods. This failure had the potential outcome of endangering Resident 58's health condition and possible decline from exposed raw foods. Cross reference F813 Findings: Review of Resident 58's admission Record indicated Resident 58 was admitted to the facility on [DATE] with diagnoses that included Malignant Neoplasm of Endometrium (cancer of uterus). On 7/30/24 at 9:20 A.M., an observation of Resident 58's room was conducted. Resident 58's door had signage which indicated Resident 58 was on neutropenic precautions. On 7/30/24 at 9:25 A.M., an interview with Resident 58's roommate (Resident 59) was conducted. Resident 59's bedside table had a basket of raw fruits which consisted of apples and oranges. Resident 59 stated her daughter brought in the basket 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 ensure staff reported in a timely manner an allegation of abuse to the facility's administration including the California Department of Public Health (CDPH- the State Survey and Certification Agency) for one resident (Resident 1) This deficient practice had the potential for a repeat abuse allegation for Resident 1, and for all other residents to be unprotected from abuse. Resident 1 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood) according to the facility's admission Record. The admission MDS (a clinical assessment tool) dated 5/16/24, listed a cognitive score of 7, indicating Resident 1 was severely impaired. During an observation and interview with Resident 1 on 7/11/24, at 12:14 P.M., Resident 1 was observed lying in bed. Resident 1 stated there were four females who pulled her around on the back of her shirt and started…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 four of four sampled residents (Residents 10, 13, 48, 169) were free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications including Seroquel (an antipsychotic medication for bipolar disorder, depression, and schizophrenia) and Nuplazid (an antipsychotic medication for Parkinson disease psychosis) when: 1. Resident 10 was administered Seroquel without an appropriate indication and/or clinical justification, no resident-centered behavioral interventions were implemented prior to initiation and during use of Seroquel, inadequate behavioral monitoring was documented during use of Seroquel, and manufacturer specified monitoring were not done during use of Seroquel; 2. Resident 169 was administered Seroquel without an appropriate indication and/or clinical justification, no resident-centered behavioral interventions were implemented prior to initiation and during use of Seroquel,…

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

Based on observation, interview and record review, the facility did not ensure kitchen staff performed their tasks safely and correctly when: 1. a Dishwasher Diet Aide (DA 1) could not correctly test the sanitizer solution (liquid that removes bacteria) on dishes used for resident meals, 2. a [NAME] (CK) did not know the correct cool down procedure timeframe for cooked meats. As a result, 61 residents who consumed food from the kitchen had the potential to be exposed to bacterial contamination through unsafe meat or unsanitary dishes. Facility Census was 65. Findings: 1. During the initial kitchen tour on 1/9/23 at 8:55 A.M., an observation of the dishmachine and interview with DA 1 was conducted. DA 1 was observed taking the breakfast plates out of the dish machine after they had gone through the wash, rinse, and sanitizing cycles. DA 1 demonstrated how to test the dish machine sanitizer on a plate that went through the machine cycles. DA 1 took a test strip from a container and touched the plate, then checked it against the color code scale and number range on the container. 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 ensure a safe and sanitary environment that lessened the risk for foodborne illness and cross contamination when: 1. the dish machine sanitation cycle failed to sanitize dishes at the correct sanitizing level, according to facility policy and standards of practice; 2. five cucumbers with a visible substance resembling white mold and multiple dark brown spots were stored and comingled with other cucumbers and vegetables in the walk-in refrigerator; 3. a plastic container of rice and of flour were not labeled or dated with a use by date; and a plastic container of powdered sugar had an expired use by date; and 4. an ice machine chute (a channel which allows things to slide or pass) displayed a dark brown film build up and black spots around the rim. These failures potentially placed residents at risk for foodborne and other illnesses from exposure to bacterial, chemical and physical contamination of the food and dishware. Findings: 1. During the initial kitchen tour on 1/9/23 at 8:55 A.M., an observation of the…

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

Based on observation, interview, and record review, the facility failed to provide treatment in accordance with the facility's policy and procedure when one of 16 sampled residents (Resident 7) was not properly positioned in the semi-Fowler's position (defined as a body position at 30 degrees head-of-bed elevation) during the administration of medications via a G-Tube (gastrostomy tube, a tube inserted through the belly that brings nutrition or medications directly to the stomach). This failure had the potential for not meeting Resident 7's therapeutic needs and had the potential of causing aspiration (breathing in medication or fluid into the lungs), which could lead to serious lung problems such as pneumonia (lung infection). Findings: During a medication pass observation on 1/10/23, at 9:12 P.M., with Licensed Nurse 1 (LN 1), LN 1 was observed giving 6 medications through Resident 7's G-tube (gastrostomy tube, a tube inserted through the belly that brings nutrition or medications directly to the stomach) while Resident 7 was laying on their bed with their body positioned leaning…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the facility medication error rate did not exceed five percent or greater when observation of 30 opportunities during the medication pass resulted in six errors. The calculated medication error rate was 20 percent. These failures placed Residents 7, 40, 43, and 46 at risk for not receiving the full therapeutic effects of medications when medications were not given according to the physician's orders and/or the manufacturer's specifications. Findings: 1. During a review of Resident 43's Physician's Pharmacy Order, dated [DATE], the Physician's Pharmacy Order, indicated a provider order for Aspirin Tablet Chewable 81 mg Give 1 tablet by mouth one time a day for stroke prevention, starting [DATE]. During a medication pass observation on [DATE], at 9:57 A.M., with Licensed Nurse 2 (LN 2), LN 2 was observed administering 13 medications to Resident 43, which included aspirin (A drug that reduces pain, fever, inflammation, and 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, and record review, the facility failed to ensure medications had proper storage and labeling when: 1. Medication Cart 100 was left unlocked during medication pass; 2. Medication Cart 200 was left unlocked during medication pass; 3. For Resident 46, an expired insulin (medication for diabetes) vial was found in medication cart 100. These failures had the potential for lost, left, misuse or abuse of medications for two out of four medication carts; and unsafe and ineffective use of medications with decreased therapeutic effectiveness when used past the expiration date for one out of 16 sampled residents (Resident 46). Findings: 1. During a medication pass observation on [DATE], at 9:45 A.M., at Hall 100, with Licensed Nurse 1 (LN 1), LN 1 did not lock medication cart 100 during medication pass to Resident 40. During an interview on [DATE] at 9:55 A.M., with LN 1, LN 1 verified medication cart 100 was unlocked during medication pass to Resident 40 and stated, Important (to lock) 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, and record review, the facility failed to implement and maintain an infection control procedures when: 1. Registered Nurse 2 (RN 2) failed to observe infection control measures by failing to properly disinfect resident's glucometer for one of 3 randomly selected residents (Resident 35) according to manufacturer's specifications; 2. Licensed Nurse 1 (LN 1) failed to observe infection control measures by failing to properly disinfect resident's glucometer for two of 3 randomly selected residents (Resident 46 and 170) according to manufacturer's specifications. These failures had the potential for the development and the spread of infection to 3 of 3 randomly selected residents. Findings: 1. During a review of Resident 35's admission Records, dated 1/10/23, the admission Records indicated Resident 35 was admitted to the facility on [DATE] with diagnoses including, diabetes and long term use of insulin. During a review of Resident 35's Physician's Pharmacy Order, dated 10/11/22, 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 ensure one of one residents reviewed for communication received services to accommodate his needs and preferences (35). This failure resulted in Resident 35 experiencing frustration when trying to communicate. Findings: Resident 35 was admitted to the facility 8/29/22, per the facility admission Record. On 1/9/23, at 2:55 P.M., a concurrent observation and interview with Resident 35 was conducted. Resident 35 was observed sitting in a wheelchair in his room next to the bed. Resident 35 repeatedly pointed to his ears, indicating he could not hear the questions asked. Resident 35 stated it was very hard to hear and he did not use a hearing aid. Resident 35 stated because it was difficult to hear, it would be helpful for staff to write things down instead of talking because it would be easier to read what they were saying. No communication/white board, pen and paper were noted in Resident 35's room. A review of Resident 35's history and physical (H&P), dated 8/31/22, indicated Resident 35 was hard of hearing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 choice to wake up late for one of one residents reviewed for choices (369) . This failure had the potential for psychosocial harm. Findings: Resident 369 was admitted to the facility on [DATE], with diagnoses which included insomnia (hard to fall asleep), per the facility's admission Record. A review of Resident 369's history and physical (H & P), dated 1/1/23, indicated Resident 369 had the capacity to understand and make decisions. A review of Resident 369's MDS (an assessment tool) dated 1/3/23, indicated Resident 369 had a BIMS score (ability to recall) of 14 indicating intact cognition. On 1/9/23 at 9:36 A.M., an observation and an interview with Resident 369 and family members (FMs) were conducted in her room. Resident 369 was lying in bed, with FMs at bedside. Resident 369's FM stated Resident 369 had a routine of sleeping later in the day. Resident 369 stated, They wake me up too early for breakfast. On 1/11/23 at 9:49…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a pressure ulcer (PU, an injury to the skin and underlying tissue resulting from pressure) was coded correctly in the MDS, (an assessment tool) for one of two residents reviewed for PU (14). This failure had the potential for incorrect information being sent to Centers for Medicare and Medicaid (CMS, the organization responsible for creating health and safety guidelines for healthcare facilities). Findings: Resident 14 was admitted to the facility on [DATE], per the facility admission Record. On 1/10/23 at 8:02 A.M., an observation of Resident 14 was conducted. Resident 14 was in bed, on a specialized mattress used to prevent PUs. Resident 14 did not respond to questions. On 1/10/23 at 2 P.M., a review of the following records were conducted: A facility document, titled MDS Resident Matrix, indicated Resident 14 had a Stage 4 (a deep wound reaching the muscle, ligament, or bone) PU. The document indicated the PU was acquired while Resident 14…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement residents' care plans related to: 1. Toileting for one of one residents reviewed for bowel and bladder (369) 2. Refusal of vaccinations for two of five residents reviewed for vaccinations (57 and 169). These failures had the potential to not meet the goals of treatment and needs of Residents 369, 57 and 169. Findings: 1. Resident 369 was admitted to the facility on [DATE], per the facility's admission Record. A review of Resident 369's history and physical (H & P), dated 1/1/23, indicated Resident 369 had the capacity to understand and make decisions. A review of Resident 369's MDS (an assessment tool) dated 1/3/23, indicated Resident 369 had a BIMS score (ability to recall) of 14 indicating intact cognition. The MDS section, Activities of Daily Living (ADLs, activities related to personal care such as toileting) indicated Resident 369 required extensive assistance and needed two plus persons physical assist 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 and record review, the facility failed to ensure a physician's order for a referral to a endocrinologist (Endo, a doctor who specializes in diabetes [a long-term condition that impacts the way the body processes blood sugar] management) was carried out for one of 16 sampled residents with diabetes (35). This failure resulted in Resident 35 having elevated blood sugars for an extended period of time, and increased the potential for infection. Findings: Resident 35 was readmitted to the facility on [DATE] with diagnoses to include diabetes, per the facility admission Record. On 1/11/23, a record review was conducted. Resident 35's History & Physical, dated 10/20/22, indicated diagnoses of diabetes and chronic osteomyelitis (a bone infection). Resident 35's physician's order, dated 10/11/22, indicated Resident 35 was prescribed insulin (a medication to lower blood sugar.) In addition, the physician ordered blood sugar monitoring four times a day. Resident 35's MAR from 11/1/22…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of one residents reviewed for bowel and bladder was scheduled for toileting program per the resident's care plan (369). This failure had the potential for Resident 369 to develop skin breakdown and urinary tract infection (UTI). Findings: Resident 369 was admitted to the facility on [DATE], with diagnoses which included hepatic encephalopathy (a decline in brain function that occurs as a result of severe liver disease), per the facility's admission Record. A review of Resident 369's history and physical (H & P), dated 1/1/23, indicated Resident 369 had the capacity to understand and make decisions. A review of Resident 369's MDS (an assessment tool) dated 1/3/23, indicated Resident 369 had a BIMS score (ability to recall) of 14, indicating intact cognition. The MDS section, Activities of Daily Living (ADLs, activities related to personal care such as toileting) indicated Resident 369 required extensive assistance and needed two…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 identify and develop an effective QAPI (Quality Assurance and Performance Improvement) plan. This failure had the potential to affect the care provided to the residents. Cross reference: F761 F880 Findings: On 3/23/23 at 1:30 P.M., an interview was conducted with the Administrator (Admin). The Admin stated QA items were usually identified from survey deficiencies, through IDT (interdisciplinary team), or staff meetings. The Admin stated QAPI's purpose was to identify and prioritize opportunities for improvement, then initiate corrective actions to address any gaps in their system. Per the Admin, their corrective actions did not address the effectiveness of the audits. The Admin stated after the recertification survey, the QAPI Committee met and reviewed their deficient practices, but did not discuss in detail how the audits were being conducted. Per the Admin, We should have followed up on each audit to see whether our corrective action was effective. Per a facility policy, effective 7/1/20 and titled QA/Quality Assurance…

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