Lassen Nursing & Rehabilitation Center

Based on observation and interview, the facility failed to maintain equipment located in the kitchen when there was not a system to track maintenance requests, and:1.One of seven food storage coolers was leaking;2.There was a leak from plumbing in relation to the ice machine;The failure to have a system for tracking maintenance requests and maintain leaks from two of over 13 pieces of equipment had the potential to result in delayed maintenance of equipment; attract and provide harborage for pests leading to contamination of food and equipment; and pose an electrical safety risk for a census of 90. Findings:During an interview on 6/23/26 at 9:01 AM, the Dietary Manager (DM) stated he was responsible for reporting maintenance issues for the kitchen. DM stated maintenance issues were mostly reported to maintenance verbally because maintenance was very quick to fix things, and there was not even time to put in a work order before something was fixed. It was noted there was not a way to track most maintenance requests from DM due to requests were mostly verbal. 1.An observation on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent verbal and physical abuse for three of five sampled residents (Residents 1, 2, and 5) when:Resident 2 hit Resident 1 in the arm twiceResident 3 pulled Resident 2's hair and spit on Resident 4Nursing Assistant (NA 2) sprayed Resident 5 in the face with the shower nozzle, tossed her in bed and verbally threatened her. These failures had the potential to result in psychological, behavioral, and psychosocial outcomes causing fear, anxiety, and adverse outcomes.During a review of the facility's policy and procedure titled, Abuse Prevention Program indicated, the residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The facility is committed to protecting our residents from abuse by anyone, including, but not necessarily limited to: facility staff, other residents, family members.During a review of the facility's policy and procedure titled, Resident Rights…

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

Based on interviews and record reviews, the facility failed to report to the California Department of Public Health (CDPH), the Ombudsman (State advocacy program for residents), and to local Law Enforcement a verbal and physical abuse allegation for two of three sampled residents when Resident 3 told the facility Administrator (FA) that Certified Nursing Assistant (CNA) A was harsh, brutal and mean to her roommates (Residents 1 and 2). This failure to report an abuse allegation prevented local and state agencies from providing prompt oversight to ensure the residents in the facility were safe and protected from abuse.Findings: A review of the facility's policy and procedure titled, Abuse Investigating and Reporting revised July 2017, indicated that, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ( abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Reporting: 1. All alleged violations…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 significant medication error was avoided for one of three sampled residents (Resident 1) when, an order written by the Family Nurse Practitioner (FNP) to restart Resident 1's Eliquis (a blood thinner) was not carried out and went unrecognized by the FNP and Licensed Nurses (LN), for 42 days.This failure contributed to Resident 1 developing a Deep Vein Thrombosis (DVT, blood clot) in his right leg which required a surgical procedure and hospitalization to remove the blood clot and had the potential to cause serious pain, emotional distress, prolonged health declines, and life-threatening conditions.Findings:During a review of the facility's policy and procedure (P&P) titled, Attending Physician Responsibilities, dated Revised August 2014,indicated, Each Attending Physician will be responsible for.initial and subsequent resident care.The physician's documentation should indicate review and acknowledgement of a resident's program of care. 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, record review, and policy review, the facility failed to ensure that one of three residents sampled (Resident 1) received care consistent with professional standards when the physician's order to change her urostomy bag (a waterproof pouch worn on the outside of the abdomen to collect urine) was not followed.This failure had the potential to cause infection.Findings:Review of a facility policy titled Administering Medications revised December 2012, indicated .must be administered in accordance with the orders, including any required time frames.Review of Resident 1's medical record indicated that she was admitted to the facility on [DATE] and had diagnoses which included history of urinary tract infections (infection of any part of the urinary tract such as the kidneys, ureters, and/or bladder), and artificial opening of urinary tract (urostomy - a surgical opening in the abdomen to create a way for urine to exit the body when the bladder is damaged or removed).During an interview on 2/4/26…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not notify the Pharmacy Consultant (PC) to complete medication reviews for three out of three sampled residents (Resident 1, 2, and 3) who experienced weight loss. This resulted in unmet pharmacy service needs and had the potential to contribute to further weight loss.Findings: A review of the facility's policies and procedures (P&P), titled, Weight Assessment and Interventions, revised 3/1/22, indicated, the facility would evaluate medication for possible side-effects that could cause weight loss. A review of the facility's (P&P) titled, Nutritional Assessment, revised 10/1/23, indicated, the PC would review the resident's current medication list and ensure the medication did not interfere with nutrition absorption or appetite. A review of the facility's P&P titled, Consultant Pharmacist Reports, dated 6/1/21, indicated, the consultant pharmacist performed a comprehensive medication regimen review (MRR) at least monthly. The P&P indicated the MRR included…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reviews, the facility failed to consistently provide three out of three sampled residents (Residents 1, 2, and 3) with Physician ordered therapeutic (customized meal plan to manage a medical condition) diets when: 1. Residents 1 and 2 were not consistently provided with a meal that was fortified (added calories); and 2. Resident 3 was not consistently served a fortified meal that included double portions of protein (examples of protein are meats, eggs, and dairy). These failures had the potential to contribute to weight loss.Findings: 1. A review of the facility's policy and procedure (P&P) titled, Therapeutic Diets, revised 10/1/17, indicated, Therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. A review of the admission Record, dated 3/29/22, indicated, Resident 1 was admitted to the facility on [DATE] with the diagnoses of major depression (a sad mood),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and the Registered Dietician (RD) did not maintain an adequate food and nutrition department for three out of three sampled residents (Resident 1, 2, and 3) with weight loss when: 1. A timely nutrition assessment was not performed for Residents 1, 2, and 3 after a weight loss triggered a change of condition. 2. The RD did not attend weight variance interdisciplinary team (IDT, a group of department heads and staff that provided resident care, to discuss resident care goals and identified concerns) meetings and did not document a progress note that indicated the IDT meeting notes had been reviewed. 3. RD did not communicate to the facility the recommendations made for residents with weight loss or collaborate with the dietary department. 4. The facility and RD were not familiar with the Agreement to Provide Dietetic Consultation Services contract that outlined the facility and RD responsibilities. This had the potential to contribute to further weight…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 treat one out of three sampled residents (Resident 1) with dignity and respect when Resident 1 wanted to return to her room during lunch and the Licensed Nurse (LN) assessed (examined) Resident 1 at the lunch table in front of three other residents. This violated Resident 1's right to maintain the privacy of her medical conditions by allowing other residents to watch and listen as the LN examined her.Findings: A review of the facility's policy and procedure (P&P) titled, Resident Rights, revised 2/1/23, indicated, facility staff would treat residents with respect and dignity. The P&P indicated, residents had the right to a dignified existence (treated with self-respect), would be provided privacy and confidentiality, and the facility would support residents in exercising (using or acting on) their rights. A review of the admission Record, dated 3/29/22, indicated, Resident 1 was admitted to the facility on [DATE] with the diagnoses of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to perform a Minimum Data Set (MDS, a resident assessment tool), assessment for one out of three sampled residents (Resident 1) when a significant change of condition was identified. This had the potential for a delay in the review and revision of the care plan (documented resident goals that included instructions for care). Findings: A review of the facility's policies and procedures (P&P) titled, Comprehensive Assessments, revised 10/1/23, indicated, a significant change in status assessment would be performed when the IDT (interdisciplinary team, healthcare professionals who care for the resident work together to coordinate care) determined the resident met the significant change in condition requirements. The P&P defined a significant change in condition as a decline that would not resolve on its own, required staff intervention, impacted more than one area of the resident's health status, and required IDT review and/or revision of the care plan. 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 the interview and record review, the facility did not monitor and evaluate the effectiveness of an intervention (instruction for obtaining goals) for one out of three sampled residents (Resident 1) when the staff did not document the amount of Boost (a nutritional drink/supplement) that was consumed. This failure prevented the facility from monitoring and evaluating the intervention's effectiveness, potentially leading to weight loss.Findings: A review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 3/1/23, indicated, assessments of residents are ongoing, and care plans are revised as information about residents and the residents' conditions change. The P&P indicated, care plans would be reviewed and revised when desired outcomes were not met. A review of the facility's P&P titled, Weight Assessment and Interventions, revised 3/1/22, indicated, care plans would include parameters for monitoring and reassessment. A review of the admission Record,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to honor food preferences for one out of three sampled residents (Resident 1) when food portions were too large, and Resident 1 stated she was tired of chocolate. This had the potential to contribute to weight loss.Findings: A review of the facility's policies and procedures (P&P) titled, Resident Food Preferences, revised 7/1/23, indicated, resident food preferences would be assessed upon or after admission, food preferences would be based on resident history and life patterns, and communicated to the dietary department. The P&P indicated, If the resident refuses or is unhappy with his or her diet, the staff would confer [talk to] the physician in order to offer a diet the resident is deemed safe to consume in order to satisfy the resident. A review of the admission Record, dated 3/29/22, indicated, Resident 1 was admitted to the facility on [DATE] with the diagnoses of major depression (a sad mood) and fatigue (extreme feeling 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 medical records were accurate and complete for three out of five residents (Residents 1, 2, and 3) when: 1. Resident 1's code status (the residents' wishes regarding life-sustaining treatment, specifically if the resident stopped breathing or the heart stopped beating) was inaccurately documented throughout Resident 1's medical records. 2. The Resident's Clothing and Possessions form, (inventory sheet, described personal belongings brought into the facility) was not signed by Residents 2, 3, or the resident's responsible party (RP, decision maker). 3. Resident 3's wedding ring and wristwatch were not added to the inventory sheet. These failures had the potential to cause a delay in life sustaining care and personal belongings to not be identified if lost or stolen. Findings: 1. A review of the facility's policies and procedures (P&P) titled, Advance Directives (written instruction on care to be provided when someone was not able to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to protect one out of three resident's (Resident 2) from misappropriation (taken without permission) of resident property when Resident 2's wedding ring was stolen. This violated Resident 2's rights and had the potential to cause psychosocial harm.Findings: A review of the facility's policy and procedure titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 4/1/21, indicated, residents had the right to be free from misappropriation of resident property. A review of the admission Record, dated, 5/1/24, indicated, Resident 2 was admitted to the facility on [DATE] with the diagnoses of unspecified dementia (memory loss) with behavioral disturbance and major depression (a sad mood). Resident 2 was not his own responsible party (RP, decision maker). A review of the Annual Minimum Data Set (MDS, a resident assessment tool), dated 4/24/25, indicated, Resident 2 had scored 6 out of 15 during a Brief Interview for Mental Status…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to report a reasonable suspicion of a crime to the California Department of Public Health (CDPH, responsible for protecting the public's health) for two out of three sampled residents (Residents 2 and 3) when the facility suspected Certified Nurse Assistant (CNA) D had stolen two wedding rings. This failure had the potential for further abuse and could negatively affect residents' mental and psychosocial well-being. Findings: A review of the facility's policy and procedure titled, Abuse, Neglect, Exploitation and Misappropriation-Reporting and Investigating, revised 9/1/22, indicated, all allegations of suspected or actual abuse, including misappropriation (taken without permission) of resident property, would be reported to the local police department, the Ombudsman's (outside person who advocated for resident rights) office, and CDPH within two hours. A review of the admission Record, dated, 5/1/24, indicated, Resident 2 was admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to maintain an effective training program when facility staff did not attend mandatory in-services (training classes), and the facility failed to provide additional opportunities to make-up the missed in-services. This had the potential for residents not to attain or maintain their physical, mental, and psychosocial well-being.Findings: A review of the facility's policies and procedures (P&P) titled, Attendance at Training Classes, revised [DATE], indicated, All personnel are required to attend their scheduled training classes. The P&P indicated, facility staff would attend make-up classes for any training class (in-service) that was missed. During a concurrent interview and record review on [DATE], at 10:10 am, with Director of Staff Development (DSD), attendance sheets for facility provided in-services were reviewed. DSD confirmed, the attendance record titled, Theft and Loss-Residents Personal Property, dated [DATE], indicated, three facility 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide palatable (tasted good) meals to five out of five sampled residents (Residents 1, 2, 5, 6, and 7) when they stated, the food was bad, had a weird flavored spice that could be tasted on all the food, and the food was cold. This caused residents to have feelings of anger and had the potential to cause unintended weight loss. Findings: A review of the facility ' s policy and procedure titled, Food and Nutrition Services, revised 10/1/24, indicated, Each resident is provided with a nourishing, palatable, well-balanced diet . and it was the responsibility of the food and nutrition department to ensure meals were .palatable and attractive, and it is served at a safe and appetizing temperature. A review of Resident 1 ' s admission Record, dated 10/29/23, indicated, admission to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD, a lung disease that caused difficulty with breathing), major depressive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe infection control practices for three out of four sampled residents (Residents 1, 2, and 3) when: 1. Facility staff did not wear personal protective equipment (PPE, gloves, gowns, or masks that were worn to reduce the spread of infection) while performing resident care with Resident 1 and did not perform hand hygiene (washing hands with soap and water or use alcohol-based hand sanitizer) after providing care for Resident 1 or before touching Resident 2; and 2. Enhanced barrier precaution (EBP, use of PPE to reduce the spread of infection for residents who have wounds or foley catheters, a tube inserted into the bladder and was attached to a bag) signage and PPE was not present outside of Resident 3's room and facility staff touched Resident 3's foley catheter tube without use of PPE. These failures had the potential for the spread of infection. Findings: 1. A review of the facility's policy and procedure (P&P) titled Enhanced…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 answer call lights in a timely manner when five out of five sampled residents (Residents 1, 2, 5, 6, and 7) stated experiencing long call light wait times. This failure caused residents to have feelings of anger, worthlessness, and had the potential to negatively impact resident health status. Findings: A review of the facility ' s policy and procedure titled, Answering the Call Light, revised 9/1/23, indicated, The purpose of this procedure is to ensure timely responses to the resident ' s requests and needs and that call lights would be answered as soon as practicable (able to be done). A review of Resident 1 ' s admission Record, dated 10/29/23, indicated, admission to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD, a lung disease that caused difficulty with breathing), major depressive disorder (a sad mood), and was dependent upon supplemental oxygen (additional oxygen that was needed for people…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 adhere to professional standards of practice for one out of three sampled residents (Resident 4) when: 1. The facility did not implement the Urologist's (a physician that specialized in the urinary system) order for daily suprapubic catheter (a catheter tube inserted through the lower abdomen into the bladder to drain urine) flushes (sterile water was inserted through the catheter tube into the bladder to remove debris or blockage). 2. Treatment nurse did not document a provided treatment or an assessment following a reported suprapubic catheter complication. These failures had the potential to cause a decline in health status. Findings: 1. A review of the facility's policies and procedure (P&P) titled, Physician's Orders, dated 11/1/23, indicated, A current list of orders must be maintained in the clinical record of each resident. A review of the admission Record, dated 7/1/22, indicated Resident 4 was admitted to the facility on [DATE] with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that there was sufficient, qualified nursing staff available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being for nine of 22 sampled residents (Residents 43, 62, 52, 17, 42, 19, 65, 12, and 285), and three of five confidentially interviewed residents, when their call lights were not answered timely and resulted in falls, being left in stool and urine because they were not taken to the bathroom. This failure had the potential to result in skin breakdown, infection, increased pain, increased accidents and injuries, and a decline in physical health status and have a negative impact on the resident's mental and psychosocial well-being. Findings: During a confidential interview of 5 residents on 10/23/2024 at 9:30 AM, three residents responsed, Sometimes they are slow in answering the light when I…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record and policy review, the facility failed to provide meals that were served at a palatable temperature when 10 of 22 sampled residents (Residents 12, 67, 28, 19, 65, 43, 62, 52, 17, and 41), and five of five confidentially interviewed residents, stated the food was cold and bland. This failure had the potential for the residents to experience a loss of appetite, decreased nutrient intake, and result in unintentional weight loss and adverse clinical outcomes. Findings: A review of the facility's policy titled, Assistance with Meals revised March 2023, indicated that, Hot foods shall be held at a temperature of 135 degrees or above until served. Cold foods shall be held at 41 degrees or below until served. Nursing and dietary services will establish procedures such that delivery of food to serving areas accommodates this requirement. 2. To minimize the risk offoodborne illness, the time that potentially hazardous foods remain in the danger zone (41°F to 135 °F) will be kept to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not ensure that the kitchen was clean when; 1. An electrical pest control device had a dark substance on the surface. 2. The floor and wall near food preparation areas was covered with black debris and patches of a gray substance. 3. There was grime on the door and doorknob of the food storage room. 4. There were black stains on the ceiling from the air that was blowing out of the vents in two storage rooms. This had the potential of contaminating food that was prepared in these areas and result in germs getting into the residents' food and make them physically sick. Findings: During a kitchen observation conducted on 10/22/24 at 6:30 AM, the following was observed; 1. A white electric pest control device (like a bug Zapper), that hung above the Victory refrigerator was covered with a dark substance. 2. The wall base and floor where the kitchen's large mixer, Victory refrigerator, and the food preparation table, had black debris and patches of gray substances accumulated on the surfaces. 3. There was visible grime and dirt 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an effective infection control program when: 1. Licensed Vocational Nurse (LVN) 6 did not perform hand hygiene (cleaning and disinfecting hands) while doing medication pass (when a nurse goes from resident to resident to give them their prescribed medication). 2. Resident 285's water tumbler's (a water drinking cup that did not have a straw) lid/drinking hole was covered with brown and white spots, dust, and black particles. These failures placed residents receiving medication and Resident 286 at an increased risk of healthcare-associated infections (infections caused by facility practices). Findings: A review of the facility's policy titled, Handwashing/Hand Hygiene revised October 2023, indicated, This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Hand Hygiene is indicated: a. immediately before touching a resident; . d. after touching a resident; . e. after…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dignity and respect were maintained for two of 22 sampled residents (Resident 39 and 285) when: 1. Certified Nursing Assistant (CNA) A sat behind Resident 39 while assisting her with the lunch meal. 2. Resident 285 received breakfast sixteen minutes after the other resident at her table. These failures resulted in Resident 285 feeling forgotten, and had the potential to result in loss of self-esteem and self-worth for both Resident 39 and 285. Findings: A review of the facility's policy titled, Dignity revised February 2023, indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. 5. When assisting with care, residents are supported in exercising their rights. For example, residents are: e. provided with a dignified dining experience. A review of facility's policy titled, Assistance with Meals…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 when: 1. The walls in two of 22 sampled resident's (Resident 285 and 76) rooms were unpainted and scratched up. 2. A Hoyer lift (a mobile assistive device that allows residents to be transferred between bed and a chair, by the use of electrical or hydraulic power using a sling to hold the resident), that was used by residents was soiled with dried thick brown and white matter. This deficient practice had the potential to create a poor quality of life that may lead to depression due to the unkept living conditions. Findings: A review of the facility's policy titled, Homelike Environment revised February 2021, indicated Residents are provided with a safe, clean, comfortable, and homelike environment 1. A review of Resident 285's admission Record (undated), indicated Resident 285 was admitted on [DATE] with the diagnoses including anxiety disorder, adult failure to thrive (the feeling of wanting to give up 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 record review and interview, the facility failed to report an allegation of abuse to The California Department of Public Health (CDPH), when Resident 25 alleged that she heard Resident 20 rape Resident 36, and the facility had not reported this allegation to CDPH. Failing to report allegations of abuse to CDPH created the potential for ongoing undetected resident abuse. Findings: Resident 20 was admitted to the facility on [DATE] with diagnoses that included dementia and heart failure. On 8/01/2024, Resident 20 received a Brief Interview for Mental Status (BIMS) test to assess his mental function. Resident 20 scored 11 on a scale of 0-15, demonstrating mild cognitive impairment. Resident 25 was admitted to the facility on [DATE] with diagnoses that included diabetes and chronic obstructive pulmonary disease (COPD- breathing difficulty related to lung damage). On 8/29/2024, Resident 25 received a BIMS score of 15, demonstrating normal mental function. Resident 36 was admitted to the facility on [DATE]…

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

Based on observation, interview, and record review, the facility had a 10 percent (%) medication error rate, when three medication errors out of 30 opportunities were observed during a medication pass. These failures resulted in medications not given in accordance with the prescriber's orders which may result in residents not receiving the full therapeutic effects of their medications. Findings: A review of the facility policy titled, Administering Medications revised April 2019, indicated, Medications are administered in a safe and timely manner, and as prescribed. During a concurrent observation and interview on 10/23/24 at 7:47 A.M, Licensed Vocational Nurse (LVN) 6 was observed dispensing medications to Resident 17. LVN 6 prepared 12 medications for Resident 17 including physician orders for: 1. COQ-10 (a dietary supplement that the body uses for growth and maintenance)100 milligrams (mg- a unit of measure) capsule, give two capsules by mouth one time a day (for a total dose of 200 mg). LVN 6 obtained a bottle of COQ-10 50 mg capsules from her medication cart drawer and put 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure an open multi-dose vial (contains more than one dose of medication) Tubersol (a solution that aids in the detection of infection with Mycobacterium tuberculosis-TB, a potentially deadly lung infection) 5TU/0.1mL (Tuberculin units / milliliters, a measurement of the solution for injection) was dated when the vial was opened. This deficient practice had the potential for the TB skin test solution to be outdated and ineffective and therefore, lose the inability to correctly detect TB in a resident or staff member and spread a potentially deadly infection. Findings: A review of the facility policy titled, Medication Labeling and Storage revised February 2023, indicated, 5. Multi-dose vials that have been opened or accessed (e.g., [for example] needle punctured) are dated and discarded within 28 days unless the manufacture specifies a shorter or longer date for the open vial. During a concurrent observation, interview and 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 ensure that one of 22 sampled residents (Resident 27) and five of five confidentially interviewed residents, were offered snacks between meals and at bedtime, without the residents having to ask. This failure had the potential to result in undesired weight loss, hunger, discomfort, and the humiliation of having to ask staff for food. Findings: On 10/23/24 at 9:30 AM, during confidential interviews, five of five residents interviewed indicated that; All five residents indicated that they were not being offered snacks between meals or at bedtime and that they get hungry between meals and at bedtime. One resident stated, They stopped snacks a long time ago. They used to bring it to us. I don't know why they stopped. Another resident stated, We used to get it in the day too. Not now. We don't get anything. They don't offer us anything. Another resident stated, We got them, and it kept our stomachs full but I don't know why they stopped. 2. 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, observation, and record review, this requirement was not met when the facility failed to follow physician's orders to cover the insertion site during showers for one of seven sampled residents (Resident 1), who had a nephrostomy tube (a surgically placed tube that drains urine from the kidney into a collection bag when the bladder no longer functions properly). This had the potential to increase the risk of infection, illness, and rehospitalizations. Findings: Resident 1 was a admitted to the facility on [DATE] for multiple fistulas (abnormal connection between body parts) between her bladder, bowel, and vagina. She suffered from frequent urinary tract infections, history of stroke, difficulty walking and was dependent on staff for care of her nephrostomy tube. Review of the facility's policy titled, Physician Services, dated 2/21, indicated that, The medical care of each resident is supervised by a licensed physician. Review of an order written by Resident 1's physician on 6/26/24 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.

Based in interview and record review the facility failed to ensure direct care staff to meet the needsfor six of nine residents (Residents 2, 3 4 9, 5, and 7) when activities of daily living (toileting showers and hydration) were delayed. This resulted in residents to unrelieved pain, to feel closed in, and forgotten. Findings: A review of a facility policy titled Grievances/Complaints, Filing revised October 2017, indicated Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g., the State Ombudsman). Upon receipt of a grievance and/or complaint, the Grievance Officer will review and investigate the allegations and submit a written report of such findings to the Administrator within five (5) working days of receiving the grievance and/or complaint. All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. The Grievance Officer, Administrator and Staff will take…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 in interview and record review the facility failed to ensure sufficient staffing to meet the needsfor six of nine residents (Residents 2,3,4,9,5, and 7) when activities of daily living (toileting showers and hydration) were delayed. This resulted in residents to unrelived pain, to feel closed in, and forgotten. Findings: A review of resident council meeting minutes indicated: On 10/19/23 at 10 am, old business call lights not being answered timely on all shifts morning, evening, and night shift, ongoing issue. On 11/30/23 at 10 am, old business call lights not being answered timely on all shifts morning, evening, and night shift, ongoing issue. On 3/22/24 at 2:30 pm, residents have expressed the evening call lights are not being answered and their meal carts are not being delivered on time. During an interview on 4/16/24 at 12:28 pm, Family Member (FM 1) stated resident call lights are not answered timely. FM 1 stated that they have observed their family member's roommate going down to the nursing station to ask for assistance. FM 1 stated her family members urinary bag often…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide care and services to address and manage the pain for one of three sampled residents (Resident 1) to support Resident 1's highest practicable level of physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and care plan, when: 1. Resident 1 was having constant pain and did not have routine pain medication. 2. The nursing staff was giving Resident 1 the wrong pain medication for the wrong pain level. This failure resulted in Resident 1 not being properly medicated when she was in severe pain. Findings: During a review of the facility's policy titled, Administering Pain medications, revised 10/2010, indicated Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. During a review of the facility's policy titled, Pain-Clinical Protocol, revised 3/2018, indicated: 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 interview and record review, the facility failed to provide nursing staff with necessary competencies and skill sets to meet the care and services for residents' need for two of nine residents (Resident 1 and Resident 2) when a change of condition was not identified and reported to the physician. These failures resulted increased pain and discomfort for Resident 1 and Resident 2 to have low blood sugars. Findings: 1. During a review of Resident 1 ' s clinical record, indicated that she was initially admitted to the facility on [DATE] with diagnoses which included vesicovaginal fistula (VVF, is an abnormal opening between the bladder and the vagina that results in continuous and unremitting urinary incontinence), congenital rectovaginal fistula (a rare type of malformation that a connection of the rectum to the vagina. This results in the potential of passing gas or feces through the vagina as it leaks through the fistula), diabetes (high blood glucose), and muscle weakness. Resident 1 was transferred to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 timely Urology consultation (evaluation by a physician who specializes in diseases of genitourinary system) as determined to be necessary and ordered by the MD (Medical Doctor) for one of nine sampled residents (Resident 1) to attain or maintain Resident 1 ' s highest practicable physical, mental, and psychosocial wellbeing in accordance with Resident 1 ' s comprehensive assessment and plan of care. This failure resulted in delayed treatment, increased pain and discomfort, and a six-month delay in scheduling/obtaining a Urology consult for Resident 1 who has suffering from multiple Urinary Tract Infection (UTI- bacterial infection in the urine) from 2/2024 to 4/2024, and pain caused by her nephrostomy. Findings: During a review of the facility ' s policy titled, Referrals, Social Services, revised 12/2008, indicated that: 1. Social Services personnel shall coordinate most resident referrals with outside agencies. 2. Social services will…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the Medical Director (MD) addressed and documented in one of the three sampled residents ' records (Resident 1) that the identified irregularity had been reviewed and acted upon. This failure resulted in Resident 1 suffering from a much worse pain because she was not proper medicated. Findings: During a review of the facility ' s policy titled, Medication Regiment Review (MRR - Monthly Report), effective date: 6/2021, no revised date given, indicated that: 1. The consultant pharmacist performs a comprehensive medication regiment review (MRR) at least monthly. The MRR includes evaluating the resident ' s response to medication therapy to determine that the resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy. 2. The findings are phoned, faxed, or e-mailed to the Director of Nursing or designee and documented and stored with the other consultant pharmacist…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 for one of four residents (Resident 2) did not receive an unnecessary medication when a diabetic medication was unavailable, the other two diabetic medications were increased and were not adjusted once the medication was available. This resulted in low blood sugars for Resident 2. Finding: A review of a facility policy titled Change in a Resident's Condition or Status revised May of 2017, indicated the nurse will notify the physician when there has been an adverse reaction to a medication, need to alter the resident ' s medical treatment, and will make detailed observations, and gather relevant information for the physician. A review of Resident 2's admission record indicated, she was admitted to the facility on [DATE], with diagnoses 3 which included type 2 diabetes, heart disease. Resident 2 was able to make her own health care decisions. During an interview on 4/17/24 at 10 am, Resident 2 stated the breakfast quiche was terrible today and her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 promptly notify the ordering physician of laboratory results for one of 3 sampled Resident (Resident 1), when: 1. Resident 1 ' s urinalysis (UA, a urine specimen that determines if there is a bacterial infection in the urine, as urinary tract infection - UTI) was obtained on 4/13/2024, two days after the physician placed the order on 4/11/2024. 2. The facility failed to notify the physician when the Urine Culture & Sensitivity (Culture- a lab test to check for bacteria or other germs in a urine sample; Sensitivity- determines the effectiveness of antibiotics against microorganisms) was reported on 4/15/2024. These failures resulted in delayed treatment, increased Resident 1 ' s pain and discomfort. Findings: During a review of the facility ' s policy titled, Nursing Services Policy and Procedure Manual for Long-Term Care, Managing Infection, revised 3/2022, indicated: 1. A nurse will assess a resident with a suspected infection and will document…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 fully inform resident's representatives (RP) of the residents' dental health status and allow participation in decision making for care to be provided for 3 of 5 residents (Resident 1, 2, and 3) and their RP's, when RP 1, 2, and 3 were not notified of oral issues and changes of conditions identified by the Registered Dental Hygienist of Alternative Practice (RDHAP), and the potential need for a dentist consult. 1. RDHAP's evaluation indicated Resident 1 demonstrated several missing teeth, visible cavitation (permanently damaged area of hard part of tooth with decay that become tiny openings), retained roots, and general demineralization (outermost layer of tooth starts to weaken and deteriorate), and RP 1 was not notified. 2. RDHAP's evaluation indicated that Resident 2 demonstrated several missing teeth, retained roots, general demineralization, and fractured teeth, and RP 2 was not notified. 3. RDHAP's evaluation indicated that Resident 3 demonstrated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurately evaluate and record assessments reflective of the resident's dental status for 4 of 5 residents (Residents 1, 2, 3, and 4), when the Minimum Data Set (MDS, a standardized assessment tool used to evaluate problems for care planning and interventions), indicated that: 1. Resident 1 did not have cavities (permanently damaged area of hard part of tooth with decay that become tiny openings),or broken natural teeth. 2. Resident 2 , did not have cavities (permanently damaged area of hard part of tooth with decay that become tiny openings),or broken natural teeth. 3. Resident 3 did not have cavities (permanently damaged area of hard part of tooth with decay that become tiny openings),or broken natural teeth. 4. Resident 4 was coded as endentulous meaning no teeth or dentures when Resident 4 had a full set of dentures. These failures had the potential to result in mismanagement of the resident's dental health status by not identifying…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pursue routine or emergency dental services with a Dentist to inspect, diagnose, obtain diagnostic testing, and provide treatment when 3 of 5 residents sampled for dental care (Residents 1, 2, 3), were evaluated by the Registered Dental Hygienist of Alternative Practice (RDHAP), who identified dental problems and there was no follow up with a Dentist. 1. Resident 1 was identified to have cavities (permanently damaged area of hard part of tooth with decay that become tiny openings) and retained roots and was not referred to a dentist. 2. Resident 2 was identified to have retained roots and fractured teeth and was not referred to a dentist. 3. Resident 3 was identified to have white spot lesions and cavities and was not referred to a dentist. These failures had the potential to result in progressive oral health decline, loss of teeth, oral pain, infection, reduced appetite, loss of weight, with overall health and emotional deterioration.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an alleged verbal abuse incident to the California Department of Public Health (CDPH) State Survey Agency within two hours for one of three sampled residents (Resident 1). Resident 1 alleged Licensed Vocational Nurse (LVN) 1 yelled at her and called her a liar in front of everyone in the dining room. Resident 1 ' s allegation of verbal abuse was made on 11/28/2023 and the first report CDPH the State Survey Agency received from the facility was on 12/1/2023. This failure had the potential to delay the investigation and affect the psychosocial well-being of Resident 1 and subject other residents to verbal abuse. Findings: During a review of the facility policy titled, Abuse Investigation and Reporting, dated July 2017, indicated all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source will be reported by the facility Administrator, or his/her designee, to the following persons or…

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

Based on interview and nursing schedule review, the facility failed to ensure that there was a Registered Nurse (RN) on duty 8 hours per day/ 7 days a week. This failure had the potential to adversely affect resident's quality of care and quality of life with regards to overall health and well-being. Findings: A review of the Payroll Based Journal (PBJ, an electronic system for facilities to submit staffing information), for Fiscal Year Quarter 4 for 2022, (7/01-09/30/22), indicated the facility had no RN on duty for; 7/2 Saturday (Sa), 7/31 Sunday (Su), 8/6 Sa, 9/24 (Sa), and 9/25/22 Su. A review of the PBJ for Fiscal Year Quarter 1 for 2023, (10/1-12/31/23), indicated the facility had no RN on duty for; 10/1 (Sa), 10/8 (Sa), 10/23 (Su), 11/6 (Su), 11/12 (Sa), 11/20 (Su), 11/24 Thursday (Th), 11/26 (Sa), 11/27 (Su), 12/4 (Su), 12/11 (Su), 12/17 (Sa), 12/18 (Su), 12/23 Friday (Fr), and 12/25/23 Su. During an interview on 8/3/23 at 3:50 pm, the Director of Nursing confirmed, We have had just a few shifts without a RN.

Based on observations, interviews, record reviews, and 6 confidentially interviewed residents, the facility failed to ensure meals and snacks met resident needs when food was not palatable, (was bland, had no flavor), and was not at the correct temperatures, (hot food was not hot, cold drinks were not cold), and meals were not served on time. This failure had the potential to result in decreased resident meal intakes, loss of appetites, weight loss and negatively impact their nutritional status, health status and quality of life. Findings: During a review of the facility's policy and procedure (P&P) titled, Food Temperatures Policy, revised 3/1/18, the P&P indicated, Hot food items may not fall below 140 degrees [Fahrenheit], after cooking . All cold food items must be stored and served at a temperature of 41 degrees or below. Foods should be transported as quickly as possible to maintain temperatures for delivery and service. During an observation of lunch meal trays in the Assistive Dining Room, (residents that required help with meals), and concurrent interview with Dietary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a home like environment for one of eight sampled residents (Resident 29) when comfortable sound levels were not maintained. This failure resulted in Resident 29 losing sleep at night and caused frustration with uncontrolled noise that interfered with Resident 29's quality of life. Findings: A review of the facility's policy titled, Noise Control, revised April 2014, indicated, The facility strives to maintain comfortable sound levels that enhance privacy when privacy is desired. This policy indicated Sound level of radios and televisions shall not disturb other residents, their families, or visitors. Resident 29 was admitted to the facility on [DATE] for diagnoses that included left femur fracture (broken bone of the upper leg), diabetes, heart disease, and anxiety (feelings of fear, dread, and uneasiness). During a record review of Resident 29's Minimum Data Set, (MDS, a resident assessment tool), the MDS indicated that Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of eight sampled residents (Resident 70), who experienced a significant change in condition, was comprehensively assessed using the CMS-specified Resident Assessment Instrument (RAI) process within 14 days of the change in condition. This failure had the potential for staff to not be fully informed of Resident 70's health status in order to determine the need for further assessment and interventions that could potentially delay care and negatively impact her health condition. Findings: A review of the facility's policy titled, Comprehensive Assessments, revised March 2022, indicated, Comprehensive assessments are conducted to assist in developing person-centered care plans. Significant Change in Status Assessment (SCSA)-The SCSA is a comprehensive assessment for a resident that must be completed when the Interdisciplinary Team, (IDT, a group of dedicated healthcare professionals who work together to provide specific care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 revise a care plan for one of eight sampled residents (Resident 70), following a significant change in condition with a new order for comfort care (the goal of care to keep the resident comfortable by managing pain and symptoms, and relieving anxiety, to improve the quality of life while allowing death to occur naturally), measures. This failure had the potential for staff not to be aware of Resident 70's end of life choices and comfort wishes. Findings: A review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, indicated, A comprehensive, person-centered care plan that includes measurable objectives, and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. This facility's policy also indicated, Assessments of residents are ongoing and care plans are revised as information about the resident and the residents' conditions…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 326), was administered and inhaler according to manufacturer's specifications when; the Director of Staff Development (DSD) administered Advair Diskus (a medication inhaled through the mouth into the lungs), without explaining the procedure to Resident 326, without ensuring her mouth was rinsed with water after the inhalation, and tilted the inhaler upwards, instead of keeping flat. This failure had the potential to cause the medication to be ineffective and result in a mouth infection. Findings: A review of the facility's policy titled, Administering Medications through A Metered Dose Inhaler, revised October 2010, indicated Explain the procedure to the resident. Ask the resident to inhale and exhale deeply for a few breath cycles. On the last cycle, instruct the resident to exhale deeply. Place the mouthpiece in the mouth and instruct resident to close his or her lips to form a seal around…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations, interviews, and record reviews, the facility failed to provide physician ordered therapeutic diets (a modified diet for nutrients, calories and textures), for two out of six sampled residents, (Resident 16 and 47), when they had not recieved fortified (added nutrients) pudding with their meals. This failure had the potential to negatively impact the necessary essential nutrition required and desired weight goals for these residents and have a negative affect on their health status. During a review of the facility's policy and procedure (P&P) titled, Therapeutic Diets, revised 10/1/17, the P&P indicated, resident diets would be determined, with the resident's informed choices, preferences, treatment goals, and wishes. The P&P indicated, A therapeutic diet is considered a diet ordered by a physician, practitioner, or dietician, as part of treatment for a disease or clinical condition, to modify nutrients in the diet . A review of Resident 16's records indicated admission to the facility on 5/20/23 with the diagnoses of small cell B-cell lymphoma (cancer that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure professional food safety and sanitation practices were in place when: 1. A table located in the dry storage area that had various boxes of food items stored on the top was visibly dirty with loose food debris. 2. Foods were stored in the dry storage area and in the refrigerator without being labeled and having use by dates. 3. Two unopened containers of half and half (a mixture of cream and milk), were expired and placed behind newer containers of half and half. 4. The floor under the kitchen's washing station was slimy and visibly dirty. 5. The grill was not cleaned after breakfast and contained food particles. 6. The unit refrigerator on Nurse Station Unit 1 had an opened Starbucks coffee drink that belonged to a staff member and the unit refrigerator on Nurse Station Unit 2 contained a yogurt and protein drink that belonged to staff and was visibly dirty. These failures had the potential to result in foodborne illness for 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.