West Covina Healthcare Center

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 sample resident (Resident 4) had a physician's order for the use of oxygen (a medical treatment used to help a person to breathe more easily) at two and a half liters per minute through nasal cannula (a medical device used for oxygen therapy). This failure had the potential to place Resident 4 at risk for complications associated with oxygen therapy. Findings: During a review of Resident 4's admission Record (AR), the AR indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD - a type of obstructive lung disease characterized by long-term poor airflow), depression (a feeling of severe sadness or hopelessness), anxiety (emotion characterized by an unpleasant state of inner turmoil), and gastro esophageal reflux disease (GERD, a chronic digestive disorder where stomach acid or contents leak back into the esophagus, causing symptoms like heartburn…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 its protocol for antibiotic (a substance used to kill bacteria and to treat infections) use for one of one sampled resident (Resident 36), who had received and was receiving antibiotics from 12/2/2025. This deficient practice had the potential for Resident 36 to develop antibiotic resistance and to receive antibiotics without justification. Findings: During a review of Resident 36's admission Record (AR), the AR indicated Resident 36 was initially admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, a type of obstructive lung disease characterized by long-term poor airflow) and depressive disorder (persistent feelings of sadness and worthlessness and a lack of desire to engage in formerly pleasurable activities). During a review of Resident 36's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 11/4/2025, the MDS indicated Resident 36 had intact…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff response/answer to Residents' call lights in a timely manor for three of three sampled Residents (Residents 1, 2, and 3).These deficient practice violated Residents 1, 2 and 3's rights, delayed in care and services and had the potential to affect Residents 1, 2, and 3's health.Findings:a) During a review Resident 1's, admission record, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included Morbid (Severe) Obesity, Hemiplegia (partial paralysis) and Hemiparesis (weakness or inability to move on one side of the body), and Neuromuscular Dysfunction (muscle weakness due to lack of nerve function) of Bladder.During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 7/1/2025, the MDS indicated Resident 1's cognition (ability to understand) was normal. Resident 1 was dependent on staff for person hygiene before and after urinating or having a bowel movement 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 interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Abuse Investigation and Reporting, by failing to report an alleged verbal abuse to the facility's Abuse Coordinator, California Department of Public Health (CDPH), the Ombudsman (an official appointed to investigate individual's complaints and assists in resolution of concerns), and the local law enforcement immediately and within 2 hours on 12/19/2024 for one of five sampled residents (Resident 2) when Resident 2 allegedly called Resident 1 derogatory words. This failure had the potential to subject Resident 1 to potential further abuse from Resident 2. Findings: 1. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses that included hypertension (HTN, high blood pressure) and hypothyroidism (thyroid gland does not produce enough thyroid hormones in the body). During a review of Resident 1's History and Physical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of needs for two of two sampled residents (Residents 29 and 80) by failing to ensure the resident's call lights (an alerting device for nurses or other nursing personnel to assist a patient when in need) were within reach and appropriate to the resident's physical ability. These deficient practices had the potential for Residents 29 and 80 not to receive necessary care or delayed services to meet their needs. Findings: a. During a review of Resident's 29 admission Records (AR), the AR indicated Resident 29 was admitted to the facility on [DATE] with diagnoses that included Peripheral Vascular Disease (PVD, a slow progressive narrowing of the blood flow to the arms and legs) and osteoarthritis (a progressive disorder of the joints, caused by gradual loss of cartilage). During a review of Resident 29's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/5/2024, the MDS indicated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident's Advance Directive (AD, a legal document indicating resident preference on end-of-life treatment decisions) was discussed, written information was provided to the residents and/or responsible parties and current copy was in the medical chart for three of three sampled residents (Residents 12, 54 and 78) consistent with the facility's policy and procedure on advance directives. These failures had the potential for facility staff to provide medical treatment and services against the resident's will. Findings: a. During a review of Resident 12's admission Records (AR), the AR indicated Resident 12 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD, a chronic lung disease causing difficulty in breathing) and asthma (a condition in which a person's airways become inflamed, narrow and swollen, which makes it difficult to breathe). During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide necessary care and services for gastrostomy tube (GT, a tube inserted through the abdomen that delivers nutrition directly to the stomach) site as ordered by the physician and as indicated in the plan of care for two of two sampled residents (Residents 45 and 54). These failures had the potential for complications related to tube feedings for Residents 45 and 54. Findings: a. During a review of Resident 45's admission Records (AR), the AR indicated Resident 45 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), anxiety (intense, excessive, and persistent worry and fear about everyday situations), depression (low mood or loss of pleasure or interest in activities for long period of time) and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach). During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to attempt the use of appropriate alternatives to grab bars before its installation for two of two sampled residents (Residents 35 and 14). These deficient practices placed Residents 35 and 14 at risk for entrapment and injury from the use of bedrails. Findings: a. During a review of Resident 35's admission Records (AR), the AR indicated Resident 35 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia (total paralysis of the arm, leg and trunk on the same side of the body), hemiparesis (weakness on one side of the body), and depression (loss of pleasure or interest in activities for long period of time). During a review of Resident 35's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 7/30/24, the MDS indicated Resident 35 had intact cognition (ability to understand). The MDS indicated Resident 35 was dependent (helper did all of the effort, resident did…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 specific and individualized person-centered care plan to meet the resident's needs for two of two sampled residents (Residents 45 and 55). a. A care plan was not developed for Resident 45 with dementia (a progressive state of decline in mental abilities). b. A care plan was not developed for Resident 55 for the use of black box medications - Furosemide (water pill that treats fluid retention) and Tylenol #3 with Codeine 3 (a combination narcotic drug that is used to relieve mild to moderate pain). These failures had the potential to result in inconsistent implementation of the care to Residents 45 and 55. Findings: a. During a review of Resident 45's admission Records (AR), the AR indicated Resident 45 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), anxiety (intense, excessive, and persistent worry and fear…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 coordinate care with hospice (compassionate care for people near the end of life) provider for one of two sampled residents (Resident 34) by failing to ensure the Hospice Registered Nurse (HRN) visited Resident 34 on 9/19/24, 9/23/24 and 9/30/24, as scheduled. This deficient practice placed Resident 34 at risk of not receiving appropriate care in a timely manner. Findings: During a review of Resident 34's admission Record (AR), the AR indicated the facility readmitted the resident on 6/28/24, with diagnoses that included Alzheimer's disease (a disease characterized by a progressive decline in mental abilities) and heart failure (also known as congestive heart failure [CHF], is a condition that develops when the heart doesn't pump enough blood for body needs). During a review of Resident 34's Physician Order Sheet (POS) dated 6/28/24, the POS indicated an order for Hospice 1 for diagnosis of CHF. During an observation on 9/30/24 at 10:46 a.m., Resident 34 was sitting in the wheelchair watching television in 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.

Based on observation, interview, and record review, the facility failed to promote healing and prevent development of pressure ulcer/injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) for one of one sampled resident (Resident 14) by failing to ensure Resident 14 was not lying on the site of the pressure ulcer and was repositioned every two hours while in bed. This deficient practice placed Resident 14 at risk for further skin breakdown, prevent healing of the wound and/or worsen the pressure ulcer. Findings: During a review of Resident 14's admission Record (AR), the AR indicated the facility readmitted the resident on 2/22/23, with diagnoses that included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and heart failure (also known as congestive heart failure [CHF], is a condition that develops when the heart doesn't pump enough blood for body needs). During a review of Resident 14's Wound Management Assessment (WMA) dated 2/22/23, the WMA indicated 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 assure one of one sampled resident (Resident 185) received care and service for parenteral antibiotic (a drug used to treat infections caused by bacteria and other microorganisms) consistent with professional standards of practice. The PICC line dressing was not labeled with date indicating when the dressing was applied. This failure had the potential to result in infection to the resident and worsen the resident's health condition. Findings: During a review of Resident 185's admission Record (AR), the AR indicated Resident 185 was admitted to the facility on [DATE], with diagnoses that included sepsis (a life-threatening blood infection) and hypertension (high blood pressure). During a review of Resident 185's Physician Order Summary Report (POSR) dated 9/20/2024, the POSR indicated the physician ordered for licensed staff to change Resident 185's PICC line dressing on day shift every Friday. During a review of Resident 185's Minimum…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 necessary care and services for one of one sampled resident (Resident 34) on oxygen therapy (treatment that provides supplemental, or extra oxygen) consistent with professional standards of practice, by failing to follow the physician's order to provide two liters of oxygen through nasal cannula (a flexible soft tube that delivers extra oxygen through a tube and into the nose) to Resident 34. This deficient practice placed Resident 34 at risk for difficulty of breathing and respiratory complications. Findings: During a review of Resident 34's admission Record (AR), the AR indicated the facility readmitted the resident on 6/28/24, with diagnoses that included Alzheimer's disease (a disease characterized by a progressive decline in mental abilities) and heart failure (also known as congestive heart failure [CHF], is a condition that develops when the heart doesn't pump enough blood for body needs). During a review of Resident 34's Physician Order Sheet (POS) dated 6/28/24, the POS indicated an order for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to perform post (after) hemodialysis (HD, a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed to function) assessment for one of two sampled residents on HD (Resident 186). This failure had the potential to placed Resident 186 at risk for complications from the hemodialysis site. Findings: During a review of Resident 186's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE] with diagnoses that included End Stage Renal Disease (ESRD, irreversible kidney failure), dependence on renal dialysis (HD) and hypotension (low blood pressure). During a review of Resident 24's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/25/2024, the MDS indicated Resident 186 had clear speech, usually understood others, and made self-understood. Resident 186 required substantial/maximal (helper does more than half the effort) assistance for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to keep an electric fan (a powered machine used to create a flow of air to cool and ventilate rooms and control humidity) in a safe and sanitary condition for one of one sampled resident (Resident 12). This failure had the potential to affect the resident's quality of life. Findings: During a review of Resident 12's admission Records (AR), the AR indicated Resident 12 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD, a chronic lung disease causing difficulty in breathing) and asthma (a condition in which a person's airways become inflamed, narrow and swollen). During a review of Resident 12's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 8/6/2024, the MDS indicated, Resident 12 had intact cognition (ability to understand) and required substantial/maximal assistance (helper did more than half the effort) with oral…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 necessary care and services as indicated in the facility's policies and procedures (P&P) titled, Change in a Resident's Condition or Status and Goals and Objectives, Care Plans for one of three sampled residents (Resident 1) by failing to: 1. Ensure assigned Licensed Vocational Nurses (LVNs) assessed, monitored, and documented Resident 1's left cheek discoloration as a change of condition (COC - clinical change from a resident's baseline in physical, cognitive, behavioral, or functional status) in Resident 1's clinical record. 2. Ensure assigned LVNs developed a care plan (CP - a formal process that outlines the goals, objectives, and evaluation of the nursing care provided for a patient) regarding Resident 1's left cheek discoloration. 3. Ensure assigned LVNs notified Resident 1's physician regarding Resident 1's left cheek discoloration. These deficient practices had the potential for a delay of care and services to Resident…

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

Based on observation, interview, and record review, the facility failed to ensure safe and secure storage of medications for one of three sampled residents (Resident 2) as indicated in the facility's policies and procedures (P&P) titled, Self-Administration of Medications, and Medication Labeling and Storage. This deficient practice had the potential for other residents and unauthorized persons to access Resident 2's medications. Findings: During a review of Resident 2's admission Record (AR), the AR indicated, the facility admitted Resident 2 on 11/22/2021, with diagnoses of hypothyroidism (a condition where the thyroid [a gland that regulates growth and metabolism] does not create and release enough thyroid hormone in the bloodstream), essential (primary) hypertension (a form of high blood pressure that is linked to genetics, poor diet, lack of exercise, and obesity), and type 2 diabetes mellitus (characterized by high levels of blood sugar in the blood). During a review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/21/2024, 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 call lights were within reach for two of three sampled residents (Residents 2 and 3). This deficient practice had the potential to result in the delay of care for Residents 2 and 3 when Residents 2 and 3 were unable to reach their call lights to call staff for assistance. Findings: a. During a review of Resident 2's admission Record (AR), the AR indicated the facility originally admitted Resident 2 on 10/3/2023, and most recently admitted the resident on 12/19/2023, with diagnoses of fracture of right femur (a break in the thighbone), muscle weakness, and dysphagia (difficulty swallowing). During a review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/19/2024, the MDS indicated Resident 2 was usually understood by others and had the ability to usually understand others. The MDS indicated Resident 2 was dependent (helper did all the effort) on staff for toileting hygiene, lower…

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

Based on interview and record review, the facility failed to develop and implement a person-centered care plan for the use of an antipsychotic medication (medication used to treat psychotic [having severe mental illness] disorders]) for one of three sampled residents (Resident 1). This deficient practice had the potential for Resident 1 to not receive the type of care and services necessary for the use of an antipsychotic medication. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 11/7/2018 with diagnoses of atherosclerotic heart disease of native coronary artery (plaque buildup in the wall of the arteries that supply blood to the heart) without angina pectoris (chest pain or discomfort), heart failure (when the heart cannot pump enough blood) and dementia (the loss of the ability to think, remember, and reason to levels that affect daily life and activities). During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 4/30/2024, the MDS indicated Resident 1 was…

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

Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Antipsychotic Medication Use, for one of three sampled residents (Resident 1) by: 1. Failing to attempt to provide non-pharmacological interventions (referring to treatments that do not involve the use of medications) before starting an antipsychotic (a medication used to treat psychotic [having severe mental illness] disorders) medication. 2. Failing to provide a psychiatric evaluation (a clinical assessment of an individual ' s mental state) for the use of the antipsychotic medication. These deficient practices had the potential to result in the use of an unnecessary medication for Resident 1. Findings: During a review of Resident 1 ' s admission Record (AR), the AR indicated the facility admitted Resident 1 on 11/7/2018 with diagnoses of atherosclerotic heart disease of native coronary artery (plaque buildup in the wall of the arteries that supply blood to the heart) without angina pectoris (chest pain or discomfort), heart failure (when the heart cannot pump enough 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.

Based on interview and record review, the facility failed to ensure all nursing staff had the appropriate skills and competencies (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics an individual needed to perform work roles or occupational functions successfully) necessary to provide nursing care safely to one of three sampled residents (Resident 1) in accordance with the facility's policy and procedure (P&P) titled, Staffing, Sufficient and Competent Nursing, and Administering Medication by failing to: Ensure Licensed Vocational Nurse (LVN) 1 had demonstrated the skills and proper techniques necessary to care for Resident 1 with regards to medication management and/or medication administration. This deficient practice resulted in Resident 1 receiving an incorrect medication which caused Resident 1 to experience chest pain, burning sensation of Resident 1's body, and Resident 1 felt like Resident 1 was dying. Resident 1 was transferred to General Acute Care Hospital (GACH) 1 on 3/14/2024 at 7:30 pm for further evaluation and was treated for…

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

Based on interview and record review, the facility failed to maintain complete and accurately documented medical record for one of three sampled residents (Resident 1) by failing to: Ensure Licensed Vocational Nurse (LVN) 1 documented the administration of Narcan nasal liquid (Naloxone Hydrochloride [HCl]- nasal [nose] spray medication used to rapidly reverse the effects of opioid [class of drugs used to treat moderate to severe pain] overdose) instead of fluticasone furoate suspension (Flonase- nasal spray medication used to treat nasal congestion, sneezing, and runny nose caused by seasonal allergies [body's reaction to normally harmless substances) to Resident 1 on 3/14/2024 at 7 pm. This failure had the potential for Resident 1 to not receive appropriate care and treatment due to an incomplete/inaccurate medical record and could lead to more medication errors. Cross Reference F760 Findings: During a review of Resident 1's admission Record (AR), the AR indicated, the facility admitted Resident 1 to the facility on 8/16/2022, with diagnoses of asthma (chronic lung disease caused…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Certified Nursing Assistant 1 (CNA 1) provided care and services to prevent a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) for one of five sampled residents (Resident 1) by failing to: Ensure CNA 1 provided two-person physical assistance (help from two person) when CNA 1 turned Resident 1 to one side while bathing Resident 1 on the bed as indicated in Resident 1 ' s Care Plan titled, Activities of Daily Living (ADL)/Self-Care Deficits, initiated on 10/6/2023, and the facility's policies and procedures titled, Fall and Fall Risk, Managing, and Care Plans, Comprehensive Person-Centered. As a result, on 12/12/2023 at 10:30 AM, Resident 1 fell from Resident 1's bed to the floor. Resident 1 sustained a displaced fracture (bone breaks into two or more pieces and move out of alignment) at the neck of the right subcapital femur (neck of the thighbone). Resident 1 was transferred and admitted to the General Acute Care Hospital (GACH) 1 on 12/12/2023 at 8:15…

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

Based on observation, interview, and record review, the facility failed to provide a safe and sanitary environment to prevent the spread of infection during a Coronavirus-19 (COVID-19 an illness caused by a virus that can spread from person to person) outbreak (the occurrence of disease cases more than normal expectancy) in the facility, which started on 11/17/2023, by failing to: 1. Ensure Resident 2 was assessed for COVID-19 symptoms and Resident 2's vital signs (measurement of essential body functions, including pulse rate, respiration [breathing] rate, body temperature, and blood pressure) were monitored at least every 24 hours during the facility's COVID-19 outbreak (OB). 2. Ensure Licensed Vocational Nurse 2 (LVN 2), Certified Nursing Assistant 2 (CNA 2), and CNA 5 correctly wore their N95 mask or respirator (a respiratory protective device designed to achieve a very close facial fit and efficient filtration of airborne particles) while in the resident care area during a COVID-19 OB. 3. Ensure CNA 2 performed hand hygiene before and after resident care. 4. Ensure CNA 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 two of four residents (Residents 8 and 11) reviewed for Bowel and Bladder Incontinence and Catheter use, was provided the necessary care and services to prevent the possible development of Urinary Tract Infection (UTI, is an infection in any part of the urinary system). a. For Resident 11, the facility failed to monitor the urine output in the resident's indwelling urinary catheter for sediments and cloudiness. b. For Resident 8, the facility failed to provide incontinent care after each episode in accordance with the plan of care. These failures had the potential risk for Residents 8 and 11 to develop UTI. Findings: a. During a review of Resident 11's admission record, the admission record indicated Resident 11 was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included sepsis ( life threatening complication of an infection), Methicillin Resistant Aureus Staphylococcus infection (MRSA,…

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

Based on interview and record review, the facility failed to provide written information on the right to formulate an advance directive (a written instruction, recognized under State law relating to the provision of health care when the individual is incapacitated [lacking the ability to meet essential requirements for physical health, safety, or self-care] ) to one of three sampled residents (Resident 238). This deficient practice had the potential for Resident 238 to not make health care decision in advance to prepare for the time when the resident becomes unable to make decisions. Findings: During a review of Resident 238's admission Record, the admission Record indicated the facility admitted the resident on 8/8/23, with diagnoses that included encephalopathy (a general term describing a disease that affects the function or structure of the brain) and resistance to multiple antibiotics ( medication to treat infection). During a review of Resident 238's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 10/3/23, the MDS indicated Resident 238 had no…

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

Based on observation, interview and record review the facility failed to provide necessary services to promote oral hygiene for one of one sampled resident (Resident 238.) This deficient practice had the potential to affect Resident 238's sense of well-being. Findings: During a review of Resident 238's admission Record, the admission Record indicated the facility admitted the resident on 8/8/23, with diagnoses that included encephalopathy (a general term describing a disease that affects the function or structure of the brain) and resistance to multiple antibiotics ( medication to treat infection). During a review of Resident 238's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 10/3/23, the MDS indicated the resident had no cognitive ( ability to understand) impairment. The MDS indicated Resident 238 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) with oral hygiene. The MDS indicated Resident 238 required partial to moderate assistance (helper…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 in-room activities based on the resident's activity assessment for one of two residents (Resident 63.) This deficient practice can lead to low stimulation which can affect Resident 63's physical, emotional and psychosocial well-being. Findings: During a review of Resident 63's admission Record, the admission Record indicated the facility admitted the resident on 10/2/22, with diagnoses that included depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and urinary tract infection (infection of the bladder or kidneys.) During a review of Resident 63's Activity Participation Review, dated 10/5/23, the Activity Participation Review indicated the resident was alert and verbally responsive and Resident 63 enjoyed sewing, crochet, music, news, and being around animals. The assessment of daily preferences indicated it was very important for Resident 63 to listen to the music she likes and to do 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.

Based on observation, interview and record review, the facility failed to provide rehabilitative treatment and services in accordance with the physician's order for one of three sampled resident (Resident 8). This deficient practice had the potential to lead to further contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). Findings: During a review of Resident 8's admission Record, the admission Record indicated the facility admitted the resident on 11/22/21 with diagnoses that included hereditary motor and sensory neuropathy (refers to damage to the nerves that worsens over time) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest.) During a review of Resident 8's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 8/24/23, the MDS indicated Resident 8 had no cognitive (ability to understand) impairment. The MDS indicated Resident 8 required extensive assistance (resident involved in activity, staff provide weight-bearing support) 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 attempt the use of appropriate alternatives to bed rails before its installation for two of two sampled residents (Residents 46 and 63). This deficient practice placed Residents 46 and 63 at risk for entrapment and injury from the use of bed rails. Findings: a. During a Review of Resident 46's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that included cerebral ischemia (brain injury that results from impaired blood flow to the brain) and hemiplegia (paralysis of one side of the body). During observations on 10/10/23 at 10:35 a.m. and 10/12/23 at 8:40 a.m., Resident 46 was observed lying in bed while watching television. Resident 46's half-length bed rails were up on both sides. Resident 46 was alert and coherent and had left sided weakness. Resident 46 stated his bed rails were always up since admission to the facility. Resident 46 stated he did not know why his bed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 sufficient nursing staff was available to provide nursing and nursing related services to two of three sampled residents (Resident 8 and Resident 63) when; a. Certified Nursing Assistant 3 (CNA3) failed to provide incontinent care to Resident 8 after each episode of bladder incontinence (unable to hold urine). b. Licensed Vocational Nurse 3 (LVN3) prepared medications on 10/12/23 at 11:06 am for the 9 a.m. scheduled medication for Resident 63. This deficient practice resulted in the failure to provide incontinent care to Resident 8 and administer medications timely to Resident 63. Findings: a. During an interview on 10/10/23 at 12:08 p.m., Resident 8 stated the last time she had incontinent care was on 10/10/23 at 5:30 a.m., and she was incontinent since 10/10/23 at 9 a.m. During an observation on 10/10/23 at 12:27 pm, three Certified Nursing Assistants (unidentified) were inside Resident 8's room, performed incontinent care then…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of five sampled residents reviewed for unnecessary medications, was administered antibiotic (medication to treat infection) with an adequate indication for its use (Resident 61). For Resident 61, there was no antibiotic stewardship done before administering Ciprofloxacin (an antibiotic medication) to ensure Resident 61 met the criteria and has adequate indication for its use. This failure had the potential for the use of antibiotics without adequate indication of use and placed the resident at risk for untoward reactions to medications Findings: During a review of Resident 61's admission record (face sheet), the admission record indicated the resident was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included acute cerebrovascular insufficiency (insufficient blood flow to the brain), hemiplegia affecting left dominant side (paralysis of the left side of the body due to brain injury), and Urinary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 incident of alleged resident physical abuse for one of three sampled residents (Resident 1) to the California Department of Public Health (State Agency) not later than two hours after the allegation was made. This deficient practice may potentially result in Resident 1 being subjected to additional physical abuse. Findings: During a review of Resident 1 ' s admission Record, the record indicated Resident 1 was admitted on [DATE], with diagnoses that included diabetes mellitus (high blood sugar), hypertension (high blood pressure) and hemiplegia (paralysis of one side of the body). During a review of Resident 1 ' s Minimum Data Set (a standardized assessment and care planning tool) dated 7/5/23, the MDS indicated Resident 1 had short term memory recall problem and required extensive assistance (staff provide weight- bearing support) in most levels of activities of daily living with one-person physical assist. During a review of Resident 1'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.