Avamere Rehabilitation of King City

Inspectors wroteBased on interview and record review it was determined the facility failed to respond timely to a change of condition for 1 of 3 sampled residents (#4) reviewed for change of condition. This placed residents at risk for a decline in overall functioning.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to acquire the correct route for an emergency (Narcan) medication for 1 of 3 sampled residents (#4) reviewed for pharmaceutical services. This placed residents at risk for not receiving the correct route for their emergency medication.

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to provide an ongoing person-centered activity program for 3 of 3 sampled residents (#s 4, 5, and 20) reviewed for activities. This placed residents at risk for a decline in psychosocial well-being and diminished quality of life.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were treated with dignity and respect for 1 of 1 sampled resident (#74) reviewed for dignity and respect. This placed residents at risk for lessened quality of life.

Inspectors wroteBased on interview and record review it was determined the facility failed to include and inform residents in advance of a change in pain medication for 1 of 1 sampled resident (#60) reviewed for pain. This placed the residents at risk for the inability to participate in their plan of care for pain management. Findings Include:Resident 60 admitted to the facility in 7/2025 with a diagnosis of Atherosclerosis (hardening of arteries) of left leg with rest pain. Resident 60's 7/15/25 Quarterly MDS indicated the resident was cognitively intact. Resident 60's 11/10/25 Physician Order indicated Resident 60's morphine was to be changed from TID to BID.Resident 60's health record revealed no evidence the decrease in morphine was discussed with the resident. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to provide mobility bars as ordered for 1 of 1 sampled resident (#16) reviewed for accommodation of needs. This placed residents at risk for loss of ability to reposition independently.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to provide nonpharmacological interventions prior to the use of a PRN psychotropic medication and provide a rationale for indications for use of a PRN psychotropic medication for 1 of 5 sampled residents (#2) reviewed for unnecessary medications. This placed residents at risk for unnecessary psychotropic medication use and adverse side effects.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to evaluate and manage increased pain after a pain medication change for 1 of 1 sampled resident (#60) reviewed for pain. This placed residents at risk for increased and unmanaged pain.

Inspectors wroteBased on interview and record review, it was determined the facility failed to comprehensively assess and develop mood and behavior interventions specific to expression of suicidal ideations for 1 of 1 sampled resident (#47) reviewed for behavioral/emotional health. This placed residents at risk for increased behaviors and a decline in psychosocial well-being.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure an account of all controlled drugs was maintained for 1 of 1 sampled resident (#2) reviewed for drug diversion. This placed residents at risk for drug diversion.

Inspectors wrote4. Resident 15 was admitted to the facility in 6/24/24 with diagnoses including urinary tract infection and diabetes. The 12/29/24 Quarterly MDS indicated Resident 15 was cognitively intact and required substantial assistance with showering. On 1/9/25 at 1:08 PM Resident 15 stated her/his shower days were on Tuesdays and Fridays and was unsure if she/he missed any showers. Resident 15's December 2024 shower log revealed the resident received a shower on 12/13/24, refused a shower on 12/17/24, and received showers on 12/20/24 and on 12/27/24. Resident 15 went seven days between showers for two weeks. On 1/10/25 at 11:32 AM Staff 16 (CNA) stated Resident 15 did not receive a shower due to staffing shortage. Staff 16 stated Resident 15 was scheduled for a shower on 12/24/24, however, due to staffing shortage, no scheduled showers were completed on that day. [...]

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure there were sufficient nursing staff available to provide the necessary care and services to meet residents' needs in 1 of 1 facility reviewed for staffing. This placed residents at risk for unmet care needs.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide an ongoing person-centered activity program for 3 of 3 sampled dependent residents (#s 9, 24 and 47) reviewed for activities. This placed residents at risk of a decline in psychosocial well-being and diminished quality of life.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure beverages were labeled and stored in a manner to minimize spoilage and bulk food items were stored in a manner to minimize cross contamination in 1 of 1 kitchen reviewed for sanitary conditions. This placed residents at risk of foodborne illness.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to accurately assess a resident's cognition for 1 of 1 sampled resident (#47) reviewed for communication. This placed residents at risk for unassessed needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a Level I PASARR (Preadmission Screening for Individuals with a Mental Disorder and Individuals with Intellectual Disability) was completed for 1 of 1 sampled resident (#45) reviewed for PASARR. This placed residents at risk for inappropriate placement in a nursing facility and a lack of needed services.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure care plans were revised to accurately reflect the needs of residents for 2 of 7 sampled residents (#s 45 and 48) reviewed for ADLs and falls. This placed residents at risk for unmet needs.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide appropriate treatment and services in the area of communication for 1 of 1 sampled resident (#47) reviewed for communication. This placed residents at risk for diminished quality of life and potential decline in their ability to carry out activities of daily living.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure dependent residents received required assistance with ADLs for 2 of 5 sampled residents (#s 19 and 28) reviewed for ADLs. This placed residents at risk for unmet ADL needs and loss of dignity.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure physician orders were followed for 1 of 5 sampled residents (#24) reviewed for unnecessary medications. This placed residents at risk for adverse medication consequences.

Inspectors wrote2. Resident 25 admitted to the facility in 10/2022 with diagnoses including history of falls, and stroke with hemiplegia and hemiparesis (paralysis and weakness of one side of the body). The quarterly MDS, dated [DATE], showed a BIMS score of 15 which indicated she/he was cognitively intact, and required minimal assistance from one staff for eating and oral/personal hygiene, maximal assistance from one to two staff for ADLs/cares, and she/he was dependent on one to two staff for wheelchair mobility and transfers. The resident's care plan, updated 4/6/23, revealed that she/he was at moderate risk for falls and needed a restorative care program to prevent decline in level of function. Interventions were updated on 6/6/24 to include a detailed ROM plan with monthly reviews. [...]

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure the appropriate diet texture was followed for 1 of 2 sampled residents (#10) reviewed for nutrition. This placed residents at risk for choking.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to implement care plan interventions in the area of dining and nutrition for 1 of 2 sampled residents (#10) reviewed for nutrition. This placed residents at risk for unmet nutritional needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to provide written information to residents concerning the right to formulate an advance directive for 5 of 5 sampled residents (#s 2, 7, 20, 23 and 50) reviewed for advance directives.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure an RN was available for at least eight consecutive hours for 16 of 40 days reviewed for RN coverage. This placed residents at risk for delayed nursing assessments.

Inspectors wroteBased on observation and interview it was determined the facility failed to store food in a sanitary manner for 1 of 1 facility kitchen reviewed for sanitary food storage. This placed residents at risk for food-borne illness and contaminated food.

Inspectors wroteBased on observation and interview it was determined the facility failed to ensure a resident's bathroom was clean and free of persistent odor for 1 of 4 sampled residents (#31) reviewed for environment. This placed residents at risk for lack of a clean, homelike environment.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident representative was able to file a grievance in a timely manner for 1 of 1 sampled resident reviewed for grievances (#31). This placed residents at risk for unresolved concerns.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to implement or develop a comprehensive care plan for 1 of 5 sampled residents (# 16) reviewed for medications. This placed residents at risk for unmet needs.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to revise care plans in the areas of nutrition and ADLs for 1 of 1 sampled resident (#309) reviewed for nutrition. This placed residents at risk for unmet needs.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure residents with limited range of motion received equipment to prevent further decrease in range of motion for 1 of 3 sampled residents (#32) reviewed for position and mobility. This placed residents at risk for worsening contractures.

Inspectors wroteBased on interview and record review it was determined the facility failed to withhold a blood pressure medication according to physician ordered parameters for 1 of 5 sampled residents (#49) reviewed for medications. This placed residents at risk for low blood pressure.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure a medication error rate of less than five percent for 1 of 6 sampled residents (#309) reviewed for medication administration. There were five errors in 29 opportunities resulting in a 17.24% error rate. This placed residents at risk for adverse medication consequences.