Jerold Phelps Comm Hosp SNF

Inspectors wroteBased on interviews and records reviews, the facility did not ensure that an allegation of financial abuse was reported within two hours of notification of the abuse to the State Survey Agency (California Department of Public Health (CDPH)) for one resident (Resident 1). This failure decreased the facility's potential to meet the minimum standards of reporting abuse and ensure Resident 1 would be free from further financial abuse. A review of Resident 1's Face Sheet indicated she was admitted to the facility on [DATE] with a diagnosis of Dementia (a progressive state of decline in mental abilities) associated with Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements). On 2/23/26 at 4:49 p.m., CDPH received a fax from the facility of a Report of Suspected Dependent Adult/Elder Abuse form (SOC 341). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Registered Nurse (RN) worked at least 8 consecutive hours a day, seven days a week for a census of 8 residents. This failure contributed to staffing shortfalls: there were no RNs on duty for 7 days between January 2025 and March 2025, thereby creating the potential that residents would not receive RN-specific care such as assessments and intravenous medication administration. Cross reference F838.

Inspectors wroteBased on administrative interview and record review, the facility failed to ensure a comprehensive facility-wide assessment (evaluation process assessing the resident population and the resources needed to provide competent care) was updated annually and included a staffing plan that ensured Registered Nurse's (RN) worked 8 consecutive hours per day, seven days a week. This failure contributed to staffing shortfalls: there were no RNs on duty for 7 days between January 2025 and March 2025, thereby creating the potential that residents would not receive RN-specific care such as assessments and intravenous medication administration. Cross reference F727.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure professional standards of practice were conducted for two residents (Resident 3, and Resident 9) of eight sampled residents when insulin orders did not include blood sugar parameters (levels that indicate when blood sugar is considered too high or too low). This failure placed residents at risk for ineffective monitoring of insulin usage and worsening of their Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing).

Inspectors wroteBased on interview and record review, the facility failed to ensure Medication Review (MRR) policy and procedures were developed and maintained for scheduled medication reviews and oversight of medication administration. This failure put residents at risk for ineffective monitoring of medications and side effects that could go undetected by licensed staff and delay for the physician to act upon irregularities.

Inspectors wroteBased upon observation, interview, and record review, the facility failed to ensure insulin pens stored in the medication cart were dated with an opened date for three residents (Resident 3, Resident 4, and Resident 8) of a sample of eight residents. This failure increased the facility's potential to administer expired medication and decrease the resident's opportunity to benefit from the full effect of the medication.

Inspectors wroteBased on observation, interview and record review, the facility's two consulting Registered Dietitians (RD A and RD B) did not provide nutritional assessments and reassessments, per policy and procedure, for one resident (Resident 6) of eight sampled residents and the facility did not have documentation of an admission nutrition Nursing Care Plan (a document that contains essential information about a patient's condition, diagnosis, goals, interventions, and outcomes) for Resident 6. These deficiencies caused Resident 6 to receive his first post-admission RD nutritional assessment almost two months later which potentially delayed the timely implementation of nutritional interventions designed to assist Resident 6 in attaining his highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure their policy regarding resident abuse indicated the person responsible for investigating abuse allegations was to submit allegations of resident abuse within 2 hours of being made aware and submit an investigation summary within 5 business days to the California Department of Public Health (CDPH). These failures decreased the facility's potential to protect a census of 8 residents from abuse and take appropriate corrective action.

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident 1) of three sampled residents was treated with respect and dignity when Certified Nursing Assistant A (CNA A) shaved Resident 1's pubic hair without Resident 1's consent. This failure had the potential to cause risks like cuts, infections, and skin irritations to Resident 1.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure: 1. An allegation of abuse was reported to the California Department of Public Health (CDPH) within 2 hours of awareness of the allegation for one resident (Resident 1) of three sampled residents when Certified Nursing Assistant D (CNA D) and Licensed Nurse E (LN E) did not report when CNA A shaved Resident 1 ' s pubic hair without medical reason and without consent; and, 2. The facility submitted the investigation summary within 5 business days to CDPH. These failures decreased the facility's potential to protect Resident 1 and other residents from abuse and take appropriate corrective action. Cross reference F607.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan for six (6) of six (6) residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 57) within 48 hours of their admission. This failure can impede continuity of care, cause uncertain communication among facility staff, and render them unprepared for adverse events that might occur right after the residents' admission as well as keeping the resident or representative in the dark of the initial plan for delivery of care and services.

Inspectors wroteBased on interview and record review, the facility failed to develop a person-centered comprehensive care plan for 5 of 6 residents (Resident 1, Resident 3, Resident 4, Resident 5, and Resident 57) to meet his or her preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs. This failure had the potential to negatively impact the residents' quality of life as well as the quality of care and services received.

Inspectors wroteBased on interview and record review, the Governing Body (individuals such as facility owner(s), chief Executive Officer(s), or other individuals who are legally responsible to establish and implement policies regarding the management and operation of the facility) failed to ensure to appoint a California Licensed Nursing Home Administrator (NHA) who was responsible for management of the facility. This failure had the potential to result in mismanagement and misguided care of the vulnerable residents and staff of the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure: 1. irregularities (refers to use of medication that is inconsistent with acceptable standards of practice, use without adequate indication, monitoring, in excessive doses, and/or in the presence of adverse consequences, etc.) noted by the pharmacist during drug regimen review (DRR) of two (2) of six (6) residents (Resident 1 and Resident 4) were documented on a separate, written report and sent to the attending physician and the facility's medical director and director of Nursing (DON) and lists, among others the irregularity that the pharmacist identified; 2. the attending physician documented in the resident's medical record that the identified irregularity has been reviewed and any action taken to address it with a rationale for not agreeing with the recommendation; and, 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of six residents (Resident 57) was informed in advance, by the physician or other practitioner or professional, of the use, the risks and benefits of a psychotropic (class of medication affecting the thoughts and behaviors of the person using the drug) and other medication options. This failure deprived Resident 57 her right to be receive information about the medication or other treatment options as basis for her decision to choose the medication or treatment she preferred.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a smoking assessment on admission for one of six residents (Resident 57) to determine Resident 57's functional capacity to safely smoke with or without assistance and need for protective devices. This failure had the potential to result to inappropriate care and provision of supervision and protective devices and result in fire hazard to both the resident and facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an environment free from accident hazards and provide assistive devices to one (1) of six (6) residents (Resident 57) to prevent avoidable accidents. This failure had the potential to result in cigarette burns to Resident 57 and create a fire hazard to residents, staff and facility.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure resident medications were stored according to Policy and Procedure, manufacturer's recommendations, and National Standards when the medication storage room and the pharmacy storage and ambient room temperatures were not monitored. This failure had the potential risk for resident harm or death if medication integrity was compromised and then administered to residents.

Inspectors wroteBased observation, interview, and record review, the facility failed to ensure the food safety requirements were met when: 1. The meats were stored above ready to eat foods. 2. One of three Dietary Staff (Dietary Staff E) handled clean dishes after touching dirty dishes using the same gloves. This failure had the potential for food-borne illness outbreak affecting vulnerable residents.

Inspectors wroteBased on interview, and record review, the facility failed to ensure four of eight residents (Resident 3, Resident 59, Resident 6, Resident 2) received a quarterly assessment using a resident assessment instrument, Minimum Data Set (MDS). This failure had the potential for the facility to miss the critical indicators of gradual change in a resident's status affecting their quality of life and quality of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to complete admission assessments and baseline care plans that were individualized, for sampled Residents 108, 109, 2, 6, 4 and 7 when: admission Assessments were not completed within 48 hours of admission for residents 108, 109, 2, and 6; and Resident 108 did not have a care plan for allergies to foods and medications; and Resident 4 did not have a care plan for pain; and Resident 7 did not have a care plan for ADLs (activities of daily living) that documented refusal of care. This failure had the potential for the facility to miss the critical indicators necessary to ensure continuity of care and communication among nursing home staff, resident safety, and interventions that would affect residents quality of life and quality of care.

Inspectors wroteBased on observation, interview and record review, the facility did not develop and implement care plans for residents that were individualized, implemented and re-evaluated for Sampled Residents 109, 6, 4 and 7 when: Resident 109's hearing loss was not assessed and a care plan was not developed and implemented, Resident 6 did not have a care plan for weight loss, Resident 4 did not have a care plan for pain, and Resident 7 did not have an intervention for refusal of care and decline of Activities of Daily Living (ADL). These failures had the potential for resident decline and harm and negatively impact the resident's quality of life, quality of care and services. Resident 109 During an observation and interview on 5/17/21, at 3:54 p.m., Resident 109 stated I am hard of hearing and when people wore those masks it makes it worse. No signs indicated the resident experienced hearing loss. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not provide professional standards of pain relief when effectiveness of pain medication administration was not assessed and documented for Sampled Residents 1, 4, 5, 6, 58, 108 and 109. This failure had the potential for increased discomfort and potential resident harm due to incomplete monitoring of the effects of scheduled and as needed (PRN) pain medication orders which may have resulted in ineffective pain relief for residents.

Inspectors wroteBased on observation interview and record review, the facility failed to ensure one of eight residents (Resident 58) received a comprehensive assessment using a resident assessment instrument, Minimum Data Set (MDS). This failure had the potential for residents, with no Medicare insurance, to not receive an assessment identifying their needs, strengths, goals, life history and preferences to provide quality of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of eight residents (Resident 7) received care to prevent diminish resident's abilities in activities of daily living (ADL) when Resident 7 was not encouraged to get out of bed to eat. This failure resulted to Resident 7's decline of in ADL abilities.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure the safe and secure disposition of medications, including narcotics destruction, and diversion prevention, when an unsecured medication disposal bin was observed in the Medication Room. This failure had the potential for theft and diversion of medications and narcotics, when the container and pills contained within, were accessible and unsecured.

Inspectors wroteBased on interview and record review, the facility failed to consistently Identify quality deficiencies and develop and implement action plans to correct identified quality deficiencies. This failure had the potential to negatively impact residents standard of care and quality of life by not identifying and quickly addressing resident care issues.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Medical Director attended the Quality Assessment and Performance Improvement (QAPI) committee meetings. This failure had the potential to not properly identify deficient practices that other committee members might be aware of.