California Terrace

In the surveyor’s words

From the most serious findings on record at California Terrace, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Nov 14, 2024

  Based on observation, interview, and record review the facility failed to follow their care plan policy to develop, implement, and supervise a newly admitted resident with self- injurious and suicidal behavioral concerns. These failures resulted in a resident (R3) gaining access to a shaving blade/razor and cutting his right arm; in a separate incident R3 found a spoon in which R3 was able to break in 2 places and use the pieces to cut his arm; and another incident in which R3 punched a picture with a glass frame which resulted in R3 sustaining an injury that required R3 to be sent to the ER (emergency room ) and receiving 7 sutures to the left hand. The facility's immediate jeopardy began on 05/31/24. […]

• Immediate jeopardy, isolatedF600Jun 29, 2022

  Based on interviews, and record reviews the facility failed to ensure one of five sampled residents [R1] was free of sexual abuse and financial exploitation from an employee [V3]. This was identified as an Immediate Jeopardy which began on 05/31/22 when R1 made it known about his personal relationship with V3. On 06/24/22 at 9:42 am the administrator was notified of the immediate jeopardy. The facility presented a final removal plan on 06/24/2022 at 4:49PM. The facility's removal plan was accepted at 2:44 PM on 06/27/2022. The surveyor conducted additional interviews and record reviews on 06/28/2022 to verify the plan was implemented. The immediate jeopardy was removed on 06/24/2022 based on actions from the removal plan. […]

• Actual harm, isolatedF600Nov 14, 2024

  Based on interviews and record reviews, the facility failed to protect a residents' (R2, R11, and R12) right to be free from verbal and physical abuse form another resident (R1) for three out of 13 residents reviewed for abuse. This failure resulted in staff not providing needed supervision for an aggressive resident causing R1 to get into a verbal altercation with R12, R11 having to physically stop R1 from striking R11 with a cane and R1 punching R2 in the face. Findings include: R1's Admission Record, Order Summary Report, and care plan documents in part diagnoses including but not limited to schizophrenia and bipolar disorder. R1's Brief Interview for Mental Status (BIMS) dated 9/09/2024 documents in part that R1 was moderately cognitively impaired. […]

• Actual harm, isolatedF600Mar 6, 2024

  Based upon observation, interview, and record review the facility failed to follow the abuse prevention policy, failed to implement interventions, failed to acknowledge (R4's) behaviors, failed to immediately remove (R4) from resident contact to ensure safety, and failed to ensure that two of four residents (R3, R5) reviewed for abuse remained free from abuse. On (11/25/23) R5 sustained blunt head trauma during physical altercation with (R4) resulting in left frontal scalp contusion/hematoma and age indeterminate mildly displaced right nasal bone fracture. R5 also reported enduring chronic dizziness and headaches subsequent the altercation. […]

• Actual harm, isolatedF689Jan 17, 2024

  Based on observation, interview and record review, the facility failed to supervise a resident and provide individualized fall prevention interventions, for a cognitively impaired resident, who had four repeated falls. This failure affected one resident (R1) of three residents, reviewed for falls. As a result, R1 was sent to the hospital three times within seven weeks. The last fall incident of R1 resulted in an open fracture of the nasal bone. Findings include: R1's Hospital Records written by V20 (emergency room Physician), dated 12/13/23 at 11:44am documented on page 83 Patient was seen one day ago for concerns of a mechanical fall and had findings for an open fracture of the nasal bones, and was discharged with Augmentin for 7 days. […]