Jerold Phelps Comm Hosp SNF

In the surveyor’s words

From the most serious findings on record at Jerold Phelps Comm Hosp SNF, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF727Sep 12, 2025

  Based 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.Findings: During a concurrent interview and record review on 9/11/25 at 4:10 p.m., the DON (Director of Nursing) reviewed the facility nurse staffing schedules dated, January 2025, February 2025, March 2025 and April 2025. […]

• No harm, potential for more than minimal, widespreadF838Sep 12, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF607Apr 17, 2025

  Based 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. Findings: A review of the facility ' s policy and procedure (P&P) titled Abuse and Neglect Investigation printed on 4/17/25 was conducted on 4/28/25. […]

• No harm, potential for more than minimal, widespreadF655Mar 1, 2024

  Based 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. Findings: During a review of records on 2/29/24 at 4:30 PM, no baseline care plans, signed by the residents or their representatives, were found among the facility documents. A request was made to the CNO. 48660 During an interview on 03/1/24 at 10 a.m. […]

• No harm, potential for more than minimal, widespreadF656Mar 1, 2024

  Based 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. Findings: A review of Resident 1's face sheet (demographics) indicated he was admitted to the facility on [DATE]. […]