Royal Gardens Healthcare

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of two (2) of six (6) sampled residents (Resident 10 and 17) observed for medication administration as indicated on the facility policy and physician's order when:Resident 17's medications were not administered within 60 minutes of scheduled time of 9 AM on 1/22/2026.Resident 10's medications were not administered within 60 minutes of scheduled time of 9 AM on 1/22/2026.This deficient practice had the potential to prevent Residents 10 and 17 from obtaining the therapeutic level of their medications (a range in the blood that is medically effective but not dangerous), which could lead to complications and negatively impacting the residents' overall well-beingCross reference: F759Findings:1. During a review of the admission Record, the admission Record indicated Resident 17 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 17's diagnoses included were…

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 monitor the use of insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) and anticoagulant therapy (a medical treatment using drugs called blood thinners to prevent or treat dangerous blood clots [thrombi] by slowing the blood's clotting process, stopping existing clots from growing, and preventing new ones from forming) for two (2) of 15 sampled residents (Residents 1, and 32) as indicated on the residents' care plan by failing to monitor: 1. Resident 1 for signs and symptoms of hypoglycemia (an abnormally low level of sugar [glucose] in the blood) and hyperglycemia (a condition where the blood glucose [sugar] levels are abnormally high), while on Insulin Lispro (Humalog, a fast-acting insulin) from 12/21/2025 to 1/23/2026. 2. a. Resident 32 for signs and symptoms of hypoglycemia and hyperglycemia while on Insulin Lispro from 11/18/2025 up to 11/23/2026. 2. b.…

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 its medication error rate was less than five (5) percent (%). 13 medication errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order/ manufacturer's specifications / accepted professional standards and principles out of 35 total opportunities (observed administered medications) for error, to yield an overall medication error rate of 37.14 % for two (2) of six (6) sampled residents (Resident 10 and Resident 17) observed for medication administration.Licensed Vocational Nurse 2 (LVN 2) failed to administer Resident 17's medications, and Registered Nurse Supervisor 4 (RNS4) failed to administer Resident 10's medication within 60 minutes of the scheduled time of 9 AM on 1/22/2026.This deficient practice had the potential to result in Resident 17 and Resident 10 experiencing adverse medication effects (unwanted, uncomfortable, or dangerous…

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 proper food handling and maintain the food service area in a clean and sanitary manner in accordance with the facility's policies and procedures (P&P) when: The can opener was chipped and soiled with food residue.The blender was chipped and inside the jar showed white to yellowish discoloration around the blade.The onion powder container lid was partially closed and did not have a label to indicate open and discard date.The stand mixer (used for mixing, whisking, and kneading ingredients) had peeling and chipped paint, with exposed metal on the adjustment handle.The coffee maker's spout (the part where the coffee flows out into the pot or cup) was cracked. These deficient practices have the potential to expose residents to pathogens (germs), placing them at risk for developing foodborne illness (food poisoning), which may cause symptoms such as upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever which could lead to serious medical complications and hospitalization.Findings: During an…

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 that the call light device (one of the major communication technologies that link nursing home staff to the needs of residents) was within reach (an arm's length) of one (1) of 15 sampled residents (Resident 4). This failure had the potential to cause a delay in care for Resident 4 and prevent the resident from receiving the necessary care and services, which could lead to illness or serious injury.Findings:During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was initially admitted to the facility on [DATE] with diagnosis of dementia (progressive brain disorder that slowly destroys memory and thinking skills), muscle weakness, and aphasia (an impairment of language, affecting the production or comprehension of speech and the ability to read or write). During a review of Resident 4's Minimum Data Set (MDS, a resident assessment tool), dated 12/10/2025, the MDS indicated Resident 4's cognitive…

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 the process of investigation and report of grievance (a complaint, either oral or written, expressing dissatisfaction with service delivery or the quality of care furnished, regardless of whether remedial action is requested) for one (1) of 15 sampled residents (Resident 8) as indicated in the facility's policy and procedure by failing to document steps taken during the investigation of grievance, summarize pertinent findings or conclusion and document the date the grievance investigation result (decision) was confirmed This deficient practice had the potential to result in miscommunication and inaccurate information of the investigations which did not meet the documentation requirements for Resident 8's grievance.Findings:During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was admitted to the facility on [DATE] and re-admitted on [DATE], Resident 8's diagnoses included chronic kidney disease (CKD, is 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 interview and record review, the facility failed to implement the facility's abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) policy regarding investigating an allegation of verbal abuse (the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability) for one (1) of two (2) sampled residents (Resident 8) reviewed for abuse.This deficient practice had the potential to compromise or impede the protection of Resident 8, which could affect resident's emotional and mental wellbeing. Cross reference with F610. Findings:During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 8's diagnoses included chronic kidney disease (CKD, a condition in which the kidneys are damaged and cannot filter blood as well as they…

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 allegation of verbal abuse (the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability) for one (1) of two sampled residents (Resident 8) reviewed for abuse, within 2-hour timeframe to the State Survey Agency (SA, where state law provides for jurisdiction in long-term care facilities), the state ombudsman (advocates for residents of nursing homes, board and care homes and assisted living facilities), and local law enforcement. This deficient practice had the potential to compromise or impede the protection of Resident 8, which could affect resident's emotional and mental wellbeing. Findings:During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 8's diagnoses included chronic kidney disease (CKD, a condition in which the kidneys are…

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 provide evidence that the alleged abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) was thoroughly investigated for one (1) of two (2) sampled residents (Resident 8) reviewed for abuse, as indicated in the facility's policy and procedure. This deficient practice had the potential to compromise or impede the protection of Resident 8, which could affect resident's emotional and mental wellbeing. Cross Reference with F607.Findings:During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 8's diagnoses included chronic kidney disease (CKD, a condition in which the kidneys are damaged and cannot filter blood as well as they should), anxiety disorder (mental health condition marked by persistent, excessive worry, fear, or nervousness that interferes 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 implement a comprehensive resident-centered care plan (care plan, a formal process that correctly identifies existing needs and recognizes a resident's potential needs or risks to achieve healthcare outcomes) for one of 15 sampled residents (Resident 10) by failing to set Resident 10's Low Air Loss mattress (LAL mattress, designed to prevent and treat pressure injury/ ulcer [localized damage to the skin and underlying soft tissue caused by prolonged pressure]) according to the resident's weight.This deficient practice had the potential for Resident 10's skin to break down and develop skin impairment such as redness and pressure ulcer. Findings: During a review of the admission record indicated Resident 10 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diabetes mellitus (high blood sugar), encounter for attention to gastrostomy (a surgical opening fitted with a device to allow feedings to…

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 grooming services for one (1) of 1 sampled residents (Resident 4) reviewed for activities of daily living (ADL, activities related to personal care that include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating), in accordance with the facility's policy and procedure (P&P) titled, Care of Fingernails/Toenails This deficient practice resulted in Resident 4's having unkempt and dirty fingernails, which could potentially lead to skin injury and infection.Findings:During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was initially admitted to the facility on [DATE]. Resident 4's diagnoses included dementia (progressive brain disorder that slowly destroys memory and thinking skills), diabetes mellitus (persistently high levels of sugar in the blood), and muscle weakness.During a review of Resident 4's Minimum Data Set (MDS, a 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide activities to support resident's choice of activity for one of two sampled residents (Resident 10) reviewed for activities as indicated on the care plan.This deficient practice had the potential to negatively impact Resident 10's physical, cognitive, emotional health, and sense of belonging.Findings:During a review of the admission Record, the admission Record indicated Resident 10 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diabetes mellitus (high blood sugar), encounter for attention to gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and lack of coordination.During a review of Resident 10's Minimum Data Set (MDS - a resident assessment tool), dated 1/2/2026, the MDS indicated Resident 10 had severely impaired cognitive (thought process and ability to reason or make…

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 appropriate treatments and services to increase, prevent, or maintain range of motion (ROM, full movement potential of a joint) for one (1) of 15 sampled residents (Resident10) as indicated on the facility's Assistive Devices and Equipment policy.This deficient practice placed Resident 10 at risk for developing contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), which could result in pain and discomfort, joint deformities, immobility, and skin breakdown.Findings:During a review of the admission Record, the admission Record indicated Resident 10 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diabetes mellitus (high blood sugar), encounter for attention to gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people 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 provide care and treatment for one (1) of two (2) sampled residents (Resident 8) reviewed for catheter (flexible tube inserted into the bladder to drain urine when a person cannot urinate naturally) by failing to monitor and empty the nephrostomy (a medical procedure in which a tube is inserted through the skin of the lower back into the kidney to drain urine when the normal flow is blocked) drainage tube in accordance with the physician's order, care plan, and the facility's Care of Nephrostomy Policy and Procedures (P&P). This deficient practice had the potential to result in Resident 8 experiencing pain, discomfort, and infection, as well as complications such as kidney damage (condition when kidneys cannot properly filter waste and excess fluids from the blood) due to urine backing up into the kidneys, which could negatively affect the resident's overall well-being.Findings:During a review of Resident 8's admission Record, 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 that one (1) of one sampled resident (Resident 17) reviewed for nutrition, who required adaptive feeding equipment (modified utensils, accessories, glasses, and plates to help improve residents' comfort and independence), was provided with built-up utensils (specialized utensils with a built-up handle designed to assist residents with limited or weakened grasping strength) during meals, as indicated in the physician's order.This deficient practice placed Resident 17 at risk for further decline in physical functioning and a decrease in self-feeding ability.Findings:During a review of the admission Record, the admission Record indicated Resident 17 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 17's diagnoses included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), dementia (a progressive state of decline in…

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 one (1) of two (2) dumpsters (a movable waste container) were closed and not overflowing, in accordance with the facility's Policy and Procedure (P&P) titled, Food Related Garbage and Refuse Disposal. This deficient practice had a potential to attract vermin (animals that are believed to be harmful, carry diseases such as rodents, parasitic worms, or insects), pests (any living thing that has a negative effect on humans), and wildlife (undomesticated animal species) which may cause disease and other health issues to residents residing in the facility, staff, and the community.Findings:During a concurrent observation of the kitchen dumpsters located at the back of the facility and interview on 1/22/2026 7:45 AM with the Dietary Supervisor (DS), 1 of the kitchen dumpsters was not covered/ sealed and trash was overflowing. DS confirmed 1 of the 2 kitchen dumpsters were left open and overflowing with trash. During an interview on 1/23/2026 at 7:32 AM with [NAME] 1, [NAME] 1 stated, the kitchen dumpsters…

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 maintain an accurate and complete record for two (2) of 15 sampled residents (Resident 8 and 17) as indicated in the facility's policy and procedure when.1.The facility failed to update Resident 8's Medication Administration Records (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) and care plan to indicate the behavior monitoring is for the use of clonazepam (a long-acting benzodiazepine with intermediate onset commonly used to treat panic disorders, severe anxiety, and seizures) and not Xanax (Alprazolam, is used to relieve symptoms of anxiety, including anxiety caused by depression [a mood disorder that causes a persistent feeling of sadness and loss of interest] and treat panic disorder[sudden, intense feelings of fear that cause physical symptoms like racing heartrate, fast breathing and sweating]). 2.Resident 17's progress notes on 1/19/2026 to 1/23/2026 indicated the 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.

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 in accordance with the standards of practice for one of three sample residents (Resident 1) by failing to: Relay to Resident 1's physician and obtain an order regarding ST (Speech Therapist's- a professional who assesses, diagnoses, and treats swallowing disorders in people of all ages, helping them to have a safe eating through individualized therapy plans) recommendation to assist the resident during mealtime to enhance safe swallow. Relay to Resident 1's physician and obtain an order for ST evaluation after Resident 1 was observed and assessed to be able to feed himself without 1:1 assistance from the staff from 11/17/2025 to 12/19/2025. This deficient practice placed Resident 1 at-risk for aspiration (food, liquid, saliva, or other foreign material accidentally enters their airway and lungs instead of going down the esophagus (food pipe) into the stomach which can lead to serious injury and/ or…

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 maintain complete medical records for two (2) of 2 sampled residents (Residents 1 and 2) in accordance with the facility's policy. This deficient practice had the potential for Residents 1 and 2 not to receive the discharge information necessary for the residents' continuity of care in the community.Findings: 1. During a record review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with the diagnoses including but not limited to acute respiratory failure (an inability to maintain adequate oxygenation for tissues or adequate removal of carbon dioxide from tissues) with hypoxia (lack of oxygen in the tissues to sustain bodily function), acute ischemic heart disease (heart damage caused by narrowed heart arteries), and chronic obstructive pulmonary disease (COPD, disease that causes obstructed airflow from the lungs) with acute exacerbation (sudden worsening of symptoms of the disease).…

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 discharge needs for one (1) of two (2) sampled residents (Resident 1) were identified by failing to ensure an oxygen concentrator (a medical device that concentrates environmental air and delivers it in the form of supplemental oxygen), portable oxygen, and nebulizer (a device for breathing mist treatment) were provided and ready for use upon resident's discharge to a Recuperative Care Center (a short-term residential care for residents who no longer require hospitalization but still need to heal from an injury or illness). This deficient practice had the potential to result in an unsafe discharge for Resident 1 due to lack of an oxygen concentrator until 8/11/2025 (four days after discharge) and not receiving respiratory treatment due to the absence of a nebulizer from 8/7/2025 to 8/20/2025, which could lead to Resident 1 suffering from respiratory complications and hospitalization. Findings: During a record review of Resident 1's admission…

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 (2) of 2 residents were seen by specialty doctor as indicated on the physician's order when the facility failed to:1. Follow up and obtain a prior authorization (process where healthcare providers must obtain advance approval from a patient's insurance company before providing certain medical services or medications), on a weekly basis, for Resident 1 to be seen by Vascular Surgery (treats diseases of the blood vessels, including arteries [blood vessels carrying oxygen rich blood away from the heart to the rest of the body], veins [blood vessels that carry blood from the body's tissues and organs back to the heart], and lymphatic vessels [network of thin tubes that collect excess fluid, called lymph, from body tissues and return to the blood stream [blood as it moves through the body's). 2. Set up the medical appointment for gastroenterology (GI-medical specialty that focuses on the study, diagnosis, and treatment of disorders…

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 observe infection control measures for two (2) of 2 sampled residents (Resident 1 and 2) as indicated on the facility policy by failing to ensure:1. Certified Nursing Assistant (CNA) 1 performed hand hygiene (the practice of cleaning and disinfecting hands to remove harmful microorganisms) when exiting Resident 1 and 2's room. 2. Resident 1 had clinical or laboratory results for Carbapenem-Resistant Acinetobactor baumannii (CRAB - a bacterial infection caused by a drug-resistant strain of bacteria) when resident was readmitted to the facility on [DATE].This deficient practice has the potential to spread infection to staff and other residents in the facility.Findings:During a review of Resident 1's admission Record, the admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with the following diagnoses of resistance to multiple antibiotics (a microorganism has developed the ability to…

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 maintain an accurate documentation of wound care treatment for two (2) of 2 sampled residents (Residents 1 and 2) on the residents Treatment Administration Record (TAR) in accordance with the facility's policy titled Charting and Documentation. This deficient practice resulted in the medical records inaccurate representation of care provided to Residents 1 and 2. Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included pressure ulcer (also known as pressure injuries - localized damage to the skin and/or underlying tissue usually over a bony prominence) on the sacral (tailbone) region of unspecified stage and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (a slight loss of strength in a leg, arm, or face) following cerebral…

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 special dietary need of one of two sampled residents (Resident 1) by failing to ensure Controlled Carbohydrate Diet (CCHO diet, a dietary approach designed to manage blood sugar levels) that is recommended by Registered Dietitian (RD, is a healthcare professional who specializes in food and nutrition) was communicated and order obtained from the resident's primary physician. This deficient practice placed Resident 1 at risk for developing high blood sugar that can lead to hospitalization and/ or death. Findings: During a review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dementia (a progressive state of decline in mental abilities), and acute kidney failure (a sudden loss of kidney function). During a review of Resident 1's care plan,…

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 maintain a safe, clean, comfortable, and home like environment for six sampled residents (Residents 8, 194, 36, 18, 28, and 19) of 11 residents when facility failed to: 1. Maintain comfortable and safe temperature levels for Resident 8. 2. Maintain a working television for Resident 194. 3. Maintain a comfortable noise level for Resident 36. 4. Maintain a clean and sanitary environment by ensuring Resident 18's floor was not soiled and room did not smell like urine. 5. Maintain a clean and sanitary environment for Resident 28 by ensuring room did not smell like urine. 6. Ensure Resident 19's room did not have a chipping wall trim/molding. These deficient practices had the potential for Residents 8, 194, 36, 18, 28, and 19 to feel discomfort/sustain injury and had the potential to negatively affect the residents' well-being and quality of life. Findings: 1. During a review of Resident 8's admission Record (front page of the chart that…

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 treatment for the prevention of pressure ulcer (painful wound caused as a result of pressure or friction) by failing to ensure that the low air loss mattress (LAL, mattress used for residents who are at risk for developing sores or already have pressure ulcer designed to circulate a constant flow of air for the management of pressure sores) was on the correct settings for three (3) of 3 sampled residents (Residents 30, 6, and 1), in accordance with the facility's policy and procedure (P&P) titled, Pressure Injury,. This deficient practice had the potential for Resident 30 and 6 to develop a pressure ulcer and place Resident 1 to have worsening stage 3 pressure ulcer (full-thickness skin loss in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole [rolled wound edges] are often present). Findings: 1. During a review of Resident 30's admission Record indicated Resident 30 was admitted to 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.

Based on observation, interview, and record review, the facility failed to ensure safe provision of pharmaceutical services as indicated in the facility policy by failing to ensure: 1. Medication storage freezer did not have an ice built up. 2. Medication storage room counters were free of dust. 3. Medications were stored under proper temperature control. This deficient practice had the potential for adverse reaction in the event that these medications, which were not stored under proper control temperature were administered to the residents and potential source of infection if cleanliness were not maintained. Findings: During a concurrent observation in the medication storage room and interview with the Director of Nursing (DON) on 12/5/2024 at 10:12 AM, the medication storage freezer had ice built up. The DON stated, We should not have ice built up in the refrigerator's freezer because we will not have an accurate temperature for the medications that were kept inside the refrigerator. During a concurrent observation in the medication storage room and interview with the DON on…

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 foods are handled, prepared, stored and distributed in a manner that prevents foodborne illness (infections or irritations of the gastrointestinal tract [a series of hollow organs joined in a long, twisting tube from the mouth to the anus] caused by food or beverages that contain harmful bacteria, parasites, viruses, or chemicals) by failing to ensure foods are labeled with date opened, use by date and/ or expiration date. These deficient practices had the potential to result in food contamination and/or foodborne illness for the residents in the facility. Findings: During an observation in the kitchen on 12/2/2024 at 7:50 AM, the following were observed in the presence of the Dietary Supervisor (DS), 1. One (1) opened container of butter - not labeled with use by date. 2. One (1) gallon of chocolate syrup bottle - not labeled with use by date. 3. One (1) bag of potatoes hash brown - not labeled with use by date. 4. 20 tomatoes in the plastic bin - not labeled with use by date. During an interview 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 ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed for four (4) out of fifteen sampled residents (Resident 8, 144, 44 and 22) in accordance with the facility's policy and procedure titled Infection Prevention and Control Program indicated an infection control prevention and control program (IPCP) when: 1. A urine-soaked diaper was seen sitting on top of paper towel dispenser in Room A 's communal bathroom. 2. Licensed Vocational Nurse (LVN) 1 did not use an isolation gown while administering medication via gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach, common for residents with swallowing problems) tube to Resident 8 who was on enhanced barrier precaution (EBP, an infection control practice that involves wearing gowns and gloves during…

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, interviews, and record reviews, the facility staff failed to ensure resident would not wait for 32 minutes to receive his meal tray while other residents in the same table were eating for one (1) of 15 sampled residents (Residents 25). This deficient practice violated the rights of the resident to be treated with dignity or respect. Findings: During a review of Resident 25's admission Records indicated Resident 25 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that includes dysphagia (difficulty swallowing foods or liquids) following cerebral infarction (stroke-damage to the tissues in the brain due to a loss of oxygen to the area) and type II diabetes mellitus (high blood sugar). During a review of Resident 25's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 10/13/2024, indicated Resident 25 was cognitively (relating to the process of acquiring knowledge and understanding) impaired. The MDS indicated Resident 25 was dependent…

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 the call light (device used by residents to call staff) was within reach for three (3) of 15 sampled residents (Resident 1, 6, and 5) in accordance with the facility policy and procedure. This failure had the potential for Residents 1, 6, and 5 to not be able to call for assistance, which could result in untimely delivery of care and services. Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated Resident 6 was admitted to the facility on [DATE] and re- admitted on [DATE] with diagnoses included cerebral infarction (refers to damage to tissues in the brain due to a loss of oxygen to the area) affecting left dominant side, muscle weakness, stage 3 pressure ulcer of sacral region (it is a triangular-shaped bone at the base of the spine just superior to the coccyx[tailbone]) and unspecified buttock. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), the MDS dated…

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 comprehensive person-centered care plan for one (1) of 15 sampled residents (Resident 22) for the use of antibiotic (medicines that fight bacterial infections) and anticoagulants (substance that is used to prevent and treat blood clots in blood vessels and the heart) per facility's Comprehensive Person-Centered Care Plan policy and procedure. This deficient practice had the potential for Resident 22 to not receive specific interventions to prevent decline in the resident's functional ability, not being monitored for resident's therapeutic treatment, and also may result in injury/harm and/or worsening of the resident's condition. Findings: During a review of Resident 22's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included osteomyelitis (inflammation or swelling that occurs in the bone) of lumbar vertebrae (are the five bones…

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 (1) of five (5) sampled residents (Resident 11) was free from unnecessary psychotropic drug (any medication capable of affecting the mind, emotions, and behavior) use as indicated in the facility's policy and procedure by failing to provide documented evidence that Resident 11's behavior was monitored for the use of: 1. Abilify (an antipsychotic medicine used to treat the symptoms of schizophrenia and bipolar disorder [a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration]) 2. Depakote (also used to treat acute manic or mixed episodes associated with bipolar disorder with or without psychotic features). This deficient practice had the potential to result to inaccurate re-evaluation of Resident 11's need for psychotropic medications, which may lead to an overall negative impact on the resident's physical, mental, and psychosocial well-being. Findings: During a review of Resident 11'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure its medication error rate was less than five (5) percent (%). There were 3 medication errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order/manufacturer's specifications/accepted professional standards and principles) out of 29 opportunities (observed administered medications) for error which yielded a facility medication error rate of 10.34% for one (1) of 5 sampled residents (Resident 29) observed during medication administration (med pass): Licensed Vocational Nurse 2 (LVN 2) failed to administer multivitamin (a pill containing a combination of vitamins), vitamin C (a nutrient your body needs to form blood vessels, cartilage, muscle and collagen in bones), and vitamin D3 (group of vitamins fond in the liver and fish oils, essential for the absorption of calcium and the prevention of rickets in children and osteomalacia in adults)…

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 staffing information was posted and placed in a visible and prominent place on a daily basis. As a result, the total number of staff and the actual hours worked by the staff was not readily accessible to residents and visitors and had the potential to inaccurately reflect the actual nurses providing direct care to the residents. Findings: During an observation on 9/30/2024 at 8:40 AM near the nursing station, the Census and Direct Care Service Hours Per Patient Day (DHPPD; a form that provides staffing information for the day) was observed with the date 9/27/2024 and the section named Actual Direct Care Service Hours and DHPPD (section 8) was observed blank. During a concurrent observation and interview on 9/30/2024 at 9:19 AM with Registered Nurse (RN) 1, the DHPPD posted near the nursing station was observed. RN 1 stated, The date on the DHPPD is 9/27/2024 but today is 9/30/2024. The DHPPD section 8 is not filled out. During a concurrent record review and interview with the Director of Nursing (DON)…

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 three of three sampled residents (Residents 1, 2 and 3) received consistent treatment to promote the healing and prevention of pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure on the skin) by failing provide treatments as ordered by physician. These deficient practices placed the Residents 1, 2 and 3 at risk of worsening of current pressure ulcers and increased chance for the development of new pressure ulcers. Findings: 1. During a review of Resident 1's admission Record, indicated Resident 1 was readmitted to the facility on [DATE] with diagnoses that included morbid obesity (a severe and dangerous level of being overweight that significantly and negatively impacts health and shortens the lifespan), generalized muscle weakness, congestive heart failure (CHF - a chronic condition in which a weakness of the heart leads to a buildup of fluid in the lungs) and type 2 diabetes mellitus (DM2 - condition that…

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 Resident 1 was free from physical abuse (an act where one person uses their body to inflict intentional harm or injury upon another person) when struck by Resident 2 in the face. This failure resulted in preventable and unnecessary physical abuse with the potential for emotional and mental trauma for Resident 1. Findings: A review of Resident 1's admission Record indicated Resident 1 was readmitted to the facility on [DATE] with diagnoses that included difficulty in walking, type 2 diabetes mellitus (DM2 - condition that results in too much sugar circulating in the blood), dementia (a condition characterized by progressive or persistent loss of intellectual functioning) and chronic kidney disease (CKD - longstanding disease of the kidneys leading to failure). A review of Resident 1's Minimum Data Set (MDS - a standardized resident assessment care screening tool), dated 4/8/2024, indicated Resident 1 with severely impaired cognitive skills…

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, facility failed to revise the care plan (a document that outlines the facility's plan to provide personalized care to a resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs) for one of one resident (Resident 2), to include revised specific interventions for the care and safety of Resident 2 after a physical altercation with Resident 1. This failure had the potential for Resident 2 to receive care that is not revised to meet the changes in his condition and needs, which could result in decreased quality of care and safety for Resident 2 and other residents in the facility. Findings: A review of Resident 2's admission Record indicated Resident 2 was readmitted to the facility on [DATE] with diagnoses that included unspecified psychosis (severe mental condition involving abnormal thinking, perceptions, and loss of contact with reality), gastro-esophageal reflex disease (GERD - chronic digestive…

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 rehabilitation (rehab, restoring function) services per physician's orders to two of three sampled residents (Resident 1 and 2) who required rehab services by failing to: 1. Ensure Resident 1's physician's orders for Occupational Therapy (OT, profession aimed to increase or maintain a person's capability of participating in everyday life activities) and Speech Therapy (ST, profession aimed to assess and provide treatment for disorders of communication, speech production, language, and swallowing) were carried out. 2. Ensure OT and Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) treatment sessions were provided five times a week per physician's orders for Resident 2. These deficient practices prevented Resident 1 and Resident 2 from receiving skilled therapy (services that require specialized training and experience of a licensed therapist or therapy assistant)…

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 notify the physician of a change of condition for one of three sampled residents (Resident 1) when a resident did not have a bowel movement (evacuation of stool from the body) from 12/7/2023 to 12/11/2023 , as indicated in the facility policy. This deficient practice had the potential to result in the delay of needed care and services to address Resident 1's constipation (condition in which there is difficulty on emptying the bowels), which could result in fecal impaction (hard, dry stool stuck in the colon or rectum) and hospitalization. Findings: A review of Resident 1's admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including right pubis fracture (break in the pelvic bone), right humeral shaft fracture (break in the upper arm bone), and end stage renal disease (chronic kidney disease that causes gradual loss of kidney function). 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete the admission Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool) within the regulatory time frame for one (1) of three (3) sampled residents (Resident 2) in accordance with the facility policy. This deficient practice had the potential to result in not developing a comprehensive resident centered care plan, which could negatively affect the provision of necessary care and services for Resident 2. Findings: A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including congestive heart failure (weakness of the heart that leads to buildup of fluid in the lungs and other parts of the body), atrial fibrillation (irregular heart rate), and cardiomegaly (enlarged heart). During a concurrent record review of Resident 2's MDS List clinical record and interview on on 12/20/2023 at 10:35 a.m., the Minimum Data Set Director (MDSD) confirmed Resident 2'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure two out of two sampled residents (Resident 24 and 36) were free from physical restraints (any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to the resident's body; cannot be removed easily by the resident; and restricts the resident's freedom of movement or normal access to his/her body). a. For Resident 24, the facility failed to obtain a physician's order for the use of geriatric chair (Geri chair, a large, padded, and mobile reclining chair that prevented the resident from rising). There was no consent and assessment for the use of Geri chair in resident's medical records. b. For Resident 36, the facility failed to obtain a physician's order for the use of geriatric chair with the duration for the use of Geri chair. There was no consent and assessment for the use of Geri chair in resident's medical records. These deficient practices had the potential to result in entrapment (an…

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 wound treatment for two (2) of 2 sampled residents (Resident 10 and 37) in accordance to the physicians order. 1. Resident 37 did not receive antifungal cream to his bilateral (affecting both sides) buttocks extending to perineum (the area between the anus and scrotum) and right hip moisture-associated skin damage (MASD). 2. Resident 10's calcium alginate (a highly absorptive dressing that absorbs fluids from covered wounds and form a protective gel) was not given during treatment observation on 12/09/23. This deficient practice had the potential for Resident 37 and 10's wounds to worsen and develop an infection. Findings: 1. A review of Resident 37's admission Record indicated Resident 37 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included complete traumatic amputation (loss of a body part that occurs as the result of an accident or injury) of the right great toe, type 2…

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 respiratory care services and treatment for three (3) of 3 sampled residents (Residents 28, 197, and 199). 1. The facility failed to change Resident 28's nasal cannula tubing (oxygen tubing used to deliver supplemental oxygen that is placed directly on the nostrils) every Sunday according to physician's order and failed to ensure that the nebulizer (a drug delivery device used to administer medication in the form of a mist inhaled in the lungs) face mask and tubing were placed in a bag after use. This deficient practice had the potential for the Resident to develop a respiratory infection. 2. The facility failed to follow Resident 197's physician order to receive one (1) liter of oxygen per minute (LPM) via nasal cannula continuously. The facility failed to follow their policy to display an Oxygen in Use sign outside of the room entrance door and failed to ensure Resident 197's head of bed was elevated while…

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 that the facility was free of a medication error rate of five percent (%) or greater as evidenced by the identification of seven (7) medication errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order; manufacturers specifications [not recommendations] regarding the preparation and administration of the medication or biological; accepted professional standards and principles which apply to professionals providing services) out of 29 opportunities (observed administered medications) for error, which yielded a facility medication error rate of 24 %. This deficient practice had the potential to result in harm to Residents 22 by not administering medications as prescribed by the physician in order to meet the resident's individual medication needs. Findings: A review of Resident 22's admission Record indicated Resident 22 was admitted to 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 safe provision of pharmaceutical services when: 1. One (1) of two (2) medication refrigerators were not set within the proper temperature range, in the medication room. This deficient practice had the potential for loss of strength of the medications, and the potential for the residents to receive ineffective medication dosages. 2. The facility failed to indicate the date when the iodine (solution used to prevent and treat infections on minor scrapes and cuts) bottle was opened to readily identify when the bottle should be discarded. This deficient practice had the potential for the loss of effectiveness of iodine and for unintentional use of possible expired medication. Findings: 1. During the medication inspection of the Medication Storage Room on [DATE] at 5:21 p.m., one of the medication refrigerators thermometers indicated a temperature reading of 30 degrees F (Fahrenheit, a unit of temperature measure), which is below 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.

Based on observation, interview, and record review, the facility failed to store food in a sanitary manner to prevent growth of microorganisms that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food, as well as toxins) by failing to: 1. Store food properly when the plastic packaging of 15 frozen coffee cakes was observed broken and unlabeled 2. Date an opened jar of peanut butter 3. Ensure food items stored in two (2) of three (3) freezers were labeled 4. Ensure kitchen equipment are free of rust and black residue These deficient practices have the potential to result in the residents ingesting expired food and can result in foodborne illnesses and can lead to symptoms such as nausea, vomiting, stomach cramps and diarrhea. Findings: During an observation of the kitchen on 12/08/23, at 5:43 PM, in the presence of Dietary Service Manager (DSM) the following were observed: 1. 1 unlabeled pack of 15 frozen coffee cakes in a broken plastic packaging in Freezer…

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 in observation, interview and record review, the facility failed to ensure residents were provided a homelike environment for one of 16 sampled residents (Resident 28) by failing to clean the oxygen concentrator (a device that provides oxygen) handle and oxygen flow meter (a device used to measure the volume or mass of a gas or liquid). This deficient practice had the potential to negatively impact the resident's quality of life. Findings: A review of Resident 28's admission Record indicated Resident 28 was initially admitted on [DATE] and was readmitted on [DATE] with diagnoses that included unilateral primary osteoarthritis (the wear and tear of the joint cartilage and the underlying bone that causes stiffness and pain) of the right knee, morbid obesity (weight is more than 80 to 100 pounds above their ideal body weight) , and hereditary and idiopathic neuropathy (a nerve condition that can lead to pain, numbness, weakness or tingling in one or more parts of the body). A review of Resident 28'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a care plan for intravenous (IV- administration of medicines or fluids through a needle or tube inserted into a vein) hydration (the process of adding back water to the body that has been lost in order to keep it functioning properly) comprehensive for one of 16 sampled residents (Resident 22) in accordance with the facility policy. This deficient practice had the potential for Resident 22 to not be appropriately cared for by the facility staff in providing resident-centered care and services. Findings: A review of Resident 22's admission Record indicated Resident 22 was admitted on [DATE] with diagnoses that included sepsis (infection of the blood), type 2 diabetes mellitus (a disease that occurs when the blood sugar is too high), and protein-calorie malnutrition (inadequate intake of food that leads to changes in the body). A review of Resident 22's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated…

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 review and revise the care plans for one (1) of 16 sampled residents (Resident 37) who has a history of falls. This deficient practice had the potential to place Resident 37 at risk for recurrent falls, which could lead to serious injury and harm. Findings: A review of Resident 37's admission Record indicated Resident 37 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included complete traumatic amputation (loss of a body part that occurs as the result of an accident or injury) of the right great toe, type 2 diabetes mellitus (a disease that occurs when the blood sugar is too high), and muscle weakness. A review of Resident 37's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 10/19/23, indicated Resident 37 had severely impaired cognition (thought process and ability to reason or make decisions) for daily decision making and was dependent (helper does all the effort) 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, facility failed to ensure the wander guard (used to keep track of patients) was checked according to facility's policy and procedure (P&P) for one of four sampled resident (Resident 33) who was cognitively (ability to think and reason) impaired and displayed behaviors of wandering (walking around aimlessly without a fixed plan) in the facility. This deficient practice placed Resident 33 at risk for eloping (a resident who is incapable of adequately protecting himself, and who departs the health care facility unsupervised and undetected) with the potential of being exposed to severe environmental conditions including excessive cold, possible motor vehicle accident, medical complications including malnutrition (health problems that may arise due to lack of nutrients [substances found in food necessary for the body to function normally]), dehydration (abnormally low fluid levels in the body), and death. Findings: A review of Resident 33's admission Record 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 observation, interview and record review, the facility failed to ensure one of one sampled resident's (Resident 10) urinary indwelling catheter (Foley catheter [brand name] a flexible tube [a catheter] inserted into the bladder that remains (dwells) there to provide continuous urinary drainage) order was carried out on 12/10/2023. Resident 10 did not have a urinary indwelling catheter on 12/10/2023. This deficient practice placed Resident 10, who has a diagnosis of neuromuscular dysfunction of bladder ([neurogenic bladder] a problem in which a person lacks bladder control due to a brain, spinal cord, or nerve condition) at risk for bladder distention due to delayed bladder emptying, other urological problems including infections, kidney damage and serious medical condition such as sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs). Findings: A review of the admission Record indicated Resident 10 was originally admitted to…

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 one (1) of two sampled residents (Resident 22) who is fed by enteral (passing through the intestine either naturally or through an artificial opening) means received appropriate treatment and services by failing to elevate the head of the bed (HOB) while receiving formula through the gastrostomy tube (GT - a tube inserted through the abdomen that delivers nutrition directly to the stomach). This failure had the potential to place Resident 22 at risk for aspiration (inhaling small particles of food or drops of liquid into the lungs) that can lead to lung problems such as pneumonia (a lung infection) and death. Findings: A review of Resident 22's admission Record indicated Resident 22 was admitted on [DATE] with diagnoses that included sepsis (infection of the blood), type 2 diabetes mellitus (a disease that occurs when the blood sugar is too high), and protein-calorie malnutrition (inadequate intake of food that leads to changes in…

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 pharmaceutical services to meet the needs of residents as indicated on the facility policy by failing to ensure the Change of Shift Narcotics (drug that produces analgesia [pain relief], narcosis [state of stupor or sleep], and addiction [physical dependence on the drug]) Reconciliation Records contained two Licensed Nurses' signatures. This deficient practice had the potential for inaccurate record of narcotic medication use and loss of accountability, which could result to drug loss, diversion, and could potentially harm the resident if ingested. Findings: 1. On 11/03/2023, the evening shift (3 PM to 11 PM shift) licensed nurse did not sign off the Controlled Drugs Count Record (CDCR) for the start of shift narcotic count. 2. On 11/05/2023, the day shift (7AM to 3 PM shift) licensed nurse did not sign off the CDCR for the start of the shift narcotic count and end of shift narcotic count. 3. On 11/05/2023, the evening shift licensed nurse did not sign off the CDCR for the start of the shift narcotic…

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 (Resident 22) was ordered for psychotropic (acting on the mind) medication with an adequate indication of use. Resident 22 was ordered for Lorazepam (a medication used to treat anxiety) 0.5 milligram (mg, unit of measurement of mass) via gastrostomy tube (GT - a tube inserted through the abdomen that delivers nutrition directly to the stomach) for anxiety manifested by (m/b) increase agitation. This deficient practice had the potential to place Resident 22 at risk for unrecognized adverse reactions associated with the use of psychotropic drug. Findings: A review of Resident 22's admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses that included sepsis (a life-threatening infection) and type 2 diabetes mellitus (a disease that occurs when the blood sugar is too high). A review of the History and Physical Examination, dated 11/12/23, indicated Resident 22 has…

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 accurately document the resident's medical record for one of 22 sampled residents (Residents 21) by failing to ensure the facility have the correct physician's order in the Resident's electronic health records (eHR) for the resident's code status (describes the type of resuscitation procedures the resident would like the health care team to conduct if the resident's heart stopped beating and/or the resident stopped breathing). This deficient practice had the potential to result in confusion on the delivery of care and services during a medical emergency. Findings: A review of Resident 21's admission Record indicated Resident 21 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, chronic kidney disease, and dependence on renal dialysis. A review of Resident 21's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated [DATE], indicated Resident 21 had intact memory and cognition (thought…

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 (1) of 1 sampled resident (Resident 27) had adequate indication for use of antibiotic therapy as indicated on the facility policy. This deficient practice had the potential for Resident 27 to experience adverse events (undesired harmful effects), including the development of antibiotic-resistant organisms (bacteria that are not controlled or killed by antibiotics), from unnecessary or inappropriate antibiotic treatment. Findings: A review of Resident 27's admission Record indicated the resident was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnosis that included pneumonitis (general inflammation of lung tissue) due to inhalation of food (food enters airway/lung by accident) and vomit. A review of Resident 27's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 11/6/23, indicated Resident 27 had moderate cognitive impairment (ability to think, understand, and reason). The MDS…

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.