Sunny Village Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney/s have failed) access site and access site dressings (a sterile, protective covering applied to an insertion site to prevent infection, stabilize and/or protect) for one (1) of three (3) sampled Residents (Resident 87) reviewed for dialysis were assessed and documented on the Nurses Dialysis Communication Record prior to dialysis as indicated on the physician's order and in the facility's policy and procedure (P&P). This failure placed Resident 87 at risk for a delay in detecting any complications to the dialysis access site including redness, swelling and/or draining and necessary communications to the Resident 87's health care providers including the dialysis staff for timely treatment as needed. Findings:During a review of Resident 87's admission Record, the admission Record indicated Resident 87 was readmitted 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 verify the identify for one (1) of 5 (five) sampled residents (Resident 20) observed for medication administration, prior to administering resident's medications as indicated on the facility's policy. This deficient practice had the potential of a medication error which could result to harm hospitalization and death.Findings: During a review of Resident 20's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with the following but not limited to diagnoses of hypertension (HTN-high blood pressure), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and acute kidney failure (sudden, often reversible, loss of kidney function occurring within hours or day). During a review of Resident 20's Minimum Data Set (MDS, a resident assessment tool), dated 3/9/2025, the MDS indicated the resident had intact cognitive skills for daily decision…

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 documentation of the Medication Administration Record (MAR - a document used to record the administration of prescribed medications) was accurate for one (1) of 1 sampled resident (Resident 85), reviewed for respiratory. Resident 85's MAR did not indicate oxygen therapy (medical treatment that provides additional oxygen to individuals who cannot get enough oxygen on their own due to conditions like lung disease or acute respiratory distress) was provided for 11 days in 3/2026. This failure had the potential for Resident 85's interdisciplinary team (IDT - a coordinated group of experts from several different fields) to conclude Resident 85 did not receive or need oxygen therapy, which could lead to inappropriate care planning, delayed interventions, and an increased risk of respiratory decline.Findings:During a review of Resident 85's admission Record, the admission Record indicated Resident 85 was originally admitted to the facility on [DATE]…

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 interviews and record review, the facility to provide documented evidence that the Heating, Ventilation, and Air Conditioning (HVAC, is a mechanical system that regulates the temperature, humidity, and air quality in indoor environments to provide thermal comfort and remove contaminants which is essential for maintaining environmental temperatures within safe and acceptable ranges) system was maintained by outside HVAC maintenance services contractors and the HVAC is in safe and in good working condition. This deficient practice had the potential to cause unverified preventative maintenance by outside HVAC maintenance services contractors that could result in HVAC system failure affecting the health and comfort of 99 residents in the facility. Findings:During a review of the facility's (undated) floor plan, the facility's floor plan indicated there were 22 resident's rooms on the first floor and 32 residents' rooms on the second floor. The floor plan indicated a total of 54 residents' rooms are in the facility. During a review of the facility's census report, 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 maintain ethical standards of practice (guidelines that govern behavior and prioritize resident dignity, autonomy [independence], safety, and guided by principles of beneficence [acting in the patient's best interest], non-maleficence [do no harm], justice, and respect for rights) for one of two sampled residents (Resident 2) by purchasing a prescribed Brand 1 sensor (a small, wearable continuous blood glucose [sugar] monitor sensor that measures blood glucose levels in real-time beneath the skin) from Resident 1 on 10/13/2025. This failure resulted in the facility completing an inappropriate business transaction with Resident 1, whom they provide all care and services for, with the potential to negatively impact Resident 1's psychosocial (the interaction between an individual's mental processes [thoughts, emotions & behaviors] and their social environment [relationships, culture & community] wellbeing.Findings:During a 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 interview and record review, the facility failed to ensure a psychiatrist (a medical doctor who diagnoses and treats mental, emotional, and behavioral disorders) /psychologist (a person who specializes in the study of mind and behavior) consult was provided timely for an acute change in condition as ordered for one of two sampled residents (Resident 1) in accordance with the Physician's order, care plan, and facility policy. This failure resulted in no psychiatric consultation (evaluation) for 25 days, with the potential for Resident 1 to experience a decline in mental and/or psychosocial (having to do with the mental, emotional, social, and spiritual) wellbeing and/or a lack of services/treatments to maintain or attain Resident 1's highest practicable mental and psychosocial wellbeing.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus (DM-a disorder characterized by…

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 licensing staffs are competent with the knowledge of use of continuous Brand 1 glucose (blood sugar) monitoring systems, [(CGM), a continuous glucose monitoring system helps adults and children ages 2 years and older living with diabetes (a condition that happens when your blood sugar is too high), keep track of their glucose levels in real-time without finger sticks, (a quick, at-home method to get a small capillary blood sample by pricking a fingertip with a sterile lancet for tests of blood sugar)] for one (1) of one (1) sampled resident (Resident 1) This deficient practice had the potential to result in failure of monitoring of Resident 1's blood sugar, this can cause abnormal blood sugar ranging level, with the possibility of damage nerves, blood vessels, and vital organs due to persistently high blood sugar levels. This failure can also cause care team to make inappropriate medical decisions and inappropriate care plans to Resident 1.…

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 interview the facility failed to notify California Department of Public Health (CDPH) about COVID-19 (COVID-19 - a highly contagious respiratory disease caused by the SARS-CoV-2 virus) outbreak in the facility, in accordance with the facility's policies and procedures (P&P) titled Outbreak of Communicable Diseases.This deficient practice prevented CDPH being aware of outbreak and to ensure proper guidelines are followed to control the COVID-19 outbreak, prevent further spread and lead to irreversible health issues to the residents in the facility. During an interview on 8/28/25 at 11:31 AM with the facility's Infection Preventionist (IP), the IP stated that he did not report the facility's current COVID-19 outbreak to CDPH. IP stated that if CDPH is not notified of an outbreak it will not be fully investigated to ensure all guidelines were followed which may create gaps in infection control procedures and cause the worsening of outbreak.During a concurrent interview and record review on 8/28/2025 at 2:40 PM with the administrator (ADM), the facility's P&P titled, Outbreak…

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 Care Plan (a document that outlines how a resident will receive support and care to meet their needs) was resident centered (treating each resident as an individual with unique preferences and requirements) for one (1) of two (2) sampled residents (Resident 1) by failing to include Resident 1 requires a 2-person assistance with Activities of Daily Living (ADLs- activities such as bathing, dressing and toileting a person performs daily). These deficient practices have the potential for Residents 1 not to receive care and interventions specific to the resident's needs which could affect the resident's overall wellbeing. Findings:During a review of Resident 1's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury) and multiple…

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 promote dignity and respect for three (3) of 18 residents (Residents 10, 244, and 58) as indicated on the facility's policy when facility staff labeled Residents 10, 244, and 58 as feeders during dining observation on 1/27/2025. This deficient practice had the potential to affect Resident Residents 10, 244, and 58's sense of self-worth and self-esteem which could result in problems with emotional and mental well-being. Findings: 1. During a review of Resident 10's admission Record, the admission record indicated Resident 15 was admitted to the facility on [DATE] and re- admitted on [DATE]. Resident 15's diagnoses included metabolic encephalopathy (ME, occurs when problems with your metabolism cause brain dysfunction), diabetes mellitus (DM, is a metabolic disease, involving inappropriately elevated blood glucose levels), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and…

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 and interview, the facility failed to maintain a comfortable and safe environment for four (4) of 18 sampled residents (Resident 187, Resident 18, Resident 54, and Resident 69) by failing to: 1. 2. And 3. Failing to maintain the residents' room temperature level between 71- and 81-degree Fahrenheit ( degrees F) of Resident 187, Resident 18, and Resident 54). This deficient practice resulted in the residents' increased level of discomfort which can negatively impact the residents' quality of life, increase the residents' risk of dehydration (excessive loss of body water), hypothermia (a condition where the body's core temperature drops below 95 degrees F), and/or hyperthermia (condition where the body's core temperature is higher than 98 degrees F). 4. ensure Resident 69's belongings were safe and missing items were addressed. This deficient practice had a potential for Resident 69 losing personal items which could negatively affect resident's emotional wellbeing. Findings: 1. During a review…

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 3. During a review of Resident 73's admission Record, the admission record indicated Resident 73 was admitted to the facility on [DATE], with diagnoses of hypotension (low blood pressure) and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement, chiefly affecting middle-aged and elderly people). During a review of Resident 73's MDS, dated [DATE], the record indicated Resident 73's cognitive skills for daily decision making were moderate impaired. The MDS indicated Resident 73 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) for toileting hygiene, shower/bathe self, lower body dressing, sit to lying, and sit to stand. The MDS indicated Resident 73 was on oxygen therapy. During a review of Resident 73's Physician's Order Summary Report, dated 2/3/2025, the record indicated oxygen administration 2 l/minute via NC PRN (as needed) to maintain oxygen saturation (SpO2, amount of oxygen…

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 follow proper food handling practices in accordance with its policy and procedure by failing to: 1. Label food in the preparation area, refrigerators, and freezers in the kitchen with item name, and date opened. 2. Ensure kitchen equipment and kitchen surfaces were clean and free of food debris. 3. Ensure trash bins were not placed next to the clean serving trays. 4. Ensure dietary staff (Cook 1 and [NAME] 2) perform hand hygiene (is the act of cleaning the hands with soap or handwash and water to remove viruses/bacteria/microorganisms, dirt, grease, or other harmful and unwanted substances stuck to the hands) and change gloves during cooking and tray line assembly. These deficient practices had the potential to result in pathogen (germ) exposure to residents, which could place the residents at risk for developing foodborne illness ([food poisoning] with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever) and can lead to other serious medical complications and…

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 resident or resident's representative was informed in advance of the treatment risks and benefits, options, and alternatives by a physician or other practitioner or professional for the use of antipsychotic medication (a class of drugs used to treat mental health conditions characterized by psychosis [mental health condition characterized by a loss of contact with reality], such as schizophrenia [a mental illness that is characterized by disturbances in thought ] and bipolar disorder [extreme mood swings that include mania {emotional highs} and depression { mood disorder that causes a persistent feeling of sadness and loss of interest } which may lead to impaired functioning]) for one of five sampled residents (Resident 14). This failure had the potential to affect Resident 14's right to direct their own medical treatment. Findings: During a review of Resident 14's admission Record, the admission record indicated Resident was…

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 accurate assessment of the Minimum Data Set (MDS, a resident assessment tool) for one (1) of three (3) sampled residents (Resident 84) by failing to include the resident's correct discharge status. This failure resulted in the facility's inaccurate MDS and care screening tool reporting to the Centers for Medicare & Medicaid Services (CMS). Findings: During a review of Resident 84's Physician's Orders, dated 12/12/2024, the Physician's Orders indicated Resident 84 will be discharged home on [DATE] with home health. During a review of Resident 84's Notice of Transfer/Discharge form, dated 12/13/2024, the Notice of Transfer/Discharge indicated that Resident 84 was discharged to home. During a review of Resident 84's Post Discharge Plan of Care, dated 12/13/2024, the Post Discharge Plan of Care indicated Resident 84 was discharged /transferred to home on [DATE]. During a review of Resident 84's Physician's Discharge summary, dated [DATE], 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 the completion and implementation of the baseline care plan within 48 hours of the resident's admission for one of one sampled resident (Resident 14). This failure had the potential to affect Resident 14's health and safety by not promoting continuity of care and communication among the nursing home staff regarding the initial plan for delivery of care and services. Findings: During a review of Resident 14's admission Record, the admission Record indicated Resident 14 was admitted on dated 11/15/2024. Resident 14's diagnoses included dementia (a general term for a group of brain disorders that cause a gradual decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), psychotic disturbance (also known as psychosis [mental health condition characterized by a loss of contact with reality]), and mood disturbance. During a review of Resident 14's physician order, dated 11/15/2024, the physician order 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 two (2) of 18 sampled residents (Resident 15 and 73) were provided and were using a communication board (a sheet of symbols, pictures or photos that the resident can point to, to communicate with the staff) when the resident needed assistance. This deficient practice had the potential for a delay in the necessary care and services for Resident 15 and 73. Findings: 1.During a review of Resident 15 admission Record, the admission Record indicated resident was originally admitted on [DATE] and was readmitted on [DATE] with the following diagnoses of muscle wasting and atrophy and fracture of second lumbar vertebra (point of the spinal cord [bundle of nerves and tissues]). During a review of Resident 15 Minimum Data Set (MDS - a resident assessment tool), dated 12/12/2024, the MDS indicated resident was moderately impaired with cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS 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 (Resident 44) was provided care and services to maintain good grooming and personal hygiene. This deficient practice had the potential to result in a negative impact on Resident 44 's self-esteem. Findings: During a review of Resident 44's admission Record, the admission Record indicated Resident 44 was admitted to the facility on [DATE] with Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement, chiefly affecting middle-aged and elderly people), hypertensive (high blood pressure) heart disease without heart failure, and muscle weakness. During a review of Resident 44's Minimum Data Set (MDS- resident assessment tool), dated 11/14/24, the MDS indicated Resident 44 was independent with cognitive (a mental process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 44 required…

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 ensure 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 one (1) of 1 sampled residents (Residents 15), in accordance with the facility's Pressure Injury (painful wound caused as a result of pressure or friction) policy and procedure (P&P). This deficient practice had the potential for Resident 15 to have worsening stage 4 pressure ulcer (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) which can negatively affect resident's overall well-being.) Findings: During a review of Resident 15's admission Record, the admission record indicated Resident 15 was admitted to the facility on [DATE] and re- admitted on [DATE]. Resident 15's diagnoses included sick sinus syndrome (SSS, is a disease in which the heart'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 keep the foley catheter bag (bag that collects urine that drains through the urinary catheter [a hollow tube inserted into the bladder to drain or collect urine]) below the level of the bladder for one of two sampled residents (Resident 15), in accordance with the facility's policy. This deficient practice had the potential for Resident 15 to develop urinary tract infection (UTI - an infection in the bladder/urinary tract) due to urine back flow. Findings: During a review of Resident 15 admission Record, the admission Record indicated resident was originally admitted on [DATE] and was readmitted on [DATE] with the following diagnoses of muscle wasting and atrophy and fracture of second lumbar vertebra (point of the spinal cord [bundle of nerves and tissues]). During a review of Resident 15 Minimum Data Set (MDS - a resident assessment tool), dated 12/12/2024, the MDS indicated resident was moderately impaired with cognitive (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.

Based on observation, interview and record review, the facility failed to administer Metformin hydrochloride (medication used to treat high blood sugar levels that are caused by DM type 2 [a disorder characterized by difficulty in blood sugar control and wound healing]) within one hour of the prescribed time in accordance with the physician's order for one (Resident 23) of three (3) sampled residents. This deficient practice had the potential to result in ineffectively managing Resident 23's medical condition, which could result to harm, hospitalization, and death. Findings: During a review of Resident 23's admission Record, the admission Record indicated Resident 23 was admitted by the facility on 2/3/2024 with diagnoses that included but not limited to DM, cerebral infarction (a medical condition where blood flow to the brain is interrupted, leading to damage or death of brain tissue), dysphagia (difficulty swallowing), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body). During a review of Resident 23's Minimum Data Set (MDS-a resident assessment…

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 laboratory orders were done for one of 18 sampled residents (Resident 14). This failure had the potential to result in Resident 14's delayed treatment and increased risk of complications, such as another heart attacks or strokes if high cholesterol remains undetected. Findings: During a review of Resident 14's admission Record, the admission Record indicated Resident 14 was admitted on dated 11/15/2024. Resident 14's diagnoses included hypertensive heart disease (HHD - a condition that occurs when the heart is damaged by long-term high blood pressure) without heart failure, and hyperlipidemia (a medical condition characterized by elevated levels of fats in the bloodstream). During a review of Resident 14's physician's orders, dated 11/15/2024, the physician orders indicated pravastatin sodium (a drug to lower the amount of cholesterol in the blood and to prevent stroke and heart attack) 40 milligrams (mg - a unit of measurement) one tablet at bedtime. During a review of Resident 14's Consultant…

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 food that accommodated resident's preference was provided for one of 18 sampled residents (Resident 9). This deficient practice had the potential for resident's poor meal intake which could lead to weight loss. Findings: During a review of Resident 9's admission Record, the admission Record indicated resident was admitted on [DATE] with the following diagnoses of dysphagia (difficulty swallowing) and dementia (a progressive state of decline in mental abilities). During a review of Resident 9's Physician Orders, dated 11/25/2024, the Physician Orders indicated low sodium, low fat and low cholesterol diet dysphagia pureed (a smooth, creamy substance made of liquidized food) meat and vegetables with lunch and dinner with thin liquids (liquid that is thin and easy to pour such as water), no cold drinks, no beef and no milk. During a review of Resident 9's Care Plan with focus indicating family brings food from outside, dated 1/2025,…

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 meal trays were served timely for two (2) of 2 sampled residents (Residents 287 and 38) when Resident 287 and Resident 38 were served lunch at 12:45 PM and 12:47 PM respectively. This deficient practice resulted in residents receiving meals late and had the potential to negatively affect the psychosocial wellbeing of the residents. Findings: 1. During a review of Resident 287's admission Record, the admission Record indicated the facility admitted Resident 287 on 1/8/2025 with diagnoses that included but not limited to colon cancer (cancerous tumor that develops in the colon), presence of gastrostomy (surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) and colostomy (a surgical procedure that creates an opening in the abdomen to divert stool away from the colon or rectum. This opening, called a stoma, is where a bag is placed to collect…

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 that the nurses were documenting the complete orthostatic blood pressure (the measurement of blood pressure when a person stands up from a sitting or lying position) for the lying position for one of 18 sampled residents (Resident 14). This failure had the potential to result in Resident 14's orthostatic BP lying a risk for fall incident from hypotension (a medical condition characterized by abnormally low blood pressure) or from dizziness. Findings: During a review of Resident 14's admission Record, the admission Record indicated Resident 14 was admitted on dated 11/15/2024. Resident 14's diagnoses included dementia (a general term for a group of brain disorders that cause a gradual decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), psychotic disturbance (also known as psychosis [mental health condition characterized by a loss of contact with reality]), and mood disturbance. During a review of Resident 14's physician order, dated 11/15/2024, the physician order…

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 facility staff doff (take off) Personal Protective Equipment (PPE; protective clothing, goggles, or other garments to prevent or minimize exposure to and spread of infection or illness) and perform hand hygiene (cleaning hands to prevent germs) after providing peri-care (cleaning the genitals and anal area) for one of 18 sampled residents (Resident 15), in accordance with the policy. This deficient practice has the potential to spread infection to staff and residents. Findings: During a review of Resident 15's admission Record, the admission Record indicated resident was originally admitted on [DATE] and was readmitted on [DATE] with the following diagnoses of muscle wasting and atrophy and fracture of second lumbar vertebra (point of the spinal cord [bundle of nerves and tissues]). During a review of Resident 15 Minimum Data Set (MDS - a resident assessment tool), dated 12/12/2024, the MDS indicated resident was moderately…

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 a safe, functional, sanitary and comfortable environment by failing to ensure there was no water leak in the kitchen ceiling from 1/26/2025 to 1/27/2025. This deficient practice had the potential to result in unsafe and non-functional kitchen. Findings: During an initial observation in the kitchen on 1/27/2025 at 7:48 AM, there were moderate amount of water on the floor near the dishwashing area. There was a wet/dry vacuum (a specialized piece of cleaning equipment designed to handle both wet and dry debris pickup) in the middle of the area and suctioning water from the floor. There were rolled bed sheets placed on the floor surrounding the puddle of water t. During a concurrent observation in the kitchen and interview with Dietary Supervisor (DTS) on 1/27/2025 at 8:23 AM, DTS stated, there is a puddle of water on the floor near the dishwashing area and it is coming form the leak from the ceiling. During an interview with Maintenance Supervisor (MTS) on 1/27/2025 at 12:41 PM, MTS stated, the metal…

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 keep accurate documentation in the medical records for 1 of 2 sampled residents by having a Certified Nursing Assistant (CNA) administer a topical cream and a Licensed Vocational Nurse (LVN) documenting the administered topical cream in the Treatment Administration Record (TAR - is a report detailing the treatments administered to a resident by a licensed professional). This deficient practice had the potential to negatively impact the delivery of services. Findings: During a review of Resident 1's admission Record indicated resident was admitted on [DATE] and is readmitted on [DATE] with the following diagnosis of quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury) and multiple sclerosis (MS - a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment 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 follow their policy to ensure proper disposal of medication for one (1) of two (2) sampled residents (Resident 1). As a result, Resident 1's medication that was still in use have been disposed. Findings: During a review of Resident 1's admission Record indicated resident was admitted on [DATE] with the following diagnosis of hypertensive heart disease (changes in the heart structure that results in chronic blood pressure elevation) with heart failure (HF - occurs when the heart muscle doesn't pump blood as well as it should) and atherosclerotic heart disease (plaque buildup in artery walls). During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 8/1/2024, indicated resident is independent in cognitive skills (ability to understand and make decisions) for daily decision making. The MDS also indicated resident required supervision or touching assistance (helper provides verbal cues 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 provide a written notice of bed hold (a resident's right to keep a bed vacant and available for seven days after their transfer to the hospital in anticipation of their return to the facility) policy during the resident's transfer to the General Acute Care Hospital (GACH) on 9/29/2024 for one of one sampled resident (Resident 1) in accordance with the facility's policy and procedure. This deficient practice violated the resident to make informed decisions and receive information of their rights to have the bed hold and return to the facility from the GACH or therapeutic leave. Findings: During review of the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] with diagnoses that included unspecified fracture (a break or crack in a bone, whether partial or complete) of the right lower leg and left lower leg, abnormalities of gait and mobility (gait refers to the pattern of walking or running, while mobility refers 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: 1. Failed to have a process in place and include in their policy and procedure for Medications Brought to the Facility by the Resident/Family (dated April 2007) and Bedside storage of medications (dated September 2010) the handling and management of Resident 1's Ozempic (an injectable medication used to help manage type 2 diabetes mellitus [high blood sugar]) brought in by the Resident 1's family, being stored at bedside and administered by the facility's nursing staff. 2. Failed to ensure licensed nurse documented the injection site for 1 of 4 Ozempic injections (administered on 8/14/2024) that Resident 1 received on August 2024. 3. Failed to ensure two (2) expired medications and discontinued medications of discharged residents would be stored and discarded as per facility's policy. 4. Failed to document the temperature monitoring of a medication refrigerator located in the infection preventionist's office for 30 out of 62 days in July and…

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 Registered Nurse (RN) 1 was competent and skilled to administer medication via injection to one of three sampled residents (Resident 1) in accordance with the facility's policy and procedure. As a result, RN 1 instructed Resident 1 to administer his own medication, Humalog (insulin, medication that helps treat diabetes) and had the potential for Resident 1 to not receive the medication properly. Findings: A review of Resident 1's admission Record, indicated resident was originally admitted on [DATE] and was readmitted on [DATE] with the following diagnoses of diabetes mellitus (a group of diseases that result in too much sugar in the blood) and legal blindness. A review of Resident 1's History and Physical, dated 10/4/2023, indicated resident has the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS; a standardized care screening and assessment tool), dated 5/2/2024, indicated resident is independent 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy to ensure one of three sampled residents (Resident 1) did not self- administer his Humalog (medication for diabetes [a group of diseases that result in too much sugar in the blood]) injection. As a result, Resident 1 administered his own medication and had the potential for Resident 1 to not receive the medication properly. Findings: A review of Resident 1's admission Record, indicated resident was originally admitted on [DATE] and was readmitted on [DATE] with the following diagnoses of diabetes mellitus and legal blindness. A review of Resident 1's History and Physical, dated 10/4/2023, indicated resident has the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS; a standardized care screening and assessment tool), dated 5/2/2024, indicated resident is independent in cognitive skills for daily decision making. The MDS also indicated resident is independent (resident completes the activity by…

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 one of three sampled residents (Resident 1) or Resident 1's Representative, a copy of the resident's medical records upon request and within two working days from notice in accordance with the facility's policy. This deficient practice violated Resident 1's /Resident 1's representative right to have access to resident's personal and medical records. Findings: A review of the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included but not limited to urinary tract infection (an infection in any part of the urinary system), chronic obstructive pulmonary disease ( recurrent inflammatory lung disease that causes obstructed airflow from the lungs), pneumonia (an infection of one or both of the lungs caused by bacteria, viruses, or fungi), and unspecified asthma (a disease in the lungs become narrowed and swollen, making it difficult to breathe). A review of…

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 an environment free of accident hazards for two out of three sampled residents (Residents 43 and 22) for the accidents care area: a. Certified Nurse Assistant 1 (CNA 1) did not lower the height of Resident 43's bed prior to exiting resident's room. b. Ensure Resident 22's sensor pad alarm (an alarm used to detect motion and are designed to notify caregivers if the resident is getting out of the bed or wheelchair or moving about and need assistance) worked at all times. These deficient practices had the potential to result in Resident 43 and 22 sustaining an injury such as a fall (an unintentional coming to rest on the ground) and complications that could occur because of a fall. Findings: 1. A review of Resident 43's admission Record indicated resident was admitted at the facility on 8/24/2023 with diagnoses that included muscle wasting (a decrease and wasting of muscle tissue) and osteoporosis (a medical condition in which 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 observation, interview, and record review, the facility failed to follow its policy and procedure on storage and disposal of medication as evidenced by: 1. Opened probiotic (widely regarded as live microorganisms that, when administered in sufficient amounts, confer a health benefit) bottle was not stored in the refrigerator, as per manufacturer's instructions medication cart 1 (MC1). This deficient practice had the potential for residents to be exposed to adverse side effects such as allergic reaction, like rash, itching, severe dizziness and trouble breathing in the event a resident ingests the unrefrigerated probiotic. 2. Hospice Comfort kit (prescribed medications used to treat end-of-life symptoms, such as pain and nausea) of a Resident who has already been discharged , which contained acetaminophen (drug used to relieve mild or chronic pain and to reduce fever) suppositories (a solid but readily meltable cone or cylinder of usually medicated material for insertion into a bodily passage or cavity…

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 storage, preparation and distribution of food was performed under sanitary conditions for ninety-eight (98) residents of the facility according to the policy and procedure by not labeling food and perishables to indicate the received, opened, use by, and expiration dates. This deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead hospitalization. Findings: During concurrent observation and interview with the Dietary Staff Supervisor (DSS) on 3/5/2024 at 7:50 AM, DSS confirmed there was no use by date on the Hungarian style paprika container. The DSS stated once the Hungarian style paprika container was open, the contents were only good for 6 months. During a concurrent observation and interview with DSS 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 properly dispose food waste products into a covered trash bin located under the food preparation (prep) table as indicated on the facility policy. This failure had the potential to attract and spread vermin (animals that are believed to be harmful or that carry disease, e.g., rodents, parasitic worms, or insects) that could potentially infiltrate the facility, affect the resident care areas, and pose a disease threat to residents of the facility. Findings: During an observation on 3/5/2024 at 8:14 AM, a trash can bin was observed under the food prep station table. The trash bin was not covered, and trash can lid was on the floor. During an interview with the dietary staff supervisor (DSS) on 3/5/2024 at 8:15 AM, DSS confirmed the trash can was not covered and stated, the trash can should be covered to prevent any type of contamination to the food being prepared. During a concurrent observation and interview of the kitchen food prep station on 3/5/2024 at 11:29 AM, the trash bin was still uncovered. 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.

Based on observation, interview, and record review, the facility failed to remove the lint from the dryer lint catcher for two (2) of three (3) dryers as indicated in the facility's Maintenance and Cleaning Laundry policy, This deficient practice had the potential to cause fire in the facility. Findings: During a concurrent observation of the laundry room and interview with Laundry Staff (LS) as translated by the Central Supply Manager (CSM), on 3/7/2024, at 4:27 PM, four (4) dryers were observed in the dryer room. Dryer 3 had linen inside and was running. LS stated Dryer 4 was new and has not been used. LS removed the lint catchers from the bottom of Dryers 1 and 2. Lint was observed on both lint catchers. LS stated lint should be removed from lint catcher every 2 hours. LS stated she did not and should have removed the lint from Dryer 1 and 2 at 4 PM, as scheduled. During a concurrent record review of the Dryer Lint Clean Out Schedule, dated 3/1/2024 and interview with LS on 3/7/2024, at 4:31 PM, LS verified the Dryer Lint Clean Out Schedule indicated a scheduled lint removal time…

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 residents' clinical record were updated with a copy of the resident's advance directives (a written statement of a resident's wishes regarding medical treatment made to ensure those wishes are carried out should the resident be unable to communicate them to a physician) for two (2) of eight (8) sampled residents (Residents 74 and 79) for advance directives care area, in accordance with the facility Advance Directives policy. This deficient practice had the potential to cause conflict in carrying out the resident's wishes for medical treatment and health care decisions. Findings: 1. A review of Resident 74's admission Record indicated Resident 74 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (a disease that occurs when the blood sugar is too high), hypertensive heart disease (HTN, high blood pressure), and adult failure to thrive (a decline in older adults that shows as a downward spiral of health…

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 inform two of 22 sampled residents (Residents 47 and 80) of their potential financial liability (the state of being responsible for something) after exhausting their Medicare Part A (insurance which covers inpatient hospital care, skilled nursing facility [SNF], hospice [focuses on the care, comfort, and quality of life of a resident with serious illness, who is approaching the end of life], lab tests, surgery, home health care [wide range of health care services that can be given in the resident's home for an illness or injury]). SNF benefit (Medicare coverage in a SNF) by not providing the SNF Advance Beneficiary Notice of Non-coverage (SNFABN, notice of liability form) at least 48 hours of the last anticipated covered day, in accordance with the facility's policy on Medicare Advance Beneficiary (a person or thing that receives help or an advantage from something) and Medicare Non-Coverage Notices. This deficient practice had the potential for 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 develop a resident-centered comprehensive care plan (a care plan developed and implemented to meet his or her preferences and goals, and addressed the resident's medical, physical, mental, and psychosocial needs) for one (1) of 22 sampled residents (Resident 80) after the resident was hospitalized for gastrostomy tube (g- tube, a flexible tube surgically inserted through the wall of the abdomen directly into the stomach for feeding, fluid, and medication administration) dislodgement. This deficient practice had the potential to result in future g-tube dislodgement and had the potential to result in a lack of or delay in delivery of necessary care and services for Resident 80. Findings: A review of Resident 80's admission record indicated Resident 80 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included dysphagia (difficulty or discomfort in swallowing), hypotension (low blood pressure),…

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 interview and record review, the facility failed to ensure one of 22 sampled residents (Resident 52) was free from an unnecessary drug (any drug when used without adequate indications for its use) in accordance with the facility policy by failing to have the accurate indication for the use of propranolol (medication to treat high blood pressure and also used to treat certain types of tremors) 10 milligrams (mg, a unit of measurement) by mouth once a day. This deficient practice had the potential to place Resident 52 at risk for significant adverse (harmful) consequences from the use of unnecessary drug. Finding: A review of Resident 52's admission Record indicated an admission to the facility on 4/26/2021, with diagnoses of schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves), major depressive disorder (depression, a mood disorder that causes a persistent feeling of sadness and loss of interest), and hypertensive heart disease (a condition in which a patient has high blood pressure). A review of Resident 52's 11/2023…

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 accurate and complete vital signs (measurements of the body's most basic functions that include body temperature, blood pressure, pulse rate, breaths per minute, and the amount of oxygen circulating in blood, also known as oxygen saturation [level of oxygen in the blood]) were taken for one out of 22 sampled residents (Resident 51) as indicated in the resident's care plan (a form that summarizes and addresses a patient's health care needs and interventions to meet those needs). This failure had the potential for Resident 51 to not have received required medication leading to decline in resident's care. Findings: A review of Resident 51's admission Record indicated Resident 51 was admitted to the facility on [DATE] with diagnoses that included hypertensive heart disease (a condition in which a patient has high blood pressure) with heart failure (a lifelong condition in which the heart cannot pump enough blood to meet the body'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 one out of 22 sampled residents, (Resident 62) had their call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) within the resident's reach (an arm's length). This failure had the potential for Resident 62's needs to be met in a safe and timely manner. Findings: A review of Resident 62's face admission Record indicated Resident 62 was admitted to the facility on [DATE]. Resident 62's diagnoses included epilepsy (a disorder that causes recurring seizures, sudden uncontrolled burst of electrical activity in the brain that can cause changes in behavior, movements, feelings, and levels of consciousness) and hypertensive heart disease (a condition in which a patient has high blood pressure). A review of Resident 62's History and Physical (H&P) dated 10/14/2023, indicated Resident 62 have fluctuating (rising and falling irregularly in number or amount) capacity to understand and 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 interview, and record review, the facility failed to ensure one of two registered nurse (RN 1) was competent with the administration of Ozempic (a weekly injection that helps lower blood sugar) in accordance with the facility's policy and procedure. This deficient practice had the potential for Resident 3 to not receive the prescribed medication which can result to uncontrolled blood sugar level and adverse reactions. Findings: A review of Resident 3's admission Record indicated Resident 3 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included anemia (condition where the body does not have enough healthy red blood cells), type 2 diabetes mellitus (a disease that occurs when the blood sugar is too high), and systolic congestive heart failure (when the left bottom chamber of the heart is weak and cannot contract normally when the heart beats). A review of Resident 3's Initial History and Physical (H&P), dated 10/14/2023, indicated Resident 3 had 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 provide a safe and sanitary environment by failing to ensure Housekeeping (HKP) Staff doff (remove) personal protective equipment (PPE- gowns, gloves, N95 masks [respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles], and face shields worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) before leaving Resident 4 and Resident 5's room. This deficient practice had the potential to result in the spread of Coronavirus (COVID-19, a respiratory illness caused by a virus that can spread from person to person) to residents and staff that could cause respiratory illness, hospitalization, and death. Findings: 1. A review of Resident 4's admission Record indicated Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included type 2 diabetes mellitus (a disease that occurs when the blood…

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 pharmaceutical services to one of two sampled residents (Resident 1) when: a. License Vocational Nurse (LVN1) administered Ozempic (a weekly injection that helps lower blood sugar) pen to Resident 1 with cap on. b. Registered Nurse Supervisor (RN Sup) and Physician Assistant (PA) attempted to give Resident 1's a medication that is not labeled with patient's name. c. Charge Nurse (CN) left insulin syringe (a device used to inject solutions into the body) on Resident 1 roommates' food tray. These deficient practices had the placed Resident 1 at risk for side effects of skipping a medication dose and potentially result in uncontrolled blood sugars or weight gain. In addition, it places Resident 1 at risk for receiving the wrong medication if medication was not verified by residents' name. Insulin syringe left could result in a needlestick injury (accidentally poking with used needle) for a resident or a staff. Finding: During a record review…

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 one of two sampled residents (Resident 1) with meals that accommodated the resident's food preferences by failing to ensure no watermelon is included in Resident 1's food tray. The deficient practice had the potential to alter Residents 1's nutritional status. Findings: During a record 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 with unspecified complications (is a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), morbid severe obesity (weight is more than 80 to 100 pounds above their ideal body weight) due to excess calories and difficulty in walking. During a record review of Resident 1's History and Physical dated 2/25/23 indicated Resident 1 had the capacity to understand and make own decisions. During a record review of Resident 1's Minimum Data Set (MDS- 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.