Huntington Drive Health And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide oxygen therapy (treatment that provides supplemental, or extra oxygen) as indicated on the physician's order for two (2) of two sampled residents (Resident 71 and 15) reviewed for respiratory/oxygen. This deficient practice had the potential to place Resident 71 and 15 at risk for shortness of breath and/or hypoxia (low levels of oxygen in the body tissues) which could lead to irreversible damages of health and/or death. Findings:1. During a review of Resident 71's admission Record, the admission Record indicated Resident 71 was admitted to the facility on [DATE] and re-admitted on [DATE]. The admission record indicated Resident 71's diagnoses included respiratory failure (a serious condition that makes it difficult to breathe on your respiratory system [organs/ structures in the body that allow you to breath such as lungs]), pulmonary edema (when fluid collects in the air sacs of the lungs, making it difficult to breathe) 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.

Based on interview and record review, the facility failed to ensure competencies and skills sets to provide nursing and related services were completed for two (2) of four (4) nursing staff in accordance with the facility assessment and policy and procedures (P&P). This deficient practice had the potential to cause increased risk for improper resident assessments, and inadequate documentation which could negatively impact the quality of care provided to the residents.Findings: 1. During a concurrent interview and record review on 2/25/2026 at 2:26 PM with Director of Staff Development (DSD), Treatment Nurse (TN1, a licensed vocational nurse) employee records were reviewed. DSD stated TN 1 was hired on 10/17/2022. DSD stated TN1 did not have documented evidence of completed competency and training for Foley catheter (tube that drains urine from the bladder into a drainage bag) care. During an interview on 2/25/2026 at 2:06 PM with TN 1, TN 1 stated she was not evaluated for Foley catheter care. During an interview on 2/25/2026 at 2:19 PM with TN 2, TN 2 stated she does not remember…

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, staff interviews, and review of facility records, the facility failed to correctly measure the calorie and sugar content of breakfast meals for 14 of 14 residents who were ordered to receive a fortified diet (an enhanced meal meant to provide extra protein, calories, and nutrients).This deficient practice had the potential for residents on fortified diet to not receive the increased nutrients, protein and calories required which could result in malnutrition or weight loss.Findings:During a review of the facility's menu from 2/22/2026 to 2/28/2026, the menu indicated hot or cold cereal was served for breakfast on 2/24/2026.During a review of the facility's menu, titled, Super Cereal (fortified cream of wheat), the menu indicated the following ingredients:Evaporated milk 5/8 cup (c)Water 1 1/8 quart (qt- unit of measurement for volume of liquid)Dry milk powder 1/2 cRolled oats 2 1/2 cEvaporated milk 1 3/4 cMargarine 1 1/4 cLight brown sugar 10 ounce (oz- unit of measurement for weight in cooking)Granulated sugar 3/4 cDuring a review of the facility's menu,…

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, record review, facility failed to provide food that accommodated food preferences and offer meal substitutes of the same nutritive values for two (2) of two sampled residents (Resident 107 and Resident 75) reviewed for food. This deficient practice had the potential to result in decreased meal intake and can lead to weight loss and malnutrition (when the body does not get the right amount of nutrients, either too little or too much, causing health problems).Findings:During a review of Resident 107's admission Record, the admission Record indicated Resident 107 was admitted to the facility on [DATE] with diagnoses that included displaced midcervical fracture of right femur (injury where the neck of the upper thigh bone is broken and misaligned), abnormalities of gait and mobility (change from a normal, smooth, and effortless walking pattern), and muscle weakness. During a review of Resident 107's Minimum Data Set (MDS- a resident assessment tool), dated 2/23/2026, 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.

Based on observation, interview, and record review, the facility failed to prepare and store food in a sanitary manner in accordance with facility policy by failing to ensure:Soaps and cleaning solutions were not combined with food items.Kitchen equipment and surfaces were free from food debris and cleaned after use.Food items stored in the refrigerator were labeled and dated.Opened food item in the freezer was properly sealed.Multiple clear bags of brown bread in the dry storage room were labeled.Dietary [NAME] (DC) changed gloves and performed hand hygiene in between documentation, checking the food temperature during the tray line assembly, food preparation, and before serving the residents' meal trays.DC's apron did not come in contact with the residents' clean plates and DC did not touch the center of the clean plates during tray line assembly. These deficient practices had the potential to result in chemical and pathogen (germ) exposure to residents' food and placed the residents at risk for developing foodborne illness (food poisoning- any illness resulting from consuming…

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 safe, clean, comfortable sanitary and home-like environment for three (3) of four (4) sampled residents (Resident 15, 29 and 37) reviewed for environment by failing to ensure: 1.a. Resident 15's room was free of soiled diaper and a used cup containing chocolate on the floor.1.b. Resident 15's electric fan was free of sticky gunk (any thick, sticky, greasy, or slimy substance, often representing unwanted, dirty, or unidentifiable residue). 2. Resident 29's floor was free of used wet wipes. 3. Resident 37's curtain was free of brownish colored stains. These deficient practices caused an unsanitary environment for Resident 15, 29 and 37 and had the potential to result in the spread of diseases and infection.Findings: 1. During a review of Resident 15's admission Record, the admission Record indicated Resident 15 was initially admitted to the facility on [DATE] with diagnosis of type 2 diabetes mellitus (a disease that occurs when…

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 inform one (1) of 22 sampled residents (Resident 86) the risks and benefits of the use of bilateral bedside rails (a metal or plastic bars attached to the sides of the bed) in accordance with the facility's policy. This deficient practice had the potential for Resident 86 not to be able to exercise their right to choose his treatment plan.Findings: During a review of Resident 86's admission Record, the admission Record indicated Resident 86 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included epilepsy (brain activity that cause sudden uncontrollable electrical disturbance in the brain and sometimes loss of awareness), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (a medical condition that occurs when brain tissue dies due to a lack of 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 ensure a Level 1 Preadmission Screening and Resident Review (PASRR, initial screening for all applicants to Medicaid-certified nursing facilities [meets federal and state standards for care and is approved to receive payment from Medicaid {a government health insurance program that provides free or low-cost coverage to eligible low-income individuals and families} for services provided to eligible residents] for possible serious mental disorder [MD, a health condition characterized by clinically significant alterations in thinking, mood, or behavior associated with distress and/or impaired functioning], intellectual disability [ID, a condition characterized by significantly subaverage intellectual functioning and substantial limitations in adaptive behavior] or a related condition, which is completed prior to admission to a nursing facility) was completed and was accurate for two (2) of six (6) sampled residents (Resident 71 and 81) reviewed for…

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 staff failed to keep one (1) of six (6) sampled residents (Resident 37) reviewed for Activities of Daily Living (ADLs, are activities related to personal care including bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) face and blanket clean and free of food particles on 2/26/2026, as indicated on the facility's dignity policy. This deficient practice had the potential to result in a negative effect on Resident 37's quality of life and self-esteem.Findings:During a review of Resident 37's admission Record, the admission Record indicated Resident 37 was admitted to the facility on [DATE] and re-admitted on [DATE], Resident 37's diagnoses included epilepsy (a chronic brain disorder characterized by recurrent, unprovoked seizures [are brief episodes of abnormal electrical activity in the brain that can cause a variety of symptoms, including involuntary movements, loss of consciousness, 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 hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) emergency kit (E-Kit, an emergency supply kit used for residents who received hemodialysis) was readily accessible at the bedside for one (1) of two (2) sampled residents (Resident 29) reviewed for dialysis. This failure may result in the inability to manage Resident 29's bleeding from hemodialysis access site in the event of complications such as uncontrolled bleeding.Findings: During a review of Resident 29's admission Record, the admission Record indicated Resident 29 was initially admitted to the facility on [DATE] with diagnosis of type 2 diabetes mellitus (a disease that occurs when there is a problem in the way the body regulates and uses sugar as fuel), hypertension (high blood pressure), dependence on renal dialysis hemodialysis with end-stage renal disease (ESRD, medical condition 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 observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures to ensure the accurate acquiring, administering of drugs and biologicals to meet the needs for two (2) of 22 sampled residents (Residents 89, and 2) in accordance with the facility's policy and procedure (P&P) by failing to ensure: 1. Resident 89's Bactrim double strength ([DS] type of antibiotic medication used to treat infection) tablet 800-160 milligrams (mg-unit of measurement) and Prevymis oral (medicine used to prevent viral infection) tablet 480 mg were not left at bedside.This deficient practice had the potential for Resident 89 not to receive the medication which could delay the resident being free from infection and the deficient practice also increased the risk for diversion (the transfer of a controlled substance or other medication from a lawful to an unlawful channel of distribution or use) and accidental exposure to harmful medications in the event that other residents…

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 anticoagulant therapy ( a medical treatment using drugs, called blood thinners, to prevent or treat dangerous blood clots [thrombi] by slowing down the blood's clotting process, stopping existing clots from growing, and preventing new ones from forming) for one (1) of five (5) sampled residents (Residents71) reviewed for unnecessary medications, in accordance with the facility's policy and the resident's care plan by failing to monitor resident for side effects of anticoagulant medication, bruising, bleeding, and hematoma (localized collection of blood outside a blood vessel that has leaked into surrounding tissues and clotted). This deficient practice had the potential for Resident 71 to experience complications from the use of anticoagulant therapy which could place the resident at risk for injury and harm.Findings:During a review of Resident 71's admission Record, the admission Record indicated Resident 71 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.

Based on observation, interview, and record review, the facility failed to ensure one (1) of one trash can was covered with a lid while not in use in accordance with the facility's policy and procedure (P&P). This deficient practice had the potential to spread odors and bacteria (germ), cause contamination (presence of a germs, chemicals, or dirt in a place making it unsafe) and attract vermin (animals that are believed to be harmful, carry diseases such as rodents, parasitic worms, or insects) 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 and interview on 2/23/2026, at 7:47 AM, with the Dietary Supervisor (DS), one large gray trash can was observed next to the steam table (a table with slots to hold food containers which are kept hot by steam). DC confirmed the trash can had trash inside and was not covered with a lid. During an interview on 2/25/2026, at 1:20 PM, with the Registered Dietician (RD), the RD stated trash cans should always be covered for pest…

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 two (2) of 22 sampled residents (Resident 37 and Resident 4) on Enhanced Barrier Precautions (EBP, refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) by failing to ensure:Certified Nursing Assistant 2 (CNA 2) was wearing a gown while providing bed bath and dressing to Resident 37. Licensed Vocational Nurse 1 (LVN 1) changed gloves between tasks and wore a gown while administering medications to Resident 4 via resident's gastrostomy tube (G-tube, is a tube inserted through the belly that brings nutrition directly to the stomach).These deficient practices have potential to place the residents and staff at risk for…

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 maintain documentation of screening, education, offering and current Influenza (a contagious respiratory illness caused by influenza viruses that infect the nose, throat, and lungs) vaccination status for one (1) of four (4) sampled staff member (CNA 1) reviewed for infection prevention, control, and immunizations. This deficient practice had potential to miss potential gaps in identifying, tracking, implementing strategies to increase vaccination rates among staff, which helps to protect vulnerable residents.Findings:During a concurrent interview and record review on 2/25/2026 at 2 PM, Covid-19 and Influenza staff vaccination record for 2026 was reviewed. Infection Prevention Nurse (IPN) stated Certified Nursing Assistant 1 (CNA 1) refused Influenza vaccination but did not have a documentation of the consent which indicated the staff declined both vaccinations. The IPN also stated records of the staff vaccination was to keep track of staffs' vaccination status and to identify staffs who are required to wear mask when 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.

Based on interview and record review, the facility failed to maintain documentation of screening, education, offering and current Coronavirus disease (Covid-19, an infectious disease caused by the SARS-CoV-2 virus that causes respiratory illness primarily affecting lungs and breathing) vaccination status for one (1) of four (4) sampled staff member (CNA 1) reviewed for infection prevention, control, and immunizations. This deficient practice had potential to miss potential gaps in identifying, tracking, implementing strategies to increase vaccination rates among staff, which helps to protect vulnerable residents.Findings: During a concurrent interview and record review on 2/25/2026 at 2 PM, Covid-19 and Influenza staff vaccination record for 2026 was reviewed. Infection Prevention Nurse (IPN) stated Certified Nursing Assistant 1 (CNA 1) refused Covid-19 vaccination but did not have a documentation of the consent which indicated the staff declined both vaccinations. The IPN also stated records of the staff vaccination was to keep track of staffs' vaccination status and to identify…

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 failed to ensure one (1) of two (2) sampled residents (Resident 1) bed rails (are adjustable metal or rigid plastic bars that attaches to the bed) are safe, functional and in good working condition in accordance with the facility's policy. This deficient practice has the potential for Resident 1 to be at risk of injury when getting in and out of bed.Findings:During a review of Resident 1's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses that included lack of coordination (unsteadiness) and abnormalities of gait and mobility (any noticeable change in a person's walking pattern or ability to move around safely and easily). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 1/9/2026, the MDS indicated Resident 1 had severe impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily…

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 treat two (2) of 2 sampled residents (Resident 1 and 2) with respect and dignity when:1) Resident 1 was left sitting on the wheelchair for 2 and half hours while waiting for the resident's clothes and personal belongings left on the resident's bed to be put away on 12/11/2025 when resident was transferred to a new room. Resident 1 was also not provided with a functional television (TV) remote control since 12/11/2025.2) Resident 2 was provided with a TV without the channel of resident's choice since 12/15/2025.These deficient practices had the potential to negatively affect Residents 1 and 2's psychosocial well-being and quality of life.Findings:1. During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included bilateral primary osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of the hip and presence…

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 Restorative Nursing Assistant (RNA- responsible for providing restorative and rehabilitation care for residents/patients to maintain or regain physical, mental, and emotional well-being) services on 12/22/2025, 12/26/2025, and 1/2/2026 for one (1) of 1 sampled resident (Resident 1) with limited range of motion (ROM - movement of the joints) in accordance with the physician's order. This deficient practice had the potential to cause complications such as pain, swelling, and contractures) to Resident 1.Findings: During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included bilateral primary osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of the hip and presence of right artificial knee joint. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 9/11/2025, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide respiratory care services for two (2) of two sampled residents (Resident 1 and 2) in accordance with the facility's policy and procedure by failing to ensure: 1. Resident 1 received oxygen on 11/18/2025 as ordered via nasal cannula (NC, device used to deliver supplemental oxygen placed directly on a resident's nostril). 2. Resident 2's oxygen saturation (level of oxygen found in a person's blood, normal reference= 95-100 %) which was below 92% on 10/4/2025, 10/11/2025 and 10/15/2025 was reported to the physician per physician's order.These deficient practices have the potential to place Resident 1 and 2 at risk for shortness of breath and/or hypoxia (low levels of oxygen in the body tissues) which could lead to irreversible health damages and/or death.Findings:1. During a review of Resident 1's admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included acute…

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 the physical environment in a safe and sanitary condition by failing to ensure there was no water leak in the facility ceiling from 11/15/2025 to 11/18/2025 by failing to:Ensure there was no water leak in the ceiling at the hallway in front of the oxygen room from 11/15/2025 to 11/16/2025.Ensure there was no water leak in the ceiling of Resident 4's room.This deficient practice had the potential to cause harm by creating slip hazards, increase the risk for mold growth and compromise the safety and comfort of residents, staff and visitors. Findings: 1. During an observation of the facility's ceiling in the hallway in front of oxygen room on 11/17/2025 at 6:33 AM, the ceiling was observed with a large hole with visible water damage. The water leaked from the damaged area, into a large gray bin that was placed underneath to catch the water. Towels were placed on the floor around the large gray bin.During a concurrent interview 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure staff followed the facility's policy and procedures (P&P) titled Indwelling (Foley) Catheter Insertion, Female Resident for one (1) of three (3) sampled residents ( Resident 1) by not documenting the indication for Foley catheter (tube that drains urine from the bladder (organ that collects and stores urine ) into a drainage bag) use as required by the P&P. This failure had the potential to cause harm by increasing the risk of infection, improper catheter use, and inadequate monitoring of the resident condition. Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] with diagnosis which included hypertension (high blood pressure), osteoarthritis (the cartilage within a joint begins to break down and the underlying bone begins to change causing reduced function and disability), lack of coordination. During a review of Resident 1's Minimum Data Set (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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to document an episode of dizziness for one (1) of two (2) sampled residents (Residents 1) who experienced change with condition in the resident's nurses' progress notes (nurses detailed, day-to-day journal about patient care) in accordance with the facility's policy and procedure (P&P) titled, Charting and Documentation. This deficient practice resulted in the medical records inaccurate representation of care provided and placed Resident 1 at risk of complications.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 was readmitted on [DATE] with diagnoses that included 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 infarction (damage to tissues in the brain due to a loss of oxygen to the area) affecting left non-dominant (weaker)…

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 two (2) of 3 residents (Residents 2 and 3) based on the facility's policy by failing to: 1. Ensure Resident 2's privacy curtain was closed and the resident's (a movable fabric barrier designed to provide a private enclosure and block views, commonly used in healthcare settings like hospitals and nursing homes to create patient seclusion) inner thighs were covered and were not exposed while the resident was lying on his bed on 8/11/2025.2. Accommodate Resident 3's request to be gentle when providing perineal care (cleaning the private areas of a resident) from Certified Nursing Assistant 1 (CNA 1). This deficient practice had the potential to affect Resident 2 and 3'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 2's admission Record, the admission record indicated Resident 2 was admitted to the facility 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a safe and sanitary environment for two (2) out of three (3) sampled residents (Residents 1 and 2) in accordance with the facility's Infection Control and Pet Programs policies. This deficient practice had the potential to put Resident 1 and 2 at risk of being exposed to potential health and safety risks which include infection. During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included type 2 Diabetes (a disease in which your body does not produce enough insulin needed to control sugar levels in the blood), and liver cancer. During a review of Resident 1's History and Physical (H&P) dated 7/21/2025, the H&P indicated that Resident 1 has the capacity to understand and make decisions. During a review of Resident 2's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included…

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 (2) sampled residents (Resident 1) was free from unnecessary drugs (medications used in situations where they are not providing adequate benefit to the patient/ reisdent, or may even be causing harm) by failing to monitor Resident 1's hours of sleep for the use of Ambien (drug used to treat [insomnia-inability to sleep]) 5 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) the physician ordered for insomnia. This deficient practice had the potential to result in unnecessary use of the Ambien for Resident 1 and could cause delayed provision of necessary care and services. Findings:During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included insomnia and anxiety disorder (a mental health disorder characterized by feeling of worry, or fear that are strong enough to interfere with one'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 document assessment, notify attending physician (MD), do a Change of Condition (CoC) and monitor the CoC for one of two sampled residents (Resident 1) in accordance with the facility's Change in a Resident's Condition policy after Resident 1 reported that the resident hit her head while in the bathroom to the Director of Staff Development (DSD) on 6/30/2025. This deficient practice had the potential to cause Resident 1 to have delayed treatment, untreated injury and worsening injury. Findings:During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (loss of blood flow to a part of the brain) and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 4/7/2025, the MDS indicated the resident was assessed to have intact…

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 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) to prevent falls (unintentionally coming to rest on the ground, floor, or other lower level but not as a result of an external force) for one of three residents (Resident 1). Resident 1's care plan did not indicate the type of assistance facility staff needed to safely provide incontinent care (support and management provided to individuals experiencing involuntary loss of urine of stool) for Resident 1 who had a history of fall, had bilateral (both) leg weakness, and was on a low air loss mattress (LALM- an air mattress covered with tiny holes designed to distribute the resident's body weight over a broad surface area to help prevent skin breakdown). This deficient practice resulted in Resident 1 suffering a witnessed fall while Certified…

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 ensure one of two sampled residents (Resident 1) was treated with respect and dignity in accordance with the facility policy by failing to allow the resident to voice grievances (statement of complaint over something believed to be wrong or unfair) without discrimination (to treat that person differently or less favorably) or reprisal (the act of retaliation). This deficient practice has the potential for Resident 1 to not voice future grievances and affect the resident's self-worth and self-esteem. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted on [DATE] and was readmitted on [DATE] with the following diagnoses of major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or the inability to move on one side of 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 10 of 43 resident rooms (Rooms: A, B, C, D, E, F, G, H, I, and J) were free of chipped/ peeling paint and unpainted patched areas in accordance with the facility policy. This deficient practice had the potential for unsafe and unclean resident's environment with the potential to place residents at risk for physical discomfort. Findings: During an observation on 1/14/2025 at 8:06 AM, the wall on the head part of two beds in the middle of Room B had white patched area over the old paint measuring approximately 16 inches x 11 inches. During an observation on 1/14/2025 at 3:36 PM, the wall directly behind the head part of the bed in Room C had a large white patched area over the old paint measuring approximately 5 feet x 1.5 feet. The foot part had a large white patched area over the old paint measuring approximately 14 inches x 12 inches. During an observation on 1/15/2025 at 9:42 AM, the wall on the right side close to Bed-2 in Room D had a large white patched area over the old paint measuring…

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 ensure: 1. Opened food items were labeled with used by date. 2. To discard expired food in the kitchen. These deficient practices have 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 to other serious medical complications and hospitalization. Findings: During a concurrent initial kitchen tour observation and interview with Dietary Supervisor (DS) on 1/14/2025 at 7:48 AM, DS stated several expired and opened items as follows did not have a proper label of open date and used by date: a. One (1) opened bottle of seasoning salt with label date of 1/9/2025. b. 1 opened bottle of ginger ground with label date of 3/4/2024. c. 1 opened bottle of pure vegetable oil with label date of 1/7/2025. d. 1 opened bottle of browning…

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 staff followed the facility's enhanced barrier precautions (EBP- refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs-bacteria that have become resistant to certain antibiotics and these antibiotics can no longer be used to control or kill the bacteria] that employs targeted gown and glove use during high contact resident care activities) and standard precautions (a set of infection control practices used to prevent the spread of diseases), and perform handwashing/hand hygiene (cleansing your hands with soap and water or alcohol based hand sanitizers) in accordance with the facility's policy for four of 19 sampled residents (Residents 6, 18, 28 and 88) by failing to ensure: 1. Staff doffed (remove) gloves and hand hygiene after peri-care (cleaning the genitals and anal area) for Resident 6. 2. Staff doffed gloves and hand hygiene after emptying urinal for Resident 88.…

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 49) was treated with respect and dignity in accordance with the facility policy by failing to ensure by failing to keep the resident's clothes clean and free of food particles. This deficient practice has the potential to affect the resident's self-worth and self-esteem. Findings: During a review of Resident 49's admission Record, the admission Record indicated resident was admitted to the facility on [DATE] with the following diagnoses of muscle weakness and spinal stenosis (space inside the backbone is too small). During a review of Resident 49's History and Physical (H&P), dated 10/22/2024, the H&P indicated resident has the capacity to understand and make decisions. During a review of Resident 49's Minimum Data Set (MDS - a resident assessment tool), dated 10/24/2024, the MDS indicated resident was moderately impaired in cognitive (the ability to understand and make decisions) skills for…

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 88) was informed in advance, of the risks and benefits of proposed care by failing to obtain an informed consent prior to the use of psychoactive medication (a drug that changes brain function and results in altercations in perception, mood, consciousness, or behavior) in accordance with the facility policy. This deficient practice had the potential for Resident 88 not to be able to exercise the right to choose the resident's treatment plan. Findings: During a review of Resident 88 admission Record, the admission Record indicated resident was admitted on [DATE] with the following diagnoses of unspecified fracture of the left fibula (calf bone), dislocation of the left ankle joint, gout (a form of arthritis that causes severe pain, swelling, redness and tenderness in joints) and unsteadiness on feet. During a review of Resident 88's Minimum Data Set (MDS - a resident assessment tool), dated 12/27/2024, 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 one (1) of 1 sampled resident (Resident 77) who were unable to carry out activities of daily living (ADL) received the necessary care and services to maintain good personal hygiene. This deficient practice had the potential for unmet resident's needs, which can result to a decline in physical and emotional well-being. Findings: During a review of Resident 77's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included generalized muscle weakness, difficulty walking, and neuromuscular dysfunction of the bladder (when a person lacks bladder control due to brain, spinal cord, or nerve problems). During a review of Resident 77's Care Plan, initiated on 10/4/2024, the Care Plan indicated a focus on Resident 77's bowel incontinence and an approach plan to assist the resident with toileting needs every shift. During a review of Resident 77'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 88) was free of accident hazards by failing to provide a wheelchair with tires that were not torn. This deficient practice has the potential to cause injury and/or fall to Resident 88. Findings: During a review of Resident 88 admission Record, the admission Record indicated resident was admitted on [DATE] with the following diagnoses of unspecified fracture of the left fibula (calf bone), dislocation of the left ankle joint, gout (a form of arthritis that causes severe pain, swelling, redness and tenderness in joints), and unsteadiness on feet. During a review of Resident 88 History and Physical (H&P), dated 12/26/2024, the H&P indicated resident had the capacity to understand and make decisions. During a review of Resident 88's Minimum Data Set (MDS - a resident assessment tool), dated 12/27/2024, the MDS indicated resident was independent in cognitive (the ability 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.

Based on observation, interview, and record review, the facility failed to provide the necessary respiratory care services for one of one sampled resident (Resident 294) by failing to ensure oxygen (O2, a colorless, odorless gas necessary for most living organisms to breathe and function properly) was administered according to the physician's orders. This deficient practice placed Resident 294 at risk for experiencing complications such as respiratory distress (a condition that occurs when the body needs more oxygen, resulting in difficulty breathing, rapid breathing, and low blood oxygen level) that can lead to serious illness and/or death. Findings: During a review of Resident 294's admission Record, the admission Record indicated the facility admitted the resident on 1/6/2025 with diagnoses that included acute and chronic respiratory failure (loss of the ability to ventilate adequately or to provide sufficient oxygen to the blood and multiple organs) with hypercapnia (excessive CO2 in the blood stream typically caused by inadequate respiration), chronic obstructive pulmonary…

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 the physician's order for fluid restriction of 1200 cubic centimeters (cc - units of volume on liquids) a day by ensuring accurate monitoring of the resident's fluid intake for one of 2 sampled residents (Resident 38) with a diagnoses that included end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life) with dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). This deficient practice had the potential to place the resident at risk for fluid overload (a condition where the body has too much fluid). Findings: During a review of Resident 38's admission Record, the admission Record indicated the resident was initially admitted on [DATE] and was readmitted on [DATE] 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 one of 19 sampled residents (Resident 15) was assessed for the use of bedside rails (adjustable metal or rigid plastic bars that attaches to the bed) in accordance with the facility's policy. This deficient practice placed the Resident 15 at risk for potential accident such as a body part being caught between the bedside rails, falls if a resident attempts to climb over, around, between, or through the bedside rails, which could result in injury, harm, and/or death. Findings: During a review of Resident 15'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 cerebral infarction (a lack of adequate blood supply to the brain cells), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and history of falling. During a review of Resident 15's Minimum Data Set (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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a coordination of care between facility and hospice (care designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than cure) staff for one of one sampled resident (Resident 76) in accordance with the facility's hospice program by failing to ensure: a. Certified Home Health Agency (CHHA) staff followed physician's order to visit and provide care to Resident 76 twice (2) per week. b. Hospice care plan was developed for Resident 76. These deficient practices have the potential for Resident 76 to not receive the required hospice care and services necessary to promote comfort and quality of life. Findings: During a review of Resident 76's admission Record, the admission Record indicated Resident 76 was originally admitted to the facility on [DATE]. Resident 76's diagnoses included cirrhosis of liver (permanent scarring that damages liver and interferes with its functioning),…

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 (an alerting device for nurses or other nursing personnel to assist a resident when in need) was within the resident's reach (arm's length) for one (1) of 19 sampled residents (Residents 15) as indicated on the facility's call light policy. This deficient practice had the potential for Residents 15 not being able to call the facility's staff for help or assistance especially during an emergency. Findings: During a review of Resident 15'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 cerebral infarction (a medical condition that occurs when brain tissue dies due to a lack of blood flow and oxygen), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and history of falling. During a review of Resident 15's Care Plan initiated on 7/25/2023,…

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 observations, interview, and record review, the facility failed to provide pain management (the process of alleviating pain) for one of four sampled residents (Resident 1), after Resident 1 verbalized experiencing pain. This deficient practice resulted in a delay in pain relief for Resident 1. 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 displaced subtrochanteric fracture of left femur (a break in the upper part of the thigh bone, just below the hip joint, that has shifted out of place), difficulty in walking and anxiety disorder (mental disorder involves persistent and excessive worry that can interfere with daily activities). During a review of Resident 1 ' s Minimum Data Sheet (MDS–a resident assessment tool), dated 12/9/2024, the MDS indicated Resident 1 had moderately impaired cognitive skills (ability to understand and make decisions). The MDS indicated 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.

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 plan of care that summarizes a resident ' s health conditions, specific care needs, and current treatments) to address a resident ' s behavior of refusing care from certain Certified Nursing Assistants (CNA) for one out of two sampled residents (Resident 1). This deficient practice had the potential to deliver inappropriate care for Resident 1 due to miss communication of staff and may result in continuity of inappropriate care and interventions for residents. Findings: During a review of Resident 1 ' s admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included hemiplegia (loss of movement and/or sensation, to some degree, of one side of the body), paranoid schizophrenia (a mental illness that is characterized by disturbances in thought) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from 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 and/or implement an individualized resident-centered care plan (a care plan that prioritizes the unique health needs and desired outcomes of the resident) for one (1) of three (3) sampled residents (Residents 1) who had a left hip hemiarthroplasty (a surgical procedure that replaces the femoral head of the hip with a prosthetic component) due to a left hip fracture (a partial or complete break in the upper part of the thigh bone [femur] where it meets the pelvic bone), as indicated on the facility policy. This deficient practice had the potential to not meet Resident 1's specific needs, which could result to harm. Findings: During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 1 's diagnoses included a left hip hemiarthroplasty, left hip fracture, and hypertension (high blood pressure) During 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 observation, interview, and record review, the facility failed to provide the necessary care and treatment for one (1) of three (3) sampled residents (Resident1) who had undergone a left hip hemiarthroplasty (a surgical procedure that replaces the femoral head of the hip with a prosthetic component) due to a left hip fracture (a partial or complete break in the upper part of the thigh bone [femur] where it meets the pelvic bone) when: 1. Licensed Nursing staff did not monitor the resident for signs of hip dislocation such as uneven leg/hip length. 2. There was no documented evidence that the Resident 1 ' s bilateral hips/ legs were assessed on 7/23/24 during the Nurse Practitioner ' s visit. 3. Failing to complete a Change of Condition on 7/21/24 when Resident 1 was assessed as having asymmetrical hips/legs. These deficient practices have the potential to result to a delay in the treatment of Resident 1 ' s left hip dislocation, which could affect the resident ' s overall wellbeing. Findings: During 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 observation, interview and record review, the facility failed to protect one (1) of three (3) sampled residents (Resident 1 from verbal abuse (a type of mental abuse [the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation] with (the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability) based on the facility's policy and procedure. This deficient practice had resulted to Resident 1 experiencing verbal abuse from Resident 2 which could affect Resident 1's emotional and psychosocial wellbeing. Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus (DM, a metabolic disease, involving inappropriately elevated blood glucose levels), dementia (impaired 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 interview and record review the facility failed to report an allegation of verbal abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) for one (1) of three sampled residents (Residents 1) 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 1, which could affect the resident's emotional and mental wellbeing. Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus (DM, a metabolic disease, involving inappropriately elevated blood glucose levels), dementia (impaired 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 ensure that the call light (a device used by patients to call for assistance from hospital staff) was within reach (an arm's length) of one of 6 sampled residents (Resident 1). This deficient practice had the potential to result in delayed provision of services, delay in care and not receiving assistance with activities of daily living (ADLs). Findings: A review of the admission record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included but not limited to unspecified fracture of lower end of right tibia (along the length of the bone, below the knee and above the ankle) subsequent encounter for closed fracture (when a bone breaks, but there is no break in the skin over the injury) with routine healing, unspecified fracture of shaft of right fibula (a break in the bone that stabilizes and supports your ankle and lower leg muscle) subsequent encounter for closed fracture with routine healing, unspecified…

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 their policy for abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish and includes verbal abuse [a range of words of behaviors used to manipulate, intimidate, and maintain power and control over someone]) for one (1) of four (4) sampled residents (Resident 1) by failure to report to the state agency (CDPH; California Department of Public Health), the state ombudsman (advocates for residents of nursing homes, board and care homes and assisted living facilities), and local law enforcement (Police Department) and failed to investigate an allegation of verbal abuse by two Certified Nursing Assistants (CNAs). This failure resulted in the facility not reporting or investigating the alleged verbal abuse and putting Resident 1 at risk for another episode of verbal abuse. Findings: During a review of Resident 1's admission Record, admission Record indicated 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 interview and record review, the facility failed to immediately notify the attending physician regarding the left sided chest pain for one (1) of four (4) sampled resident (Resident 1) in accordance with the facility's policy. This deficient practice had the potential to result in delayed provision of necessary care and services for Resident 1. Findings: A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with a diagnosis that included angina pectoris (chest pain caused by reduced blood flow to the heart muscles). A review of Resident 1's History and Physical (H&P), dated 6/7/24, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS, standardized assessment and care screening tool), MDS dated [DATE], indicated Resident 1 had moderately impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also 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 interview and record review, the facility failed to ensure the STAT (urgent) electrocardiogram (EKG, measures the hearts electrical activity) test was promptly acted on for one (1) of four (4) sampled resident (Resident 1) as indicated with the physician's order and EKG results was not relayed to the physician as soon as the result was available in accordance with the facility's policy. This deficient practice resulted in delay in conducting the EKG test which could potentially lead to a delay in diagnosis and treatment for Resident 1's abnormal EKG result of Sinus Rhythm with first degree atrioventricular block (a heart rhythm disorder that causes the heart to beat more slowly than it should). Findings: A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with a diagnosis that included angina pectoris (chest pain caused by reduced blood flow to the heart muscles). A review of Resident 1's History and Physical (H&P), dated 6/7/24, indicated 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure one of three sampled residents (Resident 1) was free from physical abuse (intentionally inflicting bodily injury such as slapping, hitting, kicking, and punching). On 4/17/2024, Resident 2 hit Resident 1 on the right cheeks. This deficient practice has the potential for Resident 1 to have psychological distress. In addition, it placed Resident 1 and other residents in the facility for being abused. Findings: A review of Resident 1's admission Record indicated resident was originally admitted on [DATE] and was readmitted on [DATE] with the following diagnosis of depressive disorder (involves a depressed mood or loss of pleasure or interest in activities for long periods of time) and epilepsy (a result of abnormal electrical brain activity, also known as seizure, kind of like an electrical storm inside your head). A review of Resident 1's History and Physical (H&P), dated 4/19/2023, indicated resident is able to make decisions. 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 report immediately not later than two hours of the allegation of physical abuse (intentionally inflicting bodily injury such as slapping, hitting, kicking, and punching) to the State Survey Agency (SSA) for one of four sampled residents (Resident 1) in accordance with the facility's policy and procedure. This deficient practice had the potential to place the residents at risk for elder abuse. Findings: A review of Resident 1's admission Record indicated resident was originally admitted on [DATE] and was readmitted on [DATE] with the following diagnosis of depressive disorder (involves a depressed mood or loss of pleasure or interest in activities for long periods of time) and epilepsy (a result of abnormal electrical brain activity, also known as seizure, kind of like an electrical storm inside your head). A review of Resident 1's History and Physical (H&P), dated 4/19/2023, indicated resident is able to make decisions. A review of Resident 1's 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 services to monitor the progress of a skin rash for one of two sampled residents (Resident 1). 1. The facility did not obtain a physician ' s order for Resident 1 to see a dermatologist after continued complaints and non- healing rash since November 2023. 2. The facility did not obtain a skin scraping test to identify the cause of Resident 1 ' s skin rash. This deficient practice had the potential to negatively affect the resident ' s physical comfort and psychosocial well-being. Findings: A review of Resident 1 ' s admission Record indicated resident was admitted on [DATE] with the diagnosis of anemia (blood produces a lower-than-normal amount of health red blood cells) and psychotic disorder (a mental disorder characterized by a disconnection from reality). A review of Resident 1 ' s History and Physical (H&P), dated 9/14/23, indicated resident had the capacity to understand and make decisions. A review of Resident 1 ' 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 ensure one of two sampled residents (Resident 1) was free from unnecessary medication. This deficient practice resulted in Resident 1 receiving medications that did not appropriately treat Resident 1 ' s skin rash. Findings: A review of Resident 1 ' s admission Record indicated resident was admitted on [DATE] with the diagnosis of anemia (blood produces a lower than normal amount of health red blood cells) and psychotic disorder (a mental disorder characterized by a disconnection from reality). A review of Resident 1 ' s History and Physical (H&P), dated 9/14/23, 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 12/22/23, indicated resident was severely cognitively impaired in daily decision making. MDS indicated resident required partial/moderate assistance (helper does less than half the effort. Helper lifts,…

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 Advanced Directive (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them) Acknowledgement Form was clearly filled out & readily available in the residents' medical chart for three of four sampled residents (Residents 46, 65 and 14) for Advance Directives care area, in accordance with the facility's policy and procedure. This failure had the potential to result in nursing staff not knowing if Residents 46, 65 and 14 had specific resident wishes to follow in case of an emergency. Findings: 1. During a review of Resident 46's admission Record, the admission record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of wedge compression fracture (the front of one of the small circular bones that form the spine collapses, but the back does not) and difficulty walking. 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, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 46 and Resident 82) for Activities of Daily Living (ADLs) care area was provided the following: 1. For Resident 46, the facility failed to ensure a communication board was provided with the language they are able to understand as indicated in the facility policy. This deficient practice had the potential to result in Resident 46 experiencing a delay in receiving appropriate care and treatment due to the staff not being able to properly communicate with the resident. 2. For Resident 82, the facility failed to ensure care and services was provided to maintain good grooming and personal hygiene when Resident 82's fingernails were left dirty and untrimmed. This deficient practice had the potential to result in injuries from scratching, and spread of germs when eating. Findings: 1. During a review of Resident 46's admission Record, the admission Record indicated the resident was initially admitted…

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 done under sanitary conditions by: 1. Facility failed to ensure that conventional oven temperature is accurate since conventional oven knob had no temperature settings. 2. Facility failed to ensure dirty utensils were not left on top of conventional oven and grease tub left inside sink was disposed of correctly. 3. Facility failed to ensure that vegetables and fruits were labeled with a received date and expiration date, and expired vegetables were discarded and not mixed with other foods. 4. Facility failed to ensure Sani Tech testing paper chlorine precision strips (to measure the concentration of free available chlorine in sanitizing solutions) are not expired to make sure the dishwasher was sanitized properly. 5. Facility failed to ensure [NAME] 1 perform hand hygiene while cooking and touching surfaces in the kitchen area. These deficient practices had the potential 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 follow transmission-based precautions (additional protection measures that are focused on the particular mode of infection transmission) to prevent spread of infection for three of five sampled residents (Residents 29, 47 and 86) for infection control care area, by not properly donning (to put on) or doffing (to take off) personal protective equipment (PPE, a barrier precaution which includes use of gloves, gown, mask, face shield, shoe covers, head covers, respirators, etc., when you anticipate contact with blood or body fluids or other communicable toxins or agents) prior to entering or exiting the resident's room. This deficient practice had the potential to result in the spread of and development of infection through possible cross-contamination (passing of bacteria, or other harmful substances indirectly from one resident to another through improper or soiled equipment, procedures, or products). Findings: 1. During 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 ensure one of one sampled resident (Resident 1) for dignity care area, was treated with respect and dignity by failing to ensure resident's shirt was clean and free from stains. This deficient practice had the potential to affect Resident 1's self-worth, self-esteem, and psychosocial well-being. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included functional quadriplegia (paralysis that affects all four limbs plus the torso), dysphagia (difficulty or discomfort in swallowing), and personal history of traumatic brain injury. A review of Resident 1's History and Physical (H&P) Examination, dated 4/17/2023, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 11/17/2023, indicated Resident 1 was assessed as severely impaired…

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 develop a baseline care plan (document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) within 48 hours after resident admission for one (1) of 1 sampled resident (Resident 82) for care plan care area, in accordance with the facility's policy. This deficient practice had the potential for delayed provision of necessary care and services. Findings: A review of Resident 82's admission Record indicated the resident was admitted to the facility on [DATE] with a diagnosis of diagnosis of dysphagia, oropharyngeal phase (difficulty swallowing and transferring food from the mouth into the pharynx and esophagus to initiate an involuntary swallowing process), difficulty walking, and lack of coordination. A review of Resident 82's History and Physical (H&P), dated 12/4/2023, indicated Resident 82 did not have the capacity to understand and make decisions. A review of Resident 82's Minimum Data Set (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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation interview and record review, the facility failed to ensure resident specific care plans (document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) were developed and implemented for two (2) of twenty (20) sampled residents (Resident 47 and 61) in accordance with the facility policy. 1. For Resident 47, the facility failed to develop a comprehensive care plan to include individualized approaches for extended spectrum beta-lactamase (ESBL, an enzyme made by some bacteria found in the urine that prevents certain antibiotics (a drug used to treat infections caused by bacteria and other microorganisms) from being able to kill the bacteria, which can be spread to surfaces that are touched by someone who has contact with the bacteria) Klebsiella Pneumoniae (a bacteria that can cause different types of healthcare associated infections) in the urine. This deficient practice had the potential to result in a delay in or lack of delivery 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 follow the physicians order not to use straw with liquids for one (1) of 20 sampled residents (Resident 1). This deficient practice could potentially result to Resident 1's higher risk of choking incidents and aspiration (when foods or fluids gets into the airway which can lead to trouble breathing or lung infection). Findings: A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with a diagnosis of dysphagia, oropharyngeal phase (difficulty swallowing and transferring food from the mouth into the pharynx and esophagus to initiate an involuntary swallowing process) and functional quadriplegia (complete inability to move due to severe disability from another medical condition without injury to the brain or spinal cord). A review of Resident 1's History and Physical (H&P), dated 4/17/2023, indicated Resident 1 did not have the capacity to understand and make decisions. A review of 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 ensure the resident's environment was free from accident hazards for one (1) of 1 sampled resident (Resident 53) for accident care area by failing to ensure the residents bed was placed on the lowest position while the resident was on bed as indicated on the care plan. This deficient practice had the potential to result in injuries in an event of a resident fall (to drop or descend under the force of gravity, as to a lower place through loss or lack of support). Findings: A review of Resident 53's admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of dysphagia, oropharyngeal phase (difficulty swallowing and transferring food from the mouth into the pharynx and esophagus to initiate an involuntary swallowing process) and confusional arousals (a sleep disorder that causes the resident to act in a very strange and confused way as they wake up or just after waking). 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 observation, interview, and record review, the facility failed to provide one out of three sampled residents (Resident 51) for food care area, with meals that accommodated the resident's food preferences. This deficient practice had the potential to alter Resident 51's nutritional status. Findings: A review of the admission Record indicated Resident 51 was admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), type 2 diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high) and major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy). A review of Resident 51's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 2/8/2023, indicated the resident has moderate cognitive impairment (mental process of thinking…

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 functioning heating, ventilation (movement of fresh air around a closed space), and air conditioning (HVAC) system (use of various technologies to control the temperature, humidity, and purity of the air in an enclosed space. It's goal is to provide thermal comfort and acceptable indoor air quality) for three (3) out of 20 sampled residents (Residents 12, 26, and 67) as indicated on the facility policy. This deficient practice had the potential to result to inadequate indoor air quality through adequate ventilation with filtration, which could affect the residents' well-being. Findings: 1. A review of Resident 12's admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD-a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it harder to breath) A review of Resident 12'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 have an effective pest control program for gnats' (small, winged insect) infestation, which affected two (2) of 94 residents residing in the facility (Resident 2 and 12). This deficient practice had the potential to cause itchy, painful bites to Residents 2 and 12, which could result to open sores (an ulcer) that are susceptible to bacterial infection. This also had the potential for transmission of infectious diseases to other residents. Findings: 1. A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included functional quadriplegia (the complete inability to move due to severe disability or frailty caused by another medical condition), essential hypertension (high blood pressure), and neuromuscular dysfunction of bladder (when a person lacks bladder control due to brain, spinal cord, or nerve problems). A review of Resident 2's History and Physical Examination (H&P),…

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 their policy and procedures for safe medication storage and handling by failing to ensure: 1. Medications including opened and unopened insulin pens (a device used to give an insulin [a hormone that lowers the level of glucose {a type of sugar} in the blood] injection) were labeled with the resident's name, an opened date, and a prescription label (contains information on how much, how often, and how to take a medication) for three out of five residents (Resident 1, 2 and 6). 2. Expired Afluria Quadrivalent Influenzae Vaccine 2023-2024 Formula (Flu Vaccine, helps the body defend against the flu virus [small particles, germs, that can cause illness]) was discarded and not stored in the facility's refrigerator and available for resident use. 3. Resident 1's Home medications (medications brought into the facility with or by the resident or resident's family) was labeled with the prescription. These deficient practices increased 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 interview and record review, the facility failed to permit one of two sampled residents (Resident 1) back to the facility after the patient was hospitalized at the General Acute Care Hospital (GACH), in accordance with the facility policy. This deficient practice resulted in a violation of Resident 1's rights to resume residency at the facility which could also cause psychosocial harm. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with the diagnoses of respiratory failure (a serious condition that makes its difficult to breathe on your own and lungs cannot get enough oxygen into the blood), hemiplegia (muscle weakness on one side of the body), and hemiparesis (one side muscle weakness). A review of Resident 1's History and Physical, dated 12/21/2023, indicated resident had the capacity to understand and make decisions. A review of Resident 1's Physician Orders, dated 12/23/2023, indicated the following: 1. Transfer to GACH emergency room…

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 one of four sampled residents (Resident 4) by: 1. Facility failed to ensure refills of Hydrocodone - Acetaminophen (Norco, controlled substances [medications with a high potential for abuse] medication to treat pain) 5-325 milligrams (mg - a unit of measure for mass) were ordered in advanced to ensure sufficient supply was available between 12/12/2023 - 12/21/2023 for Resident 4. 2. Facility failed to maintain accountability on twelve (12) tablet of Norco 5- 325 mg for Resident 4. These deficient practices increase the risk of diversion (when medications are obtained or used illegally) and possibly caused Resident 4 to missed dose of Norco 5-325 mg (pain medication). Findings: 1. A review of Resident 4's admission Record indicated the facility admitted Resident 4 on 12/11/23 with diagnosis which included hypertension (when the pressure in the blood vessels is too high), spondylosis lumbar region (osteoarthritis of the spine, a condition that usually develops with age, and is…

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 proper care and treatment for gastrostomy tube (G-tube, a tube inserted through the abdomen that delivers nutrition directly to the stomach) was provided for one of five sampled residents (Resident 3). Resident 3's head of bed (HOB) was not elevated to an angle of 30 to 45 degrees while the resident was receiving G-tube feeding (a liquid food mixture provided through the G-tube). This deficient practice had the potential for the resident to acquire aspiration (when something you swallow enters your lungs) pneumonia (infection that inflames air sacs in one or both lungs) and/or choke. Finding: A review of Resident 3's admission Record indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included hyperlipidemia (a condition in which there are high levels of fat particles ([lipids]) in the blood), dysphagia (difficulty swallowing any liquid including saliva, or solid material),…

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 for one of six sampled (Resident 4) residents by: 1. Facility failed to administer Resident 4's Fluoxetine (antidepressant; medication used to treat depressive disorder) and four supplements (product intended to supplement one's diet by taking a pill, capsule, tablet, powder, or liquid) on his dialysis (process of removing excess water, and toxins from blood in people whose kidneys [organ that helps removes waste, extra water and makes urine] no longer performs these functions) days. There were total of 14 days the medications were not given to the resident from 7/1/2023 to 8/3/2023. 2. Facility failed to call and notify Resident 4's primary physician of the resident's missed medications on total of 14 days from 7/1/2023 to 8/3/2023. This deficient practice placed Resident 4 at risk of not getting the full effect of the medication and resulted in the resident having increased behavior episodes of feeling sadness.…

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 six sample residents (Resident 4) was free from significant medication error (mean the identified preparation or administration of medications was not in accordance with the physician's order. This error may cause or have caused the resident's discomfort or jeopardizes his or her health and safety) by failing to administer Resident 4's Fluoxetine (antidepressant; medication used to treat depressive disorder) on his dialysis (process of removing excess water, and toxins from blood in people whose kidneys [organ that helps removes waste, extra water and makes urine] no longer performs these functions) days. There were total of 14 days the medication was not given to the resident from 7/1/2023 to 8/3/2023. This deficient practice placed Resident 4 at risk of not getting the full effect of the medication and resulted in the resident having increased behavior episodes of feeling sadness. Resident 4 had 32 episodes of verbalizing of feeling 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.