Artesia Christian Home Inc.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the physician when one of three sampled residents (Resident 45's) wound progressed from a pressure injury (PI- localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) stage 1 (intact skin with a localized area of redness and/or changes in sensation, temperature, or firmness) to a PI Stage 2 (partial-thickness loss of skin, presenting as a shallow open sore or wound). This failure had the potential to delay care in treating and preventing Resident 45's PI from getting worse.Findings: During a review of Resident 45's admission Record, the admission Record indicated Resident 45 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), benign prostatic hyperplasia (BPH - an enlargement of the prostate gland causing difficult urination and incomplete bladder emptying), and a urinary device-supra pubic catheter (a hollow tube inserted…

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 verify the dose of Vitamin B-12 (supplement) order for one of two sample residents (Resident 35). This deficient practice had the potential to result in medication errors. Findings: During a review of Resident 35's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 35 was admitted to the facility on [DATE] with diagnoses including anemia (a condition where the body does not have enough healthy red blood cells), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and osteopenia (condition characterized by lower-than-normal bone mineral density).During a review of Resident 35's Minimum Data set ([MDS] A resident assessment tool), dated 10/16/2025, the MDS indicated Resident 35's cognitive skills (functions your brain uses to think, pay attention, process information, and remember things) for daily decision-making was 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.

Based on observation, interview and record review, the facility failed to ensure an opened Tuberculin, Purified Protein Derivative ([PPD] medication used to do a skin test to help detect tuberculosis serious lung infection) for one of two medication rooms was labeled with the date opened. These deficient practices had the potential to result in the loss of viability (ability to work) of the PPD if used beyond recommended date. Findings: During a concurrent observation and interview on 1/20/2026 at 8:41 a.m. with Registered Nurse Supervisor (RNS) 1, in the North station medication room, the PPD vial was previously opened, and the vial was not labeled with the date it was opened. RNS 1 stated the vial should have had the open date on it. During a concurrent interview and record review on 1/20/2026 at 8:41 a.m. with RNS 1, the PPD vial carton was reviewed. RNS 1 stated the package indicated once opened vial should be discarded after 30 days. During an interview on 1/22/2026 at 3:30 p.m. with the Director of Nursing (DON), the DON stated PPD vials should be discarded in 30 days once…

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 Physical Therapy (PT, licensed professional aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation, dated 12/23/2025, and Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) Evaluation, dated 12/23/2025, were completed under the written order of a physician for one of six sampled residents (Resident 1). These deficient practices had the potential to result in inaccurate care planning, harm, inaccurate provision of care and services, and lack of physician verification and coordination of skilled needs and care.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility initially admitted Resident 1 on 9/1/2025 and re-admitted Resident 1 on 12/22/2025 with diagnoses including cellulitis (skin infection) of both legs, muscle weakness, and sepsis (illness caused…

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 they reported a suspected scabies (a contagious skin condition caused by tiny insects called microscopic mites which infest and irritate the skin causing intense itching, red patches and inflammation outbreak (two or more clinically suspect or confirmed cases identified in patients/residents, healthcare workers, volunteers and/ or visitors) to the California Department of Public Health (CDPH) for three of fourteen sampled residents (Resident 1, Resident 2 and Resident 3). This deficient practice resulted in CDPH being unaware that a possible scabies outbreak existed and a delay in their investigation, placing placed residents, staff and visitors at risk of acquiring and spreading scabies. Findings: During a review of Resident 1's admission Record (Face Sheet) the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] with a diagnosis of an anxiety disorder (mental health condition characterized by excessive worrying).…

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 three sampled residents (Resident 1) belongings were safe.This deficient practice resulted in Resident 1 jewelry being lost.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 including dementia (a progressive state of decline in mental abilities), gastroesophageal reflux disease (digestive disorder most often causes a burning and sometimes squeezing sensation in the mid-chest), and anemia (a condition where the body does not have enough healthy red blood cells).During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 10/2/2025, the MDS indicated Resident 1 had moderately impaired cognition (how we think, learn and remember). The MDS indicated Resident 1 needed set-up assistance when eating.During a concurrent interview and record review on 11/26/2025 at 1:17 p.m., with the Associate Director of Social…

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 serve requested menu items to one of three sampled residents (Resident 1).This deficient practice had the potential to result in loss of appetite and cause unplanned weight loss.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 including dementia (a progressive state of decline in mental abilities), gastroesophageal reflux disease (digestive disorder most often causes a burning and sometimes squeezing sensation in the mid-chest), and anemia (a condition where the body does not have enough healthy red blood cells).During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 10/2/2025, the MDS indicated Resident 1 had moderately impaired cognition (how we think, learn and remember). The MDS indicated Resident 1 needed set-up assistance when eating.During a review of Resident 1's General Order, dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility staff failed to ensure one of three sampled residents (Resident 1) left arm bruise was assessed and reported as a change of condition after being reported to a licensed nurse. This deficient practice resulted in a delay of care for Resident 1 and had the potential to cause pain, infection and lead to hospitalization. Findings: During a review of Resident 1’s admission Record, the admission Record indicated Resident was 1 admitted to the facility to the facility on 6/2/2025 with a diagnosis including unspecified dementia (decline in mental ability severe enough to interfere in daily life) , unspecified severity, without behavioral disturbance, hypertension (high blood pressure) and anxiety (having constant worry and fear). During a review of Resident 1’s MDS a resident assessment tool) dated 6/12/2025, the MDS indicated Resident 1’s cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and senses) were severely impaired. The MDS indicated Resident 1 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 interview and record review the facility failed to ensure Resident was assessed and evaluated after an unwitnessed fall on 12/7/2024 for one out of 2 high risks for falls (Resident 1). This deficient practice resulted in Resident 1 falling in bed sustaining multiple skin tears to the left forearm. Findings: During a review of Resident 1's Face Sheet dated 12/30/24, the face sheet indicated Resident 1 was admitted to facility with diagnoses including mild cognitive impairment (changes in thinking and memory), Atrial Fibrillation (irregular heart rate), foley catheter use(thin flexible tube that drains urine from the bladder into a collection bag), glaucoma (chronic eye disease), muscle wasting and atrophy (loss of muscle mass) and difficulty walking, history of falls. During a review of Resident 1's History and Physical (H&P) dated 11/8/24 indicated Resident 1 does not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ({MDS}- a resident assessment tool) dated 11/18/24 the MDS indicated Resident 1 has severe cognitive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the Quality Assessment Assurance ([QAA] to develop and implement appropriate plans of action to correct identified quality deficiencies)Committee and Quality Assurance Performance Improvement ([QAPI] designated to bring about constant and measurable improvement in the services provided at the facility for continual improvement of quality care) failed to identify: 1.The Licensed Pharmacist (LP) was not conducting Drug Regiment Reviews (DRR thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication) of psychotropic medications (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) monthly and as needed and made recommendations for gradual dose reduction (GDR - involves the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the medication can be discontinued altogether) or the medication…

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 residents were assessed for the use of pressure pad alarms (pressure sensitive devices that sound if a resident's position changes) and either the residents or their representatives were given the choice to give informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for two of two sampled residents (Resident 27 and 2). This deficient practice resulted in a violation of resident rights to be free from restraints (any manual method, physical or mechanical device, equipment, or material that is adjacent to the resident's body, cannot be removed easily by the resident, and restricts the resident's freedom of movement). Findings: During a review of Resident 27's admission Record, the admission Record indicated Resident 27 was originally admitted to the facility on [DATE] with diagnosis including dementia (a progressive state of decline…

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 provide documented evidence of 10 hours of continued education in the field of Infection Prevention and Control (IPC) for the Director of Nursing (DON), Assistant Director of Nursing ADON), and Director of Staff Development (DSD). This failure had the potential to result in negative health outcomes for the staff and residents of the facility. Findings: During an interview on 11/10/2024 at 3:23 p.m., with DON, ADON, and DSD, the DON, ADON, and DSD stated they do not have annual 10 hours of continuing education in the field of Infection Prevention and Control after the initial training was completed in 2019. During an interview and record review on 11/10/2024 at 3:23 p.m., with the ADON, the California Department of Public Health All Facilities Letter (AFL) 20-84, titled, Infection Prevention Recommendations and Incorporation into the Quality and Accountability Supplemental Payment (QASP) Program, 11/4/2020, was reviewed. The ADON confirmed that the AFL indicated it was important that each facility's Infection Preventionist…

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 its protocol for antibiotic stewardship program (coordinated program that promotes the appropriate use of antibiotics at the right dose, for the right duration, and only when needed by clinicians) by not monitoring and addressing triple antibiotic (a substance used to kill bacteria and to treat infection) ointment use for two of two sampled residents (Resident 1 and 60). This failure had the potential for the Resident 1 and 60 to receive an inappropriate antibiotic. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses including Chronic respiratory failure (inadequate gas exchange in the body), generalized muscle weakness. The admission Record indicated Resident 1 had a gastrotomy tube (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems).…

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 provide documented evidence of all employees screening, education offering, and current Corona virus (COVID-19 a highly contagious infectious disease) disease, vaccination (medications used to prevent diseases usually given by injection or by mouth) status. This failure had the potential to place staff and residents at risk for negative outcomes such as being hospitalized and dying due to COVID-19. Findings: During an interview and record review on 11/11/2024 at 9:14 a.m., with the Assistant Director of Nursing (ADON), the facility's employee records of COVID-19 status was reviewed, and 128 facility staff COVID-19 immunization status was unknown. During an interview and record review on 11/11/2024 at 9:14 a.m., with the ADON, the County of Los Angeles Department of Public Health order of the Health Officer, Annual Influenza and Covid-19 immunization or Masking Requirement for Healthcare Personnel during Respiratory Virus Season, issued 8/26/2024, was reviewed and the order indicated by November 1 of each respiratory virus…

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 injury of unknown origin for one of one sampled resident (Resident 210), when Resident 210 was found to have a 1.5 centimeter (cm-unit of measurement) by 1.5 cm small bluish bump on the left side of her forehead, which staff and resident could not provide an explanation of its origin. This deficient resulted in a delay of an onsite inspection by the California Department of Public Health (CDPH) and had potential for an ongoing unknown injury. Findings: During a review of Resident 210's admission Record, the admission Record indicated Resident 210 was admitted on [DATE] with the diagnoses including pneumonia (an infection/inflammation in the lungs) and difficulty in walking. During a review of Resident 210's Minimum Data Set (MDS - a resident assessment tool) dated 9/3/2024, the MDS indicated Resident 210's cognition (the mental process involved in knowing, learning, and understanding things) was moderately impaired and Resident 210 required…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to investigate injuries of unknown origin for one of one sampled resident (Resident 210). Resident 210 had a 1.5 centimeter (cm-unit of measurement) by 1.5 cm small bluish bump on the left side of her forehead, which staff and resident could not provide an explanation of its origin. This deficient practice had the potential for undetected abuse. Findings: During a review of Resident 210's admission Record, the admission Record indicated Resident 210 was admitted on [DATE] with the diagnoses including pneumonia (an infection/inflammation in the lungs) and difficulty in walking. During a review of Resident 210's Minimum Data Set (MDS - a resident assessment tool) dated 9/3/2024, the MDS indicated Resident 210's cognition (the mental process involved in knowing, learning, and understanding things) was moderately impaired and Resident 210 required set up or clean up assistance (helper sets up and resident completes the activity) from facility staff 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 interview and record review the facility failed to develop and implement a comprehensive person-centered care plan addressing the resident's noncompliance for one of two sampled residents (Resident 1). This deficient practice had the potential to result in the delay of care and services. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses including Chronic respiratory failure (inadequate gas exchange in the body), generalized muscle weakness, and a gastrotomy tube (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 10/13/2024, the MDS indicated Resident 1's cognition was intact. The MDS indicated Resident 1 needed set up assistance with oral hygiene, moderate assistance (helper does less than half 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 CROSS REFERENCE F686 Based on interview and record review the facility failed to ensure the care plan was revised when the resident developed a pressure injury (PI- skin injury from prolonged pressure on the skin and tissue underneath) on the inferior fold left buttocks area for one of five sampled residents (Resident 50). This deficient practice resulted in a delay in developing a person- centered care plan that could prevent a Stage 1 (intact skin with a localized area of redness and/or changes in sensation, temperature, or firmness) pressure injury from progressing to a Stage 4 (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) pressure injury. Findings: During a review of Resident 50's admission Record, the admission Record indicated Resident 50 was admitted to the facility on [DATE] with diagnoses including dysphagia (difficulty in swallowing), paroxysmal atrial fibrillation (a type of irregular heartbeat, or arrhythmia), and unspecified dementia with other…

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 41) with limited range of motion (ROM - the extent of movement of a joint) and/or limited mobility, received appropriate treatment and services to increase ROM, prevent decline in ROM, prevent further decline in ROM, and maintain mobility and/or improve mobility by failing to: 1. Ensure Resident 41 received ROM exercises on his upper bilateral (both) extremities as indicated in the facility's policy. Resident 41 was receiving ROM only on his lower bilateral extremities. 2. Ensure a physician's order for the application of a left-hand splint (a device that stabilizes a body part to protect it from further injury and help it heal) was followed as ordered. Resident 41 was observed to have a towel roll in the left hand. This deficient practice had the potential to place Resident 41 at risk for further ROM decline and contracture (a condition of shortening and hardening of muscles, tendons, or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 210) was free of accidents when facility staff continued to use the stand-up lift (mobility equipment used to help a person transfer from a seated position to a standing position) to transfer Resident 210 to and from the bed despite Resident 210 exhibiting agitation and combativeness during use of the stand-up lift upon transfer. The deficient practice resulted in Resident 210 suffering a 1.5 centimeter (cm-unit of measurement) by 1.5 cm small bluish bump on the left side of her forehead sustained during the use of a stand-up lift. Findings: During a review of Resident 210's admission Record, the admission Record indicated Resident 210 was admitted on [DATE] with the diagnoses including pneumonia (an infection/inflammation in the lungs) and difficulty in walking. During a review of Resident 210's Minimum Data Set (MDS - a resident assessment tool) dated 9/3/2024, the MDS indicated Resident 210's cognition…

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 dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) resident (Resident 6) had equipment and supplies necessary to manage dialysis emergencies such as bleeding. at the bedside. The deficient practice has the potential to result in complications from dialysis and bleeding. Findings: During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was originally admitted to the facility on [DATE] with diagnoses including muscle weakness, and end stage renal disease (ESRD -irreversible kidney failure), anemia (a condition where the body does not have enough healthy red blood cells), and dependence on renal dialysis. During a review of Resident 6's Minimum Data Set (MDS - a resident assessment tool), dated 8/21/2024, the MDS indicated Resident 6's cognition was intact. The MDS indicated Resident 6 needed partial…

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 the controlled medications (Controlled Medications are substances that have an accepted medical use (medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V), have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence) was stored and kept with double locked and was not accessible for non- nursing staff. This deficient practice has the potential to have drug diversion or drug misuse. Findings: During an initial tour on 11/8/2024 at 7:45 p.m. at the North and South Station it was observed that emergency kit with Ativan (belongs to a drug class called benzodiazepines) stored in the refrigerator with no lock. During an interview on 11/8/2024 at 7:47 a.m. with Licensed Vocational Nurse 3(LVN 3), LVN 3 stated that the refrigerator was never locked. LVN 3 stated that emergency kit was kept inside the refrigerator with Ativan inside the Emergency- kit(E-Kit) box. During an interview on 11/132024 at 2:16 p.m. with the Director of Nursing…

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 one resident ' s (Resident 1) Minimum data Set (MDS – a federally mandated resident assessment tool), dated 10/14/2024, indicated Resident 1 had broken teeth. This deficient practice resulted an inaccurate depiction of Resident 1 ' s current health status. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 23 was originally admitted to the facility on [DATE] with diagnoses including seizures(a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) , dementia (a progressive state of decline in mental abilities), age related osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D) and muscle weakness. During a review of Resident 1's Minimum Data Set, dated [DATE], the MDS indicated Resident 1 had severe cognitive impairment and was dependent (helper does all the effort) with all activities 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 observations, interview and record review, the facility failed to: a.Ensure an open box of red bean ice bar was labeled with open date and use by date in the freezer. b.Ensure an open bag of fresh peeled garlic was labeled with open date and expiry date in the refrigerator. c.Ensure a bag of Panko Breadcrumbs was not laying directly on the floor of the dry storage area. This failure had the potential to put residents at risk for food borne illness (any illness resulting from ingestion of food contaminated with bacteria, viruses or parasites). Findings: a.During a concurrent observation and interview on 11/14/2023, at 8:30 a.m. with the Director of Dining Services (DDS), observed an open box of red bean ice bar was not labeled with open date and use by date. The DDS stated the red bean ice bar belonged to a resident in the assisted living area and it should be labeled with the resident's name, open date and use by date. DDS asked one of the dietary staff members to label the open box of red bean ice bar.…

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 15 sampled residents (Resident 47 and Resident 20) received restorative nurse aid (RNA, certified nursing aide program that helps residents to maintain their function and joint mobility) (restorative nurse aid) services and treatment to prevent the further decrease in range of motion [ROM, full movement potential of a joint (where two bones meet)] and contractures (chronic joint stiffness associated with joint deformities and pain). This failure resulted in Resident 47 and Resident 20 not receiving the needed RNA services placing them at risk for further decline in the range of motion and at risk to acquire contractures. Findings: a. During a review of Resident 47's Face Sheet the Face Sheet indicated, Resident 47 was admitted to the facility on [DATE] with diagnoses of but limited to dementia (a decline in cognitive abilities that impact a person's ability to perform everyday activities), cerebral atrophy (a 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.

Based on observation and interview the facility failed to ensure handwashing or hand hygiene was performed before and after contact with a resident, before using gloves and after removing gloves during medication administration for 4 of 15 sampled residents, (Resident 16, Resident 43, Resident 4, and Resident 35.) This failure had the potential to result in the transmission of and exposure to infectious microorganisms, contaminants and increased the risk of the spread of infection to the residents. Findings: During an observation on 11/16/2023 at 8:33 am with Licensed Vocational Nurse (LVN 1) on the South Covenant, during medication pass, LVN 1, placed medication in a medicine cup then went to get a blood pressure machine, put on a pair of gloves, removed one of the gloves and placed it in the trash can and then grabbed another pair of gloves and while holding the pair of gloves in his hand, grabbed another blood pressure machine because the first blood pressure machine was not working put on the second pair of gloves and closed the curtains, took Resident 16's blood pressure 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 one of 15 sampled residents (Resident 51) right to refuse care was honored when two nursing staff transferred Resident 51 to the bathroom after Resident 51 refused. This failure resulted in Resident 51 crying causing distress, discomfort and resisting care. Findings: During a review of Resident 51's admission Record (Face Sheet),the Face Sheet indicated, Resident 51 was admitted to the facility on [DATE] with diagnoses of but not limited to dementia (a decline in cognitive abilities that impact a person's ability to perform everyday activities), Alzheimer's (a common and devastating form of dementia that affects memory, thinking, and behavior), anxiety 9an intense , excessive and persistent worry and fear about everyday situation), chronic kidney disease (gradual loss of kidney function that occurs over a period of months to years), and osteoporosis ( a disease that weakens the bones and makes the bones more fragile and weaker than…

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 and address the use of antibiotics (a drug to treat infection) on one of two sampled residents (Resident 53) by prescribing an antibiotic that did not meet the clinical criteria (relevant signs and symptoms of the disease) of urinary tract infection( [UTI] infection in any part of the urinary system). This failure had the potential to result in Resident 53 developing multi-drug resistance (antibiotic will not be effective to treat infection) from unnecessary or inappropriate use of antibiotic. Findings: During a review of resident 53's admission Record, the admission record indicated Resident 53 was admitted on [DATE] with diagnoses that included dementia ( a group of symptoms affecting memory, thinking and social abilities that can interfere with daily life) with other behavioral disturbance, dysphagia (difficulty in swallowing), difficulty in walking and atrial fibrillation (quivering or irregular heartbeat). 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 maintain a functional call light for one of five sampled residents (Resident 21). This failure had the potential to result in a delay in meeting Resident 21's needs for assistance and could lead to falls and accidents. Findings: During a review of Resident 21's admission Record(Face Sheet), the Face Sheet indicated the resident was admitted on [DATE] to the facility with diagnoses that included dementia( loss of cognitive functioning like remembering, thinking and reasoning that can interfere with daily life), congestive heart failure (heart capacity to pump blood cannot keep up with the body's needs), difficulty in walking, muscle weakness and encounter for palliative care ( specialized medical care for people living with serious illness, such as cancer or heart failure). During a review of Resident 21's Minimum Data Set ([MDS] standardized screening tool) dated 10/10/20223, the MDS indicated Resident 21 had moderately impaired cognition…

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.