Artesia Palms Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure monitoring orders were completed and documented as 'complete' as ordered by the physician for one of 35 sampled resident (Resident 47).This deficient practice had the potential to result in unmet medical needs and increased risk of adverse health outcomes for Resident 47.Findings: During a review of Resident 47's admission Record, the admission Record documented Resident 47 was admitted to facility on 2/25/2025 and readmitted on [DATE] with diagnoses including hypertension (high blood pressure), dysphagia (difficulty swallowing), type 2 diabetes (a condition where the body does not use insulin effectively or does not produce enough insulin leading to high blood sugar level) and a history of falling.During a review of Resident 47's Minimum Data Det (MDS- a resident assessment tool) dated 9/3/2025, the MDS documented Resident 47's cognition (ability to make decisions of daily living) was severely impaired. The MDS documented Resident 47 needed…

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 of five residents (Resident 37) was provided with floor mats on each side of the bed, as ordered by the physician. This failure put Resident 37 at a higher risk for injury in the event of a fall.During a review of Resident 37's admission Record, the admission record documented the facility readmitted Resident 37 on 7/23/2025, with diagnoses including muscle weakness and paranoid schizophrenia (a mental disorder characterized by delusions and auditory hallucinations).During a review of Resident 37's Minimum Data Set ([MDS] a resident assessment tool), dated 10/2/2025, the MDS documented Resident 37 had moderate cognitive (thought process) impairment and transfers were not attempted due to medical condition.During a review of Resident 37's untitled plan of care revised date 10/21/2025, the care plan documented, (resident) was at risk for falls and injuries due to risk factors: use of psychoactive (medications that affect the mind/brain) drugs, poor safety awareness, impaired mobility, psychiatric…

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 Identify and to intervene in one of three sampled residents' (Resident 10) history of trauma (a very upsetting or harmful experience that can affect a person's mind or body) and triggers which may cause re-traumatization (a person encounters a new event or stimulus that triggers them to re-experience the intense stress, emotional distress, and even flashbacks of a previous traumatic event as if it were happening again).This failure had the potential to result in Resident 10 experiencing unnecessary re-traumatization.Findings:During a review of Resident 10's admission record, the admission record documented Resident 10 was admitted to the facility on [DATE] with diagnoses including post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), bipolar disorder (sometimes called…

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 Certified Nursing Assistant (CNA) 1, who discovered a resident on the floor, following an unwitnessed fall (8/21/2025), reported the resident's fall and did not place the resident back in bed prior to a licensed nurse's assessment for one of three sampled residents (Resident 1) reviewed for falls. When the facility was made aware of Resident 1's unwitnessed fall, they failed to conduct a neurological (a series of simple tests to see how well your brain, spinal cord, and nerves are working) assessment, per their policy and procedure (P/P) titled, Neurological Assessment (Routine). These deficient practices resulted in a delay in care (assessment, pain management, evaluation) and transfer to a General Acute Care Hospital (GACH) on 8/22/2025 for continued evaluation and treatment. These deficient practices had the potential for unrecognized injuries as well as unrecognized changes in Resident 1's neurological status. Findings: a. 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.

Based on interview, record review, the facility failed to ensure residents received their mail in a timely manner, including mail delivery on Saturdays for seven of eleven residents (Residents 75, 76, 115, 122, 166, 191, and 212) who attended the resident council meeting (scheduled gathering of residents in a long-term care facility, where they discuss issues related to their quality of life). This deficient practice had the potential for violating their right to communicate promptly with individuals within and outside the facility. Findings: During a resident council meeting on 6/10/2025 at 2:00 p.m., seven out of eleven residents who attended the meeting stated they did not get mail and packages on Saturdays, because the mail and packages were delivered to them only on Mondays through Fridays. During an interview on 6/10/2025 at 3:29 p.m., with the Activities Director (AD), the AD stated the activities department assisted the social services department in delivering the mail and packages to the residents. The AD stated the resident mail and packages were not delivered on Saturday,…

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: 1. Ensure there were adequate indications for the use of Abilify and Risperdal (antipsychotic medications used to treat mental illness) by failing to identify and document the use of non-pharmacological interventions (attempts to modify resident behavior without the use of medications) in two of five residents sampled for unnecessary medications (Resident 179 and 209.) 2. Ensure Abilify was necessary to treat a specific condition as diagnosed and documented in the medical record in one of five residents sampled for unnecessary medications (Resident 179.) 3. Monitor and document the target behavior of self-isolation in the Medication Administration Record (MAR - a record of all medication administration and monitoring done for a resident) related to the use of Celexa (an antidepressant medication used to treat mental illness) in one of five residents sampled for unnecessary medications (Resident 179.) 4) The facility failed to monitor the targeted…

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

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1.Nutritional supplement labeled store frozen with manufactures instructions to use within 14 day of thawing were not monitored for the date they were thawed to ensure expired shakes were discarded after this time frame. Three boxes each with 50 single serve cartons of strawberry flavored nutrition supplements, two boxes of vanilla flavored nutrition supplements, 10 boxes of chocolate flavored nutrition supplements and one box containing 17 single serve cartons of chocolate and strawberry flavor supplements were stored in the reach in refrigerator with no thaw date. This deficient practice had the potential to result in food borne illness in 33 residents who are on nutrition supplements at the facility. 2.One large tray of previously prepared dessert containing fruits and cream and two plates of previously prepared salad (lettuce, tomato and chopped ham) were stored in the reach in refrigerator with no label and date. One…

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 developed a person centered care plan for two of 25 sampled residents (Residents 68 and 205). This deficient practice had the potential for the resident's care needs not to be addressed related to the use of clonazepam. Findings: 1) During a review of Resident 205's admission Record, the admission Record indicated Resident 205 was admitted to the facility on [DATE] with diagnoses including hemiplegia (a nervous system disorder causing severe or complete loss of strength or paralysis on one side of the body) and hemiparesis (a nervous system disorder causing mild or partial weakness on one side of the body) following cerebral infarction (ischemic stroke, a type of stroke which occurs when blood flow to the brain is cut off for a prolonged period of time causing tissue damage) affecting left dominant side. During a review of Resident 205's Minimum Data Set ([MDS] a resident assessment tool) dated 5/5/25, the MDS indicated Resident 205's cognition (ability…

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 revise the comprehensive care plan for accidents one of seven sample residents (Resident 156), when a care plan was not updated for Resident 156 after the resident experienced a fall. This had the potential for serious harm, including additional falls or injures, due to the facility's failure to reassess and respond to the resident's change in condition. Findings: During a review of Resident 156's admission Record, the admission Record indicated Resident 156 was admitted to the facility on [DATE], with diagnoses which included, unspecified sequelae of cerebral infarction (effects or consequences of a stroke caused by a blocked blood vessel in the brain), Type 2 diabetes mellitus (a disease where the body does not make enough insulin), and chronic pulmonary edema (long-term fluid buildup in lungs). During an initial observation and interview with the Licensed Vocational Nurse (LVN) 9 on 6/9/2025, at 2:50 p.m., in Resident 156's room, LVN 9 stated…

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 new diagnosis of schizophrenia (a mental illness characterized by hallucinations [hearing or seeing things that are not there] or delusions [firmly held beliefs that are untrue despite evidence otherwise]) was based on evidence-based criteria (such as the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition [DSM-5] criteria) consistent with professional standards affecting one of five residents sampled for unnecessary medications (Resident 209.) This deficient practice of failing to use evidence-based criteria consistent with professional standards to make a new diagnosis of schizophrenia increased the risk that Resident 209 could have experienced adverse effects (unwanted or dangerous medication-related side effects) related to psychotropic medication (medications that affect brain activities associated with mental processes and behavior) therapy, such as drowsiness, dizziness, constipation, or increased risk of fall, possibly…

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 129) who was incontinent (unable to voluntarily control retention of urine or feces in the body) of bowel and bladder, was provided a retraining and/or toileting program to regain the resident's normal bowel and bladder function as much as possible, by failing to identify Resident 129 as a candidate for retraining program. This failure had a potential to result in Resident 129's permanent inability to regain control of bowel and bladder function and can lead to a loss of dignity. Findings: During a review of Resident 129's admission Record, the admission Record indicated, Resident 129 was initially admitted to the facility on [DATE] and last re-admission was on 4/10/2025 with diagnoses including morbid obesity (a disorder that involves having too much body fat, which increases the risk of health problems), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows…

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 five sampled residents (Resident 111 and Resident 168) who received enteral feeding (nutrition delivered using the gut) through a gastrostomy tube (GT - a tube inserted through a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) received the appropriate treatment and services by: A. Failing to ensure sufficient fluid was provided as physician ordered for Resident 111. B. Failing to ensure Resident 168 was positioned safely at 45 degrees during the enteral feeding via GT. These failures had the potential to result in dehydration (a dangerous loss of body fluid could be caused by inadequate intake) for Resident 111, and aspiration (inhalation of foreign materials) and can lead to pneumonia (a lung infection) for Resident 168. Findings: A. During a review of Resident 111's admission Record, the admission Record indicated, Resident 111…

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 care for use of a Continuous Positive Airway Pressure, (CPAP a machine used to deliver a stream of pressurized air through a mask to keep the airways open during sleep, preventing pauses in breathing) as per the manufacturer's recommendation for one of one sampled resident (Resident 205) by failing to change the CPAP mask cushion every month, and clean the CPAP machine and supplies per the manufacture's guidelines. These deficient practices had the potential to affect the quality and cleanliness of the CPAP machine and supplies and may result in the growth of bacteria affecting the respiratory health and well-being of Resident 205. Findings: During a review of Resident 205's admission Record, the admission Record, indicated the resident was admitted to the facility on [DATE] with diagnoses including obstructive sleep apnea (a serious medical condition which occurs when the upper airway repeatedly collapses during sleep, blocking breathing 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 ensure a performance review for two of seven Certified Nurse Assistants (CNA 3 and CNA 4) were completed at least once every 12 months. This deficient practice had the potential to result in poor resident health outcomes. Findings: During an interview and record review with the Director of Staff Development (DSD) on 6/13/2025 at 12:51 p.m. CNA 3 and 4's personnel files were reviewed and the files did not indicate performance evaluations were completed in 2024 or annually. During an interview with the Director of Nursing (DON) on 6/13/2025 at 3:26 p.m., the DON stated performance evaluations should be completed upon hire, 90 days after hire, and then annually thereafter. During a review of the facility's Policy and Procedure (P&P) Performance Evaluations, reviewed January 2025, the P&P indicated a performance evaluation will be completed on each employee at the conclusion of his/her 90 day probationary period, and at least annually thereafter.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow up on the denture referral for one of three sampled residents (Resident 182). This failure resulted in delivery of care and services and had a potential risk for weight loss for Resident 182. Findings: During a review of Resident 182's admission Record, the admission Record indicated Resident 182 was admitted to the facility on [DATE] with diagnoses including Wernicke's encephalopathy (brain disorder caused by a vitamin B1 deficiency) and dysphagia (difficulty swallowing). During a review of Resident 182's History and Physical (H&P), dated 2/12/2025, the H&P indicated Resident 182 was not capable of making medical decisions. During a review of Resident 182's Minimum Data Set (MDS - a resident assessment tool), dated 5/19/2025, the MDS indicated Resident 182 had moderate cognitive (ability to learn, reason, remember, understand, and make decisions) impairment, required set-up assistance with eating, required supervision assistance for toileting…

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 store one open bottle of gabapentin solution (a medication used to treat nerve pain) in the refrigerator as required by the manufacturer's specifications affecting Resident 46 in one of five inspected medication carts (Villa Cart South.) This deficient practice of failing to store medication according to the manufacturers' requirements increased the risk that Resident 46 could have received medication that had become ineffective or toxic due to improper storage possibly leading to health complications resulting in hospitalization or death. Findings: During a concurrent observation and interview on [DATE] at 2:19 PM of Villa Cart South with the Licensed Vocational Nurse (LVN 2), the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as required by their respective manufacturer's specifications: 1. One opened bottle of gabapentin…

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 trash stored in the dumpster area was maintained in sanitary manner. a. One of 10 garbage dumpster cover was broken, and trash bin was not closed. The floor area around the trash dumpsters was not clean, there were disposable plastic spoons, paper and debris. This deficient practice had the potential for harborage and feeding of pests. Findings: During a concurrent observation and interview with DS and Maintenance Supervisor (MS) on 6/9/2025 at 11:00AM, one large dumpster located in the main trash area had a broken lid and was not completely covered. There was trash on the floor including plastic utensils, cups, paper, plastic bags, cigarette buds and other debris. During a subsequent interview on 6/9/2025 at 11:00 a.m. with DS, DS stated the dumpster lids should be covered and there should not be trash on the floor. DS stated housekeeping staff are responsible for sweeping the trash area. During the same observation, MS stated the trash bin lid is broken and it is not closed. MS stated All trash…

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 infection control practices for one sampled resident (Resident 168) and one nonsampled resident (Resident 80) by failing to: 1) Ensure Certified Nursing Assistant (CNA) 1 performed hand hygiene when entering and leaving Resident 168's room who was placed on Enhanced Barrier Precautions (EBP, infection control practices that use personal protective equipment [PPE] to reduce the spread of multidrug-resistant organisms [MDROs]), and to ensure Licensed Vocational Nurse (LVN) 1 performed hand hygiene when entering Resident 168's room. 2) Ensure Laundry Aide (LA) 1 performed hand hygiene when entering and leaving Resident 80's who was on EBP room, and to ensure LA 1 fully covered the residents' personal clothing during transportation to another area of the facility from Resident 80's room. These deficient practices exposed the residents and staff of the facility at risk for transmission of disease-causing microorganisms. Findings: 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 conduct a bed inspection to identify areas of possible entrapment for one of two sampled residents (Resident 205). This deficient practice had the potential to negatively impact the resident resulting in possible entrapment, serious injury, and death. Findings: During a review of Resident 205's admission Record, the admission Record indicated Resident 205 was admitted to the facility on [DATE] with diagnoses including hemiplegia (a nervous system disorder causing severe or complete loss of strength or paralysis on one side of the body) and hemiparesis (a nervous system disorder causing mild or partial weakness on one side of the body) following cerebral infarction (ischemic stroke, a type of stroke which occurs when blood flow to the brain is cut off for a prolonged period of time) affecting left dominant side. During a review of Resident 205's Minimum Data Set ([MDS] a resident assessment tool) dated 5/5/2025, the MDS indicated 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.

Based on interview and record review, the facility failed to provide training related to resident elopement (the act of leaving a facility unsupervised and without prior authorization) for eight of eight sampled employees (Certified Nursing Assistants [CNA] 1, 8, 9, 10, 11, 12 and 13 and a Restorative Nursing Assistant (RNA 1) on hire and/or annually, as indicated in their Facility Assessment. This deficient practice resulted in CNA 1 and Receptionist (RCP) 1 allowing two residents (Resident 1 and Resident 2) to enter the facility's lobby area from a locked location and then wander (a situation in which a resident leaves the premises of a safe area without the facility's knowledge and supervision, if necessary, would be considered and elopement) through the facility's front door on 5/18/2025. Findings: During a review CNAs 1, 8, 9, 10, 11, 12, 13, and RNA 1's Employee Files, the Employee files indicated there was no documented evidence that the forementioned employees received training related to resident elopement. During an interview on 5/22/2025 at 9:40 a.m., and a subsequent…

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 written notice Based on interview, and record review, the facility failed to ensure a written copy of the bed hold notice was created and provided to two of two sampled resident's (Residents 1 and 2) responsible parties (RP 1 and RP 2) within 24 hours of transferring Resident 1 and Resident 2 to a General Acute Care Hospital (GACH). This deficient practice resulted in the incomplete status of Resident 1 and Resident 2's bed hold availability and no documented notice provided to RP 1 and RP 2. Findings: a. During a review of Resident 1's admission Record, (Face Sheet) the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia (a type of schizophrenia characterized by false beliefs of being persecuted, harmed, or spied upon) and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Minimum Data Set ([MDS] a standardized resident assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure neurological (relating to disorders of the nervous system) assessments was completed, per protocol, for one of three sampled residents (Resident 3), after Resident 3 experienced a fall and hit his head. This deficient practice resulted in an incomplete/incorrect neurological assessment of Resident 3 and had the potential for a change of condition (COC) to go unnoticed which could lead to a delay in evaluation and care. Findings: During a review of Resident 3's admission Record (Face Sheet), the Face Sheet indicated Resident 3 was readmitted to the facility on [DATE] with diagnoses including Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) and muscle weakness. During a review of Resident 3's Minimum Data Set ([MDS] a standardized resident assessment tool) dated 5/1/2025, the MDS indicated Resident 3 had severely impaired cognition (a very hard time remembering…

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 create and document a Nursing Fall Assessment when one of three sampled residents (Resident 3) experienced a fall and injury to his left eyebrow. This deficient practice resulted in no documented interventions for Resident 3 following his fall and left eyebrow injury and had the potential for care not to be rendered and/or monitored. Findings: During a review of Resident 3's admission Record (Face Sheet), the Face Sheet indicated Resident 3 was readmitted to the facility on [DATE] with diagnoses including Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) and muscle weakness. During a review of Resident 3's Minimum Data Set ([MDS] a standardized resident assessment tool) dated 5/1/2025, the MDS indicated Resident 3 had severely impaired cognition (a very hard time remembering things, making decisions, concentrating, or learning) and required partial/moderate assistance…

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 ' s licensed nurses failed to ensure informed consents were obtained from residents or their Responsible Party (RP) prior to administering antipsychotic medications (medication used to treat serious mental health conditions) and/or they failed to ensure informed consents were obtained by the resident ' s provider and not licensed nurses for three of seven sampled residents (Residents 1, 5, and 6). This deficient practice resulted in the administration of anti-psychotic medications to Residents 1, 5, and 6 prior to them being informed of the medications risk versus benefits, alternative treatment and opportunity to refuse. This deficient practice had the potential for the residents to receive unnecessary medications. During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities) with other behavioral…

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 for one of three sampled residents (Resident 1) who was prescribed and administered anti-psychotic medication (a class of drugs used to treat psychosis [an abnormal condition of the mind that results in difficulties telling what is real and what is not], that the medication was prescribed and administered for appropriate indications for use, detailed evidence of behaviors were documented, non-pharmacological interventions (any type of healthcare action that does not involve the use of medication) were attempted and evaluated prior to the administration/continuance of the medication, adverse reactions associated with the use of the medication, i.e., weight gain, an increase in cholesterol and dizziness were monitored, documented and evaluated, and a comprehensive evaluation was conducted to determine if continued use of the medication was warranted. These deficient practices placed Resident 1 at risk for unnecessary 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 protected from abuse in the smoking patio area when Resident 54 hit Resident 11 on the nose. As a result of this failure, Resident 11 sustained a nosebleed and had to be sent out to the hospital for further evaluation and treatment. Findings: During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including schizophrenia (a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (a group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation), and insomnia (trouble falling asleep or staying asleep). During a review of Resident 11's Minimum Data Set…

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 Medication Regimen Review ([MRR] a thorough check of all the medications a patient is taking, done by a healthcare professional, to ensure they are safe, effective, and appropriate for their current health conditions) was conducted by the facility's Consulting Pharmacist (CP) for one of three sampled residents (Resident 1), to include a review of Warfarin (a medication used to prevent blood clots from forming), as well as Resident 1's labs. This deficient practice resulted in administration of unnecessary doses of Warfarin to Resident 1, placing Resident 1 at risk for adverse side effects of Warfarin, such as abnormal bleeding and/or excessive bruising. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with the diagnosis of atrial fibrillation ([Afib] abnormally fast heartbeat that may lead to blood clots). 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 ensure facility staff notified the physician within four hours of receiving critical (values that are significantly outside the normal range) laboratory (labs) and/or the Medical Director (MD) if there was no response by the physician for one of three sampled residents (Resident 1). This deficient practice resulted in the facility's nursing staff receiving no instructions from Resident 1's physician related to Resident 1's critically high International Normalized Ratio ([INR] a blood test that measures how long it takes for blood to clot) results. This deficient practice had the potential to result in the need to significantly alter treatment. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with the diagnosis of atrial fibrillation ([Afib] abnormally fast heartbeat that may lead to blood clots). During a review of Resident 1's Minimum Data…

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 clarify an order for aspirin ([ASA] a medication used for mild pain relief and preventions of blood clots [a gel-like substance that forms when blood hardens from a liquid to a solid]) resulting in a discrepancy that was not clarified by licensed nursing staff for three months, for one of three sampled residents (Resident 1). Resident 1's physician ordered ASA, 81 milligrams ([mg] a metric unit of measurement, used for medication dosage and/or amount) by mouth, but the facility documented ASA 1 mg by mouth. As a result of this deficient practice Resident 1's ASA order was documented as follows: Administer ASA enteric coated (a coating designed to prevent medications from dissolving in the acidic environment of the stomach), delayed release (a type of medication that is designed to release the active ingredient later than immediately after administration) 81 mg. Give 1 mg by mouth one time daily for cerebrovascular accident ([CVA] a stroke, a condition…

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 pain medication prescribed to one of eight sampled residents (Resident 5) had a specified indication for use on Resident 1's physician's order, the reason pain medication was administered was specified on Resident 1's medication administration record ([MAR] a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) and the effectiveness of the pain medication was documented These deficient practices resulted in the inability to determine what the pain medication was ordered for, the location of Resident 1's pain, and/or the effectiveness of the pain medication administration. These deficient practices had the potential for non-continuity of care, unnecessary medication administration, ineffective pain relief, adverse side effects of the pain medication, and unrecognized/assessed diagnoses. Findings: During a review of Resident 5's admission Record (Face Sheet), the Face Sheet 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 accurately document medication administration in the medical record for one out of eight residents (Resident 5). This deficient practice resulted in inaccurate documentation of the care provided to Resident 5 after he sustained a fall with injury on 10/14/2024. This deficient practice had the potential for non-continuity of Resident 5's care by other health care providers. Findings: During a review of Resident 5's admission Record (Face Sheet), the Face Sheet indicated Resident 5 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including osteomyelitis (inflammation of bone or bone marrow, usually due to infection), and dementia (a progressive state of decline in mental abilities). During a review of Resident 5's Minimum Data Set ([MDS] a resident assessment tool) dated 11/22/2024, the MDS indicated Resident 5's cognition (ability to think and reason) was moderately impaired. The MDS indicated Resident 5 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.

Based on observation, interview and record review, the facility failed to ensure one of six sampled residents (Resident 6) who had a diagnosis of legal blindness (inability to see) was supervised during mealtime (eating). This deficient practice resulted in Resident 6 feeling neglected, unsatisfied, and undignified when food particles fell on her clothing, accessories, and on the floor while eating, which had the potential to negatively affect her psychosocial and emotional well-being. Findings: During a review of Resident 6's admission Record (Face sheet), the Face Sheet indicated Resident 6 was admitted to the facility with diagnoses including Diabetes Mellitus (DM - a disorder characterized by difficulty in blood sugar control and wound healing), open angle glaucoma (a chronic eye condition characterized by increased eye pressure which can lead to vision loss [blindness]), legal blindness, and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 6's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to readmit a resident, who was transferred to a General Acute Care Hospital (GACH) on [DATE] for evaluation and treatment due to behavioral symptoms, agitation, aggression, and psychosis (mental disorder, disconnection from reality) and was ready to return to the facility from the GACH for one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1 remaining at the GACH (as of [DATE]) after Resident 1 was ready to be discharged back to the facility on [DATE] but was denied readmission. Resident 1 has remained at the GACH unnecessarily for additional six days, placing Resident 1 at risk for confusion, disorientation and psychosocial harm related to being displaced from the facility, a place that was considered Resident 1's home since initial admission on [DATE]. 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…

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 six sampled residents (Resident 87 )was positioned properly by a nursing staff during resident care by failing to identify and recognize a bedside drawer located next to the resident's bed as a potential hazard to resident's safety during care which led to resident hitting the nightstand during repositioning. This failure placed Resident 87 at risk for fall and serious injury. Findings: During a review of Resident 87's admission Record, the admission Record indicated the resident was initially admitted on [DATE] and was readmitted on [DATE] with diagnoses that included unspecified sequalae (consequences) of cerebral infarction (a stroke with full recovery or minor lingering deficits with minimal impact on daily life after a stroke), vascular dementia (problems with reasoning, planning, judgement, memory and other thought processes caused by impaired blood flow to brain), lack of coordination and cognitive communication…

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) primary care doctor (MD) and responsible party (RP) was informed of Resident 1 oral intake of less than 50 percent, in forty-two meal intakes, from 12/22/2023 to 1/5/2024. This deficient practice had the potential to result in a delay of care and services that can result in further weight loss for Resident 1. Findings: A review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility on [DATE], with diagnosis including diabetes mellitus (DM) type 2 (a chronic disease characterized by elevated levels of blood glucose [or blood sugar] in a bloodstream), paranoid (a profound fear and anxiety along with the loss of the ability to tell what's real and what's not real) schizophrenia (a serious mental illness which affects how a person thinks, feels, and behaves), dementia (the impaired ability to remember, think, or make decisions which interfere with daily activities), and major depressive…

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 quarterly Interdisciplinary ([IDT] team members from different departments working together, with a common purpose, to set goals, make decisions that ensure residents receive the best care) Care Conference meeting, involving one of six sampled residents (Resident 1) and their responsible party (RP), was held on 11/2023. This deficient practice violated Resident 1 and RP 1's right to be an active participant to discuss the resident's plan of care and services with the IDT and potentially delayed the discussion of needed care and services. Findings: A review of Resident 1's admission Record (Face Sheet), indicated Resident 1 was admitted to the facility on [DATE], with diagnosis including diabetes mellitus (DM) type 2 (a chronic disease characterized by elevated levels of blood glucose [or blood sugar] in a bloodstream), paranoid (a profound fear along with the loss of the ability to tell what's real and what's not real) schizophrenia (a serious…

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 weigh one of six sampled residents (Resident 1) weekly between 12/19/2023 to 1/10/2024 as indicated in the resident's care plan. This deficient practice had the potential to result in further weight loss. Findings: A review of Resident 1's admission Record (Face Sheet), indicated Resident 1 was admitted to the facility on [DATE], with diagnosis including diabetes mellitus (DM) type 2 (a chronic disease characterized by elevated levels of blood glucose [or blood sugar] in a bloodstream), paranoid (a profound fear and anxiety along with the loss of the ability to tell what's real and what's not real) schizophrenia (a serious mental illness which affects how a person thinks, feels, and behaves), dementia (the impaired ability to remember, think, or make decisions which interfere with daily activities), and major depressive disorder (a mood disorder which causes a persistent feeling of sadness and loss of interest). A review of Resident 1's ([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 interview, and record review, the facility failed to ensure two housekeeping (HK 1 and HK 2) staff, who were contracted by the facility from an outside agency, did not verbally abuse one of three sampled residents (Resident 1). These deficient practice resulted in HK 1 and HK 2 following Resident 1 from his room, accusing him (Resident 1) of lying, calling Resident 1 names, and impeding Registered Nurse Supervisor 1's (RNS 1) investigation, when Resident 1 accused HK 1 and HK 2 of verbal abuse against him. HK 1 and HK 2 were escorted out of the facility by a local police agency, who were called because of HK 1 and HK 2's aggressive behavior towards Resident 1 and RNS 1. These deficient practices had the potential to subject residents, staff, and visitors to fear, abuse and harm. See F943 Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnosis included dementia (describe a group of symptoms…

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 abuse training was provided to two housekeeping staff (HK 1 and HK 2), who were contracted by the facility via a outside housekeeping agency. These deficient practices resulted in HK 1 and HK 2 being unaware of the abuse regulations provided to staff at the facility, which resulted in a verbal altercation with a resident (Resident 1) who resided at the facility. This deficient practice had the potential to subject residents, staff, and visitors to fear, abuse and harm. Findings: During a review an undated Witness Interview statement of Registered Nurse 1 (RNS 1), the Witness Interview statement indicated, RNS 1 described the incident were Resident 1 came to the nursing station and stated he was threatened by the housekeeping staff. The Witness Interview statement indicated, Resident was alert, oriented (a function of the mind involving awareness of three dimensions: time, place, and person), and able to answer questions appropriately. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect one of one resident (Resident 2) from Resident 1 by keeping the residents (Resident 1 and 2) as roommates after allegations of Resident 1 having physical/ verbal aggression towards Resident 2 was reported on 8/27/2023 at 7:44 a.m. This deficient practice resulted in Resident 1 subjecting Resident 2 to preventable verbal abuse in the form of name calling the day after the incident (8/28/2023) and it placed Resident 2 at high risk for other forms of abuse. Findings: During a review of Resident admission Record (AR), the AR indicated Resident 1 was initially admitted on [DATE] with the diagnoses including schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions). During a review of Resident 1's Minimum Data Set ([MDS]-a standardized assessment tool that measures health status in nursing home residents), dated 7/25/2023, the MDS indicated Resident 1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its abuse prevention policy by failing to report the occurrence of an alleged resident-to-resident altercation to the state survey agency (California Department of Public Health [CDPH]) within 2 hours after the allegation occurred for two of two sample residents (Resident 1 and 2) on 8/27/2023 at 7:44 a.m. This deficient practice had the potential for other abuse incidents to go unreported placing other residents at risk for abuse. Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was initially admitted on [DATE] with the diagnoses including schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions). During a review of Resident 1's Minimum Data Set ([MDS]-a standardized assessment tool that measures health status in nursing home residents), dated 7/25/2023, the MDS indicated Resident 1's cognitive 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 observation, interview and record review, the facility failed to ensure proper infection control practices were implemented by: a. Failing to conduct fit testing (test protocol conducted to verify that a respirator is both comfortable and provides the wearer with the expected protection) of N95 (respiratory protective device designed to achieve a very close facial fit) masks for three of five facility staff. b. Failing to ensure Certified Nursing Assistant (CNA 1) donned (put on) an isolation gown (protective apparel), eye protection, and N95 (respiratory protective device designed to achieve a very close facial fit) mask before entering one of one isolation room designated for Resident 1 and 2, who were positive for coronavirus disease (Covid-19, contagious respiratory illness); and failing to ensure CNA 1 doffed (take of) used gloves and mask prior to exiting the isolation room for Resident 1 and 2. c. Failing to ensure the Infection Preventionist Assistant (IPA) doffed the used N95 mask after exiting…

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 readmit one of two sampled residents (Resident 1) after being discharged from the general acute care hospital (GACH) on 8/17/2023. Resident 1 was in the facility premises, accompanied by the paramedics, when Registered Nurse Supervisor 1 (RNS 1) instructed the paramedics to return the resident to the GACH. This deficient practice delayed Resident 1's return to his home (the facility) and had the potential to result in more than minimal psychosocial harm to Resident 1. Findings: During a review of Resident 1's admission Record (AR), The AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included schizophrenia (mental illness that affects how a person thinks, feels, and behaves) and antisocial personality disorder (mental health disorder characterized by disregard for other people). During a review of Resident 1's Minimum Data Set([MDS] a standardized assessment and care screening tool) dated 6/28/2023, the MDS indicated…

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