Westview Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program for a census of 154 when:Staff did not perform hand hygiene in between glove use and did not maintain clean work environment during wound care for Resident 24; Certified Nursing Assistant (CNA) 2 did not wear required personal protective equipment (PPE, clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) while providing care to a resident on enhanced barrier precaution (EBP, an infection control method);Staff did not perform hand hygiene prior to assisting Resident 121 during a meal;Laundry Aide (LA) used the same apron while loading residents' dirty laundry into the washer and when moving clean linens from the washer to the dryer; Staff did not wear required PPE while applying back brace to Resident 119 who was on EBP andLicensed Nurse (LN 15) failed to sanitize blood pressure cuff between residents. These…

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 maintain dignity for one of 37 sampled residents (Resident 50) when Certified Nursing Assistant 1 (CNA 1) was observed standing while assisting Resident 50 during the lunch meal in the dining room.This failure decreased the facility's potential to protect Resident 50's dignity.Findings:During a review of Resident 50's admission records, the records indicated Resident 50 was admitted to the facility in February 2023 with diagnoses that included dementia (a progressive state of decline in mental abilities), and abnormalities of gait and mobility. Resident 50's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 3/4/26, indicated Resident 50 had severe cognitive impairment.During a review of Resident 50's care plan, revised 3/18/26, indicated, [Resident 50] has ADL [activities of daily living - routine tasks/activities a person performs daily to care for themselves] self-care performance deficits related to cognitive and physical deficits related to Dementia.Assist with ADLs -…

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 two of 37 sampled residents (Resident 128 & Resident 156) were given showers according to the shower schedule and personal preferences when:Resident 128 did not receive her scheduled shower for seven days; and,Resident 156 did not receive shower as scheduled.These failures contributed to Resident 128 & Resident 156 not receiving scheduled shower(s), and had a potential for negative health outcomes related to hygiene. Findings: 1.During an interview on 5/5/26, at 8:57 a.m., with Resident 128, in Resident 128's room located in station 2, Resident 128 stated she was not assisted with a shower yesterday and it was her scheduled day to shower, she further stated she has not had a shower in over 5 days. Resident 128 stated she needed assistance to shower and cannot get out of bed without using the lift device. Resident 128 further stated one of the nurses told her she needed to take her showers to prevent skin issues related to her lack of mobility. Resident 128 stated she did not refuse any showers in the last week, and…

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

Based on interview and record review, the facility failed to ensure that information regarding a hospital transfer was effectively communicated to 1 of 37 sampled residents (Resident 14)'s Responsible Party (RP) when Resident 14's Notice of Proposed Transfer/ Discharge was not completed. This failure had the potential to result in Resident 14's RP to not be informed of reason for transfer and right to return to facility. A review of Resident 14's admission Record indicated Resident 14 was admitted to the facility in November 2015 with multiple diagnoses including anoxic brain damage (lack of oxygen to the brain causing brain cell death), dysphagia (difficulty swallowing), and moderate protein calorie malnutrition (does not take in enough calories or protein to meet nutritional needs). A review of Resident 14's Minimum Data Set (MDS- federally mandated assessment tool), Cognitive Patterns, dated 3/16/26, indicated Resident 14 was rarely or never understood and had long and short-term memory problems. A review of Resident 14's SBAR [Situation Background Assessment Recommendation]…

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 a comprehensive, person-centered care plan (a detailed approach outlining individual resident's concerns and needs, and the care and services needed to meet their needs) addressing resident's non-compliance (refusals) of showers was developed for one of 37 sampled residents (Resident 106).This failure resulted in Resident 106 not having clear care guidelines to the desired health outcomes of the identified issues and had the potential to impact Resident 106's health.A review of Resident 106's clinical record indicated the facility admitted the resident in 2023 with multiple diagnoses, which included absence of right leg below knee, history of falling, and depression.A review of the most recent Minimum Data Set (MDS, a federally required assessment) dated 4/18/26 indicated Resident 106 was cognitively intact. The functional abilities assessment for self-care activities indicated that Resident 106 required setup assistance from staff with personal hygiene.A review of activities of daily living (ADL,…

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 nutritional needs and interventions were identified to mitigate weight loss for 2 of 37 sampled residents (Resident 7 and Resident 14) when quarterly nutritional risk assessments by a Registered Dietitian (RD) were not completed.This failure had the potential for Resident 7 and Resident 14's nutritional needs to be unmet resulting in further weight loss. A review of Resident 7's admission Record indicated Resident 7 was admitted to the facility in December 2021 with multiple diagnoses including left leg above knee amputation (AKA), right knee below knee amputation (BKA), lymphoma (blood cancer that affects the immune system), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (mental health condition that cause fear and dread out of proportion to the situation), agoraphobia (fear of places or situations that may cause feelings of being trapped, helpless, or embarrassed) and PTSD. A review of Resident 7's Minimum Data Set (MDS-…

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

Based on observation, interview, and record review, the facility failed to accurately document oxygen saturation levels (amount of oxygen in the blood) for 1 of 37 sampled residents (Resident 1) when Resident 1's documented oxygen saturation level did not indicate Resident 1 was using supplemental oxygen (oxygen therapy that provides extra oxygen to breathe to maintain oxygen saturation levels). This failure resulted in documentation that was not accurate and did not reflect Resident 1's treatment needs. A review of Resident 1's admission Record indicated that Resident 1 was initially admitted to the facility in June 2024 and readmitted to the facility in March 2026 with multiple diagnoses including congestive heart failure (heart does not pump blood as efficiently as it should), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following a cerebral infarction (disrupted blood flow to the brain causing brain cell death), chronic respiratory failure (lungs do not deliver enough oxygen to the blood) with hypoxia (low level of oxygen 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 interview and record review, the facility failed to identify trauma triggers for 1 out of 37 sampled residents (Resident 7) with post-traumatic stress disorder (PTSD- a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event). This failure had the potential for Resident 7 to experience re-traumatization (re-experience/relives a traumatic event or experiences causing similar stress reactions to a new event), and possible increased symptoms such as restlessness, irritability, and social withdrawal. A review of Resident 7's admission Record indicated Resident 7 was admitted to the facility in December 2021 with multiple diagnoses including left leg above knee amputation, right knee below knee amputation, lymphoma (blood cancer that affects the immune system), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (mental health condition that cause fear and dread out of proportion to the situation), agoraphobia (fear of places or situations that may cause…

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

Based on observation, interview, and record review, the facility failed to provide oxygen therapy per physician orders for one of three sampled residents (Resident 1) when Resident 1's oxygen liter flow (the rate supplemental oxygen is delivered) was increased and the indication for the increase was not documented. This failure had the potential for Resident 1 to have adverse effects from more oxygen than needed including lung damage and hypercapnia (high levels of carbon dioxide in the blood causing decreased oxygen to the brain that can lead to drowsiness, confusion, and coma). A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in March 2026 with multiple diagnoses including respiratory failure with hypoxia (inability of the respiratory system to maintain adequate blood oxygen levels to preserve organ function), chronic obstructive pulmonary disease (lung and airway disease that restricts breathing), acute and chronic respiratory failure with hypercapnia (lungs unable to remove carbon dioxide from the blood causing a buildup in the body),…

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

Based on interviews and record review, the facility failed to protect one of four sampled residents (Resident 1) from abuse when Resident 2 inappropriately touched Resident 1.This failure had the potential for Resident 1 to feel shame and emotional distress.Findings: Resident 1 was admitted to the facility in July 2025 with diagnoses that included dementia (a progressive decline in mental abilities) and dysphagia (difficulty swallowing, which can cause garbled or unclear speech).A review of Resident 1's Brief Interview for Mental Status (BIMS), dated 3/9/26, showed a BIMS score of 7, which indicated severe impairment (significant memory problems and required substantial supervision).Resident 2 was admitted to the facility in June 2025 with diagnoses that included dementia with severe behavioral disturbance and cerebral infarction (a stroke caused by a blocked blood vessel in the brain).A review of Resident 2's BIMS, dated 4/1/26, showed a BIMS score of 5, which indicated severe impairment (significant memory problems and required substantial supervision).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.

Based on interview and record review, the facility failed to ensure that the resident's right to choose their own physician was honored for one of four sampled residents (Resident 1), when the facility did not promptly act upon Resident 1's Responsible Party (RP, a person designated by the resident to make decisions on their behalf) request regarding psychiatry provider.This failure deprived Resident 1's RP from exercising her rights to participate in Resident 1's plan of care and to make informed decisions about the care and treatment for Resident 1 and had the potential to negatively impact Resident 1's care.A review of the admission record indicated the facility admitted Resident 1 in 2016 with multiple diagnoses, which included after care for cerebral infarction (stroke).A review of Resident 1's clinical records indicated that the resident did not have capacity to make health-care decisions. Resident 1's wife was listed as Responsible Party (RP) and Power of Attorney (POA, a legal document that lets someone else makes decisions for person).A further review of the physician order…

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

Based on interview and record review, the facility failed to ensure treatment and care was provided in accordance with professional standards of practice for one of three sampled residents (Resident 1) when Resident 1's blood sugar was not consistently monitored and reported to the physician.This failure increased the risk for Resident 1 to experience complications due to unrecognized low or high blood sugar level. A review of the admission Record indicated Resident 1 was admitted middle of January 2026 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (a type of stroke, loss of blood flow to a part of the brain causing brain tissue to die due to lack of oxygen) affecting right dominant side, aphasia (a disorder that makes it difficult to speak) following cerebral infarction, and type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control) with ketoacidosis (a complication of DM due to lack of insulin forcing the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the resident/resident representative was involved in the care planning for one of three sampled residents (Resident 1) when the care plan conference was not conducted as scheduled. This failure increased the risk for not meeting the needs of Resident 1. A review of the admission Record indicated Resident 1 was admitted middle of January 2026 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (a type of stroke, loss of blood flow to a part of the brain causing brain tissue to die due to lack of oxygen) affecting right dominant side, aphasia (a disorder that makes it difficult to speak) following cerebral infarction, and type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control) with ketoacidosis (a complication of DM due to lack of insulin forcing the body to use fat 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 observation, interview, and record review, the facility failed to ensure resident's rights to personal privacy and confidentiality of personal medical information was maintained when a document with resident's information was left on top of the medication cart, for a census of 167.This failure had the potential to compromise the privacy of residents. During a concurrent observation and record review on 3/3/26 at 11:52 a.m. in Station 3 hallway, a document was on top of the medication cart. The document had resident's information including their room number, cognitive status (describes if alert and oriented [A & O] to person, place & time, followed by a number indicating the areas of orientation), code status (determines if and how staff should perform life saving measures if heart or breathing stops), name, and diagnosis (specific illness or condition causing a person's symptom). During a concurrent interview and record review on 3/3/26 at 11:56 a.m. with the Licensed Nurse 1 (LN 1), the LN 1 stated he left the document containing resident's information such as the name,…

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 have the current Advance Health Care Directive (AD- legal document that gives instructions about healthcare decisions and to name someone to make decisions if unable) for one of eight sampled residents (Resident 5). This failure resulted in Resident 5's first and second Designated Agent (DA) for Power of Attorney for Health Care (POA- person who will make health care decisions for you when you cannot) not being notified by the facility of Resident 5's death. Findings:A review of Resident 5's admission Record indicated Resident 5 was admitted to the facility in January 2012 with multiple diagnoses including multiple sclerosis (disease in which the immune system eats away at the protective covering of nerves resulting in nerve damage between the brain and the body), epilepsy (seizure disorder), and dysphagia (difficulty swallowing foods and liquids).Further review of Resident 5's admission Record indicated Resident 5 was her own Responsible Party (RP), Resident 5's family member was listed as emergency contact (EC) 1 and 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.

Based on observation, interview, and record review, the facility failed to protect one of eight sampled residents from physical abuse (Resident 1), when Resident 1 was struck on the face by Resident 2.This failure resulted in Resident 1 experiencing psychosocial distress and fear in the facility. Findings:A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in April 2025 with multiple diagnoses including amyotrophic lateral sclerosis (a nervous system disease that weakens muscles and impacts physical function), dysphagia (difficulty swallowing food and liquids), and cachexia (extreme weight loss and muscle loss).A review of Resident 1's Minimum Data Set (MDS- federally mandated assessment tool), Cognitive Patterns, dated 8/6/25, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 15 out of 15 that indicated Resident 1 was cognitively intact. Further review of Resident 1's MDS, Functional Abilities, dated 8/6/25, indicated Resident 1 had impairment on both sides of upper and lower extremities,…

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

Based on observation, interview, and record review, the facility failed to ensure that Care Plans were updated and documentation was complete for three of eight sampled residents (Resident 1, Resident 2, and Resident 4) when Resident 1 and Resident 2 were involved in a resident-to-resident altercation and Resident 4 reported abuse by a staff member.This failure had the potential for Resident 1, Resident 2, and Resident 4 to not receive the necessary interventions to maintain psychosocial and physical wellbeing.Findings:A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in April 2025 with multiple diagnoses including amyotrophic lateral sclerosis (a nervous system disease that weakens muscles and impacts physical function), dysphagia (difficulty swallowing food and liquids), and cachexia (great weight loss and muscle loss).A review of Resident 1's Minimum Data Set (MDS- federally mandated assessment tool), Cognitive Patterns, dated 8/6/25, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 15…

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 Resident 1's right to be free from physical abuse when Resident 2 threw a cup at Resident 1's face, a deficient practice identified for one of six sampled residents reviewed for abuse.This failure caused Resident 1 to be covered with water and left a red mark on his cheek.Findings:Resident 1 was admitted to the facility late 2016 with diagnosis that included difficulty speaking and stroke (condition where blood flow to the brain is interrupted).Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 5/29/25, the MDS showed a Brief Interview for Mental Status (BIMS, a cognitive screening tool) score of 14/15 which indicated normal cognition.Resident 2 was admitted to the facility in mid-2025 with diagnosis which included a seizure disorder, stroke, and difficulty communicating.Review of Resident 2's MDS dated [DATE], the MDS showed a BIMS score of 10/15 which indicated moderate cognitive impairment.Review of Resident 1's Progress…

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 the rights to be free from abuse for 1 of 5 sampled residents (Resident 2) when Resident 3 witnessed Resident 1 grab and place Resident 2's hand on Resident 1's groin. This failure resulted in Resident 2 not being free from abuse.Findings:During a review of Resident 1's admission record (AR), the AR indicated Resident 1 was admitted to the facility in June 2025 with multiple diagnoses including dementia (a progressive state of decline in mental abilities).During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 7/2/25, the MDS indicated Resident 1 was cognitively intact.During a review of Resident 2's AR, the AR indicated Resident 2 was admitted to the facility in June 2025 with multiple diagnosis including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2…

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

Based on interview and record review, the facility failed to ensure an allegation of abuse was reported within the required regulatory timeframe for two of five sampled residents (Resident 1 and Resident 2) when an allegation of abuse was reported to the California Department of Public Health (CDPH), three days after staff were made aware of the allegation. This failure of timely reporting had the potential to cause a delayed response by enforcement agencies to ensure resident safety.Findings:During a review of Resident 1's admission record (AR), the AR indicated Resident 1 was admitted to the facility in June 2025 with multiple diagnoses including dementia (a progressive state of decline in mental abilities). During a review of Resident 2's AR, the AR indicated Resident 2 was admitted to the facility in June 2025 with multiple diagnosis including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 1's Social Service Note, dated 8/11/25, the Social Service Note indicated, .On 8/11/25 at…

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 necessary care and services for six out of 13 sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, and Resident 6), when showers were not given as scheduled.This failure decreased the facility's potential to protect residents' rights, maintain well-being, and prevent skin breakdown. Findings:A review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility in October 2024 with a diagnosis of malignant neoplasm of lower lobe (cancer in the lower section of a lung).A review of Resident 1's Minimum Data Set (MDS, a federally mandated assessment tool), dated 7/14/25, indicated Resident 1's Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 15 out of 15 with good memory.During an interview on 8/5/25 at 12:52 p.m. with Resident 1, Resident 1 stated he was scheduled for a shower on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of four sampled residents ' (Resident1) rights to be free from abuse was protected when Resident 2 was witnessed by staff fondling Resident 1 ' s breasts without her consent. This failure resulted in Resident 1 not free from abuse by Resident 2. Findings: During a review of Resident 1 ' s admission record (AR, front page of the chart that contains a summary of basic information about the resident) indicated, Resident 1 was admitted in February 2022 with diagnoses including dementia (a progressive state of decline in mental abilities). During a review of Resident 1 ' s Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 5/24/25, indicated Resident 1 had moderate memory impairment. During a review of Resident 1 ' s Interdisciplinary Team note (IDT - documentation of care plan discussions and decisions made by the interdisciplinary team), dated 5/20/25, indicated, . per report from witness, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure pharmacy services were maintained in a consistent manner for a census of 171 when: 1. A discontinued bottle of a controlled medication, a medication with high potential for abuse or addiction, was not stored with other controlled medications in the Director of Nursing's (DON) office and it did not have a count sheet; and, 2. Unused and discontinued controlled medications were not removed from the active medication storage areas for destruction. These failures had the potential for medication error and drug diversion. Findings: 1. During an inspection of medication storage room [ROOM NUMBER] station 2 on 3/18/25 at 2 p.m. with Licensed Nurse 3 (LN 3), a discontinued bottle of lacosamide, a controlled medication used to treat seizures, 10 mg/ml (milligram/milliliter, unit of measure) was found in the medication storage room's cabinet with non-controlled medications. The bottle did not have a count sheet. During an interview on…

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

Based on observation, interview, and record review, the facility failed to implement the facility's medication storage policies and procedures, when: 1. Expired pharmaceutical products were found inside medication carts, 3 in the front station and 4 in the back station; 2. Loose pills were found in 2 medication carts; 3. Blister pack found behind drawer in the bottom of medication cart 3 front station; and, 4. Medications were found at the bedside in Random Resident 1's room and Resident 37's room. These failures had the potential for drug diversion as well as residents receiving ineffective concentrations of prescribed medications. Findings: 1. a. During an inspection of medication cart 4 back station on 3/19/25 at 10:10 a.m., an expired multi dose vial of Humulin R (regular) insulin, a medication used to treat high blood sugar, 100 unit/ml (unit/milliliter, unit of measure) was found with an expiration date of 3/16/25. During an interview on 3/19/25 at 10:10 a.m., with Licensed Nurse (LN 1), LN 1 confirmed that the vial of insulin was expired and expired insulin should have been…

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 2. During a medication administration observation on 3/18/25 at 8:22 a.m., LN 2 was observed administering medication on a medication cart that was not cleaned of white powder residue from a previously crushed medication. During an interview with LN 2 on 3/18/25 at 8:25 a.m., she indicated that the white powder was a crushed Acetaminophen (medication used for pain) tablet and medication cart surfaces should be cleaned prior to administration of medications. During an interview with DON on 3/20/25 at 11:35 a.m., she stated the expectation was to keep surfaces clean, clean with appropriate cleaner, and don't wipe the medication on the floor. A review of the facility policy statement titled, Storage of Medication, revised September 2024, indicated, The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 3. A review of Resident 100's admission record indicated he was admitted to the facility in February 2022 with diagnoses including chronic…

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 assess one of 35 sampled residents (Resident 147), when the Minimum Data Set (MDS- a federally mandated resident assessment tool) did not accurately reflect Resident 147's use of tobacco. This failure decreased the facility's potential to identify Resident 147's care needs. Findings: A review of Resident 147's admission record indicated Resident 147 was admitted to the facility in August 2024 with diagnoses including high blood pressure and generalized muscle weakness. A review of Resident 147's MDS, dated [DATE], indicated Resident 147's Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 12 out of 15 which indicated mild memory impairment. The MDS further indicated Resident 147 was not a smoker. A review of Resident 147's smoking observation/assessments, dated 11/21/24 and 2/19/25, indicated, .Resident denies smoking 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.

Based on interview and record review, the facility failed to follow up with the Preadmission Screening and Resident Review (PASRR, a federal process that ensures people with serious mental illness, intellectual or developmental disabilities are not inappropriately placed in nursing facilities and received the most appropriate care and services) for one of 25 sampled residents (Resident 117). This failure had the potential to result in inappropriate placement and unidentified specialized services for Resident 117. Findings: A review of Resident 117's admission record indicated Resident 117 was initially admitted to the facility in February 2023 and was re-admitted in November 2024 with diagnoses including unspecified psychosis (when someone experiences psychotic symptoms including but not limited to delusions or hallucinations but does not meet the criteria for a specific, named psychotic disorder) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 117's PASRR Level I Screening Result, dated 11/19/24,…

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 4. A review of Resident 147's admission record indicated Resident 147 was admitted to the facility in August 2024 with diagnoses including high blood pressure and generalized muscle weakness. A review of Resident 147's MDS, dated [DATE], indicated Resident 147's Brief Interview for Mental Status (BIMS,tests memory and recall) score was 12 out of 15 which indicated mild memory impairment. During an interview on 3/19/25 at 10:15 a.m., with Resident 147, Resident 147 stated that he smoked a cigar once daily. During an interview on 3/20/25 at 9:46 a.m., with CNA 3, CNA 3 confirmed Resident 147 was a smoker and CNA 3 had observed Resident 147 smoking. During a record review of Resident 147's care plan (CP), dated 3/3/25, there was no documented smoking CP for Resident 147. During a concurrent interview and record review on 3/21/25 at 2:23 p.m., with Director of Nursing (DON), Resident 147's CP was reviewed. DON confirmed Resident 147 did not have a CP for smoking. She stated it was her expectation that the care plan…

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

Based on Observation, interview, and record review, the facility failed to ensure assistance with use of hearing aids was provided for 1 of 35 sample residents (Resident 94). This failure had the potential to result in Resident 94's care needs not being met. Findings: A review of Resident 94's admission record, indicated resident 94 was admitted in May 2021 with multiple diagnoses including Cognitive Communication deficit and Muscle weakness. During a review Resident 94's Ear Service Record dated 12/12/2024, the record indicated resident had hearing aids for the left and right ear. The record further indicated, .Res (sic. Resident) needs help with hearing . During a review of Resident 94's Minimum Data Set (MDS- a federally mandated assessment tool), Cognitive Patterns, dated 02/26/25, indicated Random Resident 2 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 6 out of 15 which indicated severe cognitive impairment; Section B which includes Hearing indicated resident had minimal difficulty- difficulty in some environments (e.g. when person speaks…

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 resident (Resident 14) out of a census of 171, was assisted with nail care as part of their Activities of Daily Living (ADLs-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) when Resident 14 had long fingernails with brownish substance underneath the fingernails on her left hand. This failure had the potential to result in Resident 14 acquiring an infection through harboring residue and bacteria. Findings: Resident 14 was admitted to the facility in November 2015 following an anoxic brain injury (a condition where blood flow to the brain is interrupted, causing brain tissue to die). According to Resident 14's care plan, initiated 10/30/22, [Resident 14] requires extensive to total assistance of 1-2 persons with all personal care . and was left with a contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) to the right hand. Resident 14's care plan further indicated, [Resident 14] has severe…

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 a call light was within reach for two residents (Resident 14 and Resident 227), for a census of 171. This failure had the potential to result in unmet care needs and placed the residents at risk for safety. Findings: 1. Resident 14 was admitted to the facility in November 2015 following an anoxic brain injury (a condition where blood flow to the brain is interrupted, causing brain tissue to die). Resident 14's care plan, initiated 10/30/22, indicated, [Resident 14] has severe cognitive deficits .unable to participate with BIMS [Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident] interview. In addition, Resident 14's care plan indicated, [Resident 14] is non-verbal and unable to make needs known .she is dependent on others. During an observation on 3/19/25 at 8:58 a.m. in Resident 14's room, Resident 14 was sitting in a wheelchair next to her bed. Resident 14's call light was left in the bed, out 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 protect one of eight sampled residents (Resident 8) right to return to the facility following hospitalization. This failure resulted in Resident 8 facing an unanticipated discharge from the facility. Findings: Resident 8 was admitted to the facility on Fall of 2024 with diagnoses that included long-term kidney disease and breathing problems. Resident 8's Power of Attorney (POA) was her daughter. During a review of the Resident 8's Minimum Data Set (MDS, an assessment tool), dated 12/20/24, the MDS indicated Resident 8 had an acute change in mental status and altered level of consciousness on 12/20/24. Review of the record, titled, Residents 8's Order Summer Report (OSR), dated 11/11/24, the OSR indicated, Resident has capacity to make her decisions, however, POA demands all decisions for healthcare and financial go thru [through] her . During a review of Resident 8's Nurse Practitioner Note (NPN), dated 12/30/24 at 5 p.m., the NPN…

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 follow physician orders for one of three sampled residents (Resident 1) when a physician's order for Prednisone (a steroid medication used to reduce the inflammation in the body) was not followed upon resident's discharge from the hospital and when the facility did not follow up on another physician's instructions to lower the Prednisone dose. These failures resulted in Resident's 1 to receive Prednisone for an additional 17 days which increased the potential to affect Resident 1's health and experienced unwanted side-effects such as oral thrush (infection in the mouth) and fluid buildup in the body (when fluid isn't removed from the body by normal methods). Findings: A review of the admission Record indicated the facility originally admitted Resident 1 in 2021 with multiple diagnoses which included chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing) and kidney failure with dependence on dialysis (a treatment to clean the blood and extra fluids through a machine when the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect one of 4 sampled residents (Resident 2) from abuse when Resident 1 hit Resident 2 on the arm during an altercation. This failure resulted in Resident 2 sustaining a skin tear on the left forearm and for Resident 2 to potentially experience emotional distress. Findings: A review of Resident 1's admission record indicated he was admitted with multiple diagnoses including hemiplegia (paralysis or inability to move and feel on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke, blood flow to the brain was blocked) affecting the right dominant side. A review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 7/26/24, indicated, he was cognitively intact. A review of Resident 2's admission record indicated he was admitted with multiple diagnoses including paraplegia (paralysis of the lower half of the body including the legs) and unruptured cerebral aneurysm (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 one of four sampled residents (Resident 1) was given a 30-day discharge notice. This failure reduced the facility's potential to provide Resident 1 enough time to appeal the discharge. Findings: A review of an admission record indicated Resident 1 was admitted to the facility on [DATE], with several diagnoses which included diverticulitis (disease caused by an inflammation in a small pocket of lower part of the intestine), gastrointestinal hemorrhage (bleeding in the digestive system), breast cancer, difficulty in walking, and muscle weakness. A review of Resident 1's Physician's Orders, dated 5/8/24, indicated, Discharge home with home health, physical and occupational therapy, and Aide . During an interview on 8/6/24 at 11:59 a.m., with the Social Services Director (SSD), the SSD stated notice was given to Resident 1 on 5/8/24, and Resident 1 was discharged on that day. A review of Resident 1's Social Services progress note, dated 5/8/24,…

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 dignity was promoted for one of three residents (Resident 1) when the resident did not receive routine baths per their bathing schedule. This failure resulted in Resident 1 feeling upset, angry, and dirty. Findings: According to the Resident Face Sheet, Resident 1 was admitted in 2021 with diagnoses that included a leg fracture, hypertension, and cancer. During an interview on 7/31/24 at 10:35 a.m. with Resident 1, Resident 1 stated that he had not received a bath for the last three weeks. Resident 1 stated . my hair was dirty and all stuck to each other, and this made him feel pissed off. Resident 1 further stated he looked awful, didn't feel very good, and that having a bath everyday would be good. During a review of Resident 1's bathing task sheet on 7/31/24 at 11:15 a.m., the bathing task sheet indicated that Resident 1 had one partial bath on 7/19/24, with no documented bathing on 7/2/24, 7/5/24, 7/9/24, 7/12/24, 7/16/24, 7/28/24 and 7/29/24. During a review of Resident 1's care plan on 7/31/24 at…

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 have an effective pest control program and maintain sanitary conditions in the kitchen, when several flies were seen inside the kitchen and food preparation area and, small worm like creatures were observed crawling on the kitchen floor underneath the dishwashing sink. These failures had the potential to result in foodborne illnesses or inflict harm to 170 residents who received food from the kitchen. Findings: During an interview with Dietary Manager (DM) on 7/10/24, commencing at 10:05 a.m., the DM was asked if the facility had issues with flies in the kitchen. The DM stated, Might have some . Flies are worse in the summer, we have some here and there, but not a lot. The DM stated the facility had pest control company coming every month to replace fly trappers and glue traps inside the kitchen and to spray outside the facility. The DM added, If any serious issues with flies or other insects, we call pest control and they come more often. A tour of the kitchen including the food preparation area and storage…

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

Based on observation, interview, and record review, the facility failed to store foods according to professional standards for food safety when: 1. There were opened and unlabeled food items in the freezer and the cooking area; 2. A yellow cutting board was stained with black markings; and, 3. [NAME] puffy substances were observed at the bottom of the steel storage racks in the dry storage room. These failures had the potential to increase the risk of foodborne illnesses for a total of 164 residents who received food from the kitchen. Findings: 1. During the initial kitchen tour on 5/21/24 starting at 8:21 a.m., the Dietary Manager (DM) acknowledged the following food items were found opened and without labels (stickers on the packages to indicate the opened date and expiration date): - one gallon of milk in the refrigerator; - one opened box of cookie dough in the freezer; and, - 3 cans of vegetable oil spray in the cooking area. The DM stated, it was important to label the opened food items so you know when they were opened and when they should be discarded. A review of facility…

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 Resident's personal and medical information was protected when the dietary tray tickets were discarded in the general trash. This failure had the potential to compromise the privacy and confidentiality of the 164 residents receiving facility prepared meals. Findings: During a Kitchen Tour on 5/21/24 at 8:21 a.m., in the dishwashing area, tray tickets with resident's name, ID number, room number, diet order and texture, food likes/dislikes, and food allergies were observed in the general trash bin. The Dietary Manager (DM) confirmed the resident's tray tickets were in the general trash. He stated, he was aware of the issue of throwing the tray tickets in the general garbage trash and he believed it was a HIPAA (Health Insurance Portability and Accountability Act, group of law designed to protect medical records and other health records) violation if the tray tickets were thrown in the general trash bin. During an interview on 5/23/24 at 8:44 a.m., the Registered Dietitian (RD) stated, dietary tray…

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 accurate accountability of controlled medications (medications with high potential for abuse or addiction) when random controlled medication audits of the Medication Administration Record (MAR) and Controlled Drug Record (CDR) for three out of three residents (Residents 30, 119 and 120) did not reconcile to indicate the medications were given to the residents. This failure resulted in the facility not having accurate accountability of controlled medications and the potential for abuse, misuse, and diversion of these medications. Findings: Resident 30 had a physician's order dated 12/2/23 for Morphine (medication used to treat moderate to severe pain) 15 milligrams (mg, a unit of measurement), one tablet every 12 hours for pain management. The MAR indicated one tablet was administered to Resident 30 on 5/12/24 at 8 a.m. The CDR did not indicate Morphine was signed out for Resident 30 on this date and time. The CDR also indicated the tablet count was 21 on 5/11/24 at 8 p.m. but the count was 20 on the succeeding entry…

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 consistently monitor, and document side effects and behaviors associated with psychotropic medications (medications that affect the mind, emotions, and behavior) use for one of 33 sampled residents (Resident 91). This failure had the potential for unnecessary use of psychotropic medications for Resident 91. Findings: A review of Resident 91's clinical record indicated he was originally admitted to the facility winter of 2021 with multiple diagnoses that included depression (mood disorder that causes a persistent feeling of sadness and loss of interest) and other psychotic disorder (mental disorders characterized by disconnection from reality which results in strange behavior often accompanied by disturbances of thought) not due to a substance or known physiological condition. A review of Resident 91's physician's order indicated the following psychotropic medications: OLANZapine Oral Tablet 7.5 MG (MG, milligram, unit of measurement) (Olanzapine) Give 1 tablet by mouth at bedtime for Psychosis M/B [manifested…

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 opened biological's (medicine derived from living organisms), eye drops, and ear drops were dated once opened, appropriately labeled to correctly identify which resident they were for, and were not available for resident use past their expiration date for a census of 164. These failures had the potential for residents to receive medications with unsafe or reduced potency from improper storage or being used past their expiration date. Findings: During a concurrent observation and interview on 05/21/24 at 3:11 p.m. with Licensed Nurse (LN) 6, an inspection of the Station 4 Back Hall Medication Cart identified the following medications past the recommended use-by-date: - One bottle of Artificial Tears eye drops (used to relieve dry eyes) 15 mL (milliliters, a unit of measurement) - labeled opened on 4/23 - One bottle of LubriFresh P.M. Nighttime eye ointment (used to relieve irritation and dryness of the eye) 3.5 g (grams, a unit of measurement) - open date 11/2/23 LN 6 confirmed the observations 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 follow and maintain an effective infection prevention and control program for a census of 164 when : 1. There were unsanitary conditions in the laundry room; 2. Unlabeled urinals were found in shared bathrooms of two rooms and in Resident 15's shared bathroom; 3. An unlabeled jug of distilled water was found on the floor inside Resident 119's room; and 4. Staff personal belongings and a cigarette lighter were found on medication carts. These failures had the potential to spread germs and cause infection among residents, staff, and visitors. Findings: 1. In a concurrent observation and interview on 5/23/24 starting at 11:53 a.m. with the Maintenance Director (MD) in the laundry room, the vent on the ceiling right above the table that had clean laundry, appeared to be dusty. The MD confirmed that the vent was dirty and stated we clean this every day, they must have missed one spot . When asked what can happen to the clean clothes on the table…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure resident rights were maintained for one (Resident 31) out of a census of 164 when the RP (responsible party) was not given the opportunity to consent for a placement of PPD skin test (a test to help diagnose tuberculosis (TB), a lung illness) and an addition of D-Mannose (a supplement to help prevent urinary tract infections) to Resident 31's medication profile. This failure resulted in Resident 31's RP not being able to participate in the plan of care and Resident 31 receiving medical treatment without proper consent. Findings: A review of Resident 31's admission record-indicated that Resident 31 was first admitted to the facility in the fall of 2016 with several diagnoses including hemiparesis (weakness) and hemiplegia (unable to move) following cerebral infarction (decreased blood flow to the brain affecting dominant side, dysphagia (trouble swallowing) following cerebral infarction, and functional quadriplegia (paralysis of all…

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 protect one of 33 sampled residents' (Resident 106) property from loss when Resident 106's inventory sheet was not signed and not verified for accuracy. This failure resulted in Resident 106 losing her phone and feeling sad, and decreased the facility's capabilities on protecting residents' properties from loss. Findings: During a review of Resident 106's admission records, Resident 106 was admitted in November of 2021 with diagnoses which included hemiplegia and hemiparesis (weakness of one side of the body) following cerebral infarction (damage to tissues in the brain due to loss of oxygen to the area). Resident 106's minimum data set (MDS, an assessment tool), dated 2/8/24, indicated Resident 106 had moderate cognitive impairment. During an interview on 5/21/24 at 8:54 a.m. with Resident 106, Resident 106 stated, My phone was lost here when I moved to this room several months ago, I told my son, reported to staff, everybody looked, no one found it, that made me feel terrible, my [family members] call me…

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 develop a comprehensive person-centered care plan for one of 33 sampled residents (Resident 126) when Resident 126's care plan did not address the order for nectar thick fluid consistency when it was initiated. This failure had the potential for the order to be missed and not implemented. Findings: A review of Resident 126's clinical record indicated she was admitted in 7/2022 with diagnoses including cerebral infarction (stroke, blood flow to the brain is disrupted) with residual effects and seizures. A review of Resident 126's Minimum Data Set (MDS, an assessment tool used to guide care), dated 4/18/24, indicated that Resident 126 had severe cognitive impairment, unable to make own healthcare decisions. A review of Resident 126's Order Summary Report, dated 10/17/23, and the quarterly Nutritional Risk Review, dated 4/18/2024, both documents indicated a diet order of finger food regular chopped meat texture with thickened liquids nectar consistency. In a concurrent interview and record review on 5/24/24 at 10:28 a.m. with…

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

Based on interview and record review, the facility failed to meet professional standards of quality for Resident 59 in a census of 167 when Licensed Nurse (LN) 12 and LN 13 failed to report to the facility's physician about Resident 59's verbalization to commit suicide. This failure had the potential to adversely affect Resident 59's safety. Findings: A review of Resident 59's 'admission Record' indicated Resident 59 was admitted to the facility under Hospice services in early April 2024 with terminal diagnosis of cognitive social or emotional deficits following Cerebral Vascular Accident (damage to the brain from interruption of its blood) with underlying Dementia (group of thinking and social symptoms that interferes with daily functioning), Bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) and depression. In a review of Resident 59's Minimum Data Set (MDS, a standardized assessment tool), dated 4/9/2024, the section about the resident's mood showed symptoms of little interest or pleasure in doing things,…

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 33 sampled residents (Resident 43) received care in accordance with professional standards when Resident 43 was not turned and repositioned every two hours as ordered. This failure increased Resident 43's risk to develop skin breakdown. Findings: A review of an admission Record indicated Resident 43 was admitted in late 2/2015 with diagnoses including contractures (fixed stiffening of the muscle fibers) of the upper extremities, hips, and ankles and a history of left ankle pressure ulcer (localized damage to skin and soft tissue because of prolonged pressure and shear). During observations on 5/22/24 at 7:50 a.m., 9:50 a.m. and 10:36 a.m., Resident 43 was lying flat on his back with both legs bent to the side. A review of Resident 43's Minimum Data Set (MDS, an assessment tool used to guide care) dated 3/17/24, showed he was dependent with bed mobility which required two-person assistance to complete the activity. A review of Resident 43's Order Summary Report dated 1/6/2022 and 11/14/2023…

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

Based on observation, interview, and record review the facility failed to provide necessary care and services for two of 33 sampled residents (Resident 126 and Resident 153) when: 1. Resident 126's order for thickened fluid consistency was not implemented; and 2. The fluid restriction order was not maintained and accurately monitored for Resident 153. These failures had the potential to increase the risk of aspiration for Resident 126 and to delay the improvement of Resident 153's bilateral lower extremity edema (swelling caused by trapped fluid in the body tissue). Findings: 1. A review of Resident 126's clinical record indicated she was admitted in 7/22 with diagnoses including cerebral infarction (stroke, blood flow to the brain is disrupted) with residual effects and seizures. A review of Resident 126's Minimum Data Set (MDS, an assessment tool used to guide care), dated 4/18/24, indicated that Resident 126 had severe cognitive impairment, unable to make own healthcare decisions. A review of Resident 126's Order Summary Report, dated 10/17/23, indicated a diet order of finger…

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 physician's order to change the oxygen cannula (a small, flexible tube with two open prongs used to deliver supplemental oxygen to the nose) was followed for two of 33 sampled residents (Resident 27 and Resident 99). This failure increased the potential for residents to have infections (growth of germs) caused by oxygen tubing not being changed as ordered. Findings: 1. A review of the 'admission RECORD' indicated Resident 27 was admitted with diagnoses including acute respiratory failure with hypoxia (a condition wherein there was not enough oxygen in the blood). A review of Resident 27's physician order, dated 4/23/24, indicated, Change Nasal Cannula, as needed AND every night shift every Sun [Sunday]. In an observation on 5/21/24 at 11:02 a.m., Resident 27's oxygen tubing was dated 5/12/24. A concurrent observation and interview was conducted on 5/21/24 at 3:25 p.m. with the Licensed Nurse 5 (LN 5). Resident 27's oxygen tubing was dated 5/12/24. The LN 5 stated she would check Resident 27'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 the fluid intake for one of 33 sampled residents (Resident 27) was accurately monitored and communicated to the physician. This failure increased the potential for Resident 27 to experience fluid overload (too much fluid in the body). Findings: A review of the 'admission RECORD' indicated, Resident 27 was admitted with diagnoses including end stage renal disease (the kidneys [remove waste products from the blood] can no longer function on their own) and dependence on renal dialysis (the blood goes through a dialyzer [special machine removing waste and extra fluid from the blood] before it is pumped back to the body). A review of Resident 27's physician order dated 4/23/24 indicated, Fluid Restrictions- Trial 1 L [liter - approximately 34 fluid ounces]/day. every shift for Trial period recommended by Dialysis RD [Registered Dietitian] Please notify NP [Nurse Practitioner] if [Resident 27] noncompliant. 1.0 L [liter] FR [Fluid…

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

Based on interview, and record review, the facility failed to ensure one of 33 sampled residents (Resident 10) was free from unnecessary medication when Resident 10's antibiotic (medication used to treat infections caused by bacteria) was renewed without documented clinical rationale. This failure resulted in unnecessary medication for Resident 10, which had the potential for increased risk of antibiotic resistance and exposure to side effects associated with prolonged antibiotic use. Findings: During a review of Resident 10's admission record, the record indicated Resident 10 was admitted to the facility in February of 2024 with multiple diagnoses which included overactive bladder (a problem with the organ that stores urine that causes the sudden need to urinate), chronic kidney disease (gradual loss of kidney function), and urinary tract infection (UTI, an infection in any part of the system of organs that makes urine). Resident 10's Minimum Data Set (MDS, an assessment tool) indicated Resident 10 had intact cognition. During an interview on 5/22/24 at 9:09 a.m., within the…

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

Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided for 1 of 9 sampled residents (Resident 7) when her fall risk care plan was not consistently implemented. This failure had the potential to increase the risks for falls for Resident 7 who sustained multiple falls in the past. Findings: A review of Resident 7's clinical records indicated, she was admitted to the facility summer of 2019 with multiple diagnoses that included muscle weakness (generalized) and repeated falls. Her most recent Minimum Data Set (MDS, an assessment tool) indicated she required assistance of two or more staff for transferring to wheelchair and to bed. A review of Resident 7's .Communication Form dated 3/30/24 and 4/10/24 indicated Resident 7 had a fall on both days. A review of Resident 7's REHAB -STATUS POST FALL SCREEN, dated 4/2/24 indicated, NSG[nursing] reports finding [Resident 7] sitting on the floor at her bedside on her bedside fall mat. [Resident 7] stated that she fell during an attempt to self-transfer. At baseline, [Resident 7] .is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide a copy of medical records for one resident (Resident 1) of three sampled residents when Resident 1's Responsible Party (RP) did not receive the medical record via electronic mail (email) as requested. This failure decreased the facility's potential to provide resident medical records consistent with state laws and regulations. Findings: A review of an admission record indicated Resident 1 was initially admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure with hypoxia (when oxygen is unavailable in sufficient amounts to sustain bodily function). This admission record also indicated Resident 1 had a RP and POA (Power of Attorney, a person chosen as a representative to make health care and/ or financial decisions for a resident who is unable to do so). A review of a facility document titled Patient Authorization for Disclosure of Health Information, dated 10/11/23 at 3 p.m., indicated, .authorize the use 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.

Based on interview and record review, the facility failed to provide nursing services in accordance with professional standards for one of three sampled residents (Resident 1), when the facility did not follow a dental provider post operative instructions after Resident 1 had a dental surgical procedure and had her teeth extracted. In addition, the facility failed to assess Resident 1 for oral discomfort and/or pain, bleeding, and other complications associated with teeth extraction. This failure resulted in Resident 1's experiencing oral pain and had the potential to cause bleeding and other complications related to the oral surgical procedure. Findings: A review of the admission Record indicated the facility admitted Resident 1 in the summer of 2022 with multiple diagnoses which included depression, anxiety, and chronic pain. A review of the Minimum Data Set (MDS, an assessment and care planning tool), dated 8/30/23, indicated Resident 1 had no memory impairment. During an observation and interview on 11/8/23, at 11:50 a.m., Resident 1 was in a wheelchair, alert and oriented.…

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 monitor and report changes for one of four sampled residents (Resident 1) when: 1. Resident 1 was not monitored by nursing staff every day after a fall, and; 2. Medical Providers (MP) were not made aware by staff of abnormal vital signs (measurements of the body's most basic functions) and mood when Resident 1 had a documented low temperature and oxygen saturation (a measure of the oxygenation in the blood). These failures had the potential to delay care and decreased the potential for medical interventions to prevent a worsening change of condition. Findings: 1. A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in April 2021 with diagnoses that included hemiplegia (complete paralysis of one side of the body) and hemiparesis (partial weakness that affects one side of the body) of the right side, abnormal weight loss, urinary tract infections and frequent falls. During a review of Resident 1's Nurse's Note, dated 10/03/2023 at 12:59 p.m., the nurse's note indicated, resident had 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.