Bakersfield Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure three of 53 sampled residents (Resident 79, Resident 23, and Resident 81) were treated with respect and dignity when facility staff converse in a language other than the resident's primary language while providing care. This failure had the potential to negatively affect Resident 79, Resident 23, and Resident 81's psychosocial well-being.Findings:During a review of Resident 79's Minimum Data Set, (MDS - an assessment tool), dated 12/18/25, the MDS indicated Resident 79's BIMS (Brief Interview for Mental Status- standardized assessment tool used to evaluate the mental processes that allow individuals to think, learn, and remember) score was 15 (13 to 15 points indicates the resident has cognitive intactness).During a review of Resident 79's admission Record, (AR), the AR indicated, Resident 79's primary language was English.During an interview on 4/9/26 at 2:34 p.m. with Resident 79, Resident 79 stated Certified Nursing Assistants (CNAs) will…

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 their policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, when allegations of abuse were not investigated timely for one of 53 sampled residents (Resident 81). This failure resulted in Resident 81's abuse allegation not being investigated timely.Findings:During a review of the facility provided document titled, Resident to Resident Altercation Investigation for [Resident 81] (RRAI), dated 4/9/26, the RRAI indicated, Interview with [Certified Nursing Assistant (CNA) 1] PM Shift. [CNA 1] stated that on 04/03/2026, [Resident 81] informed him that his roommate had hit him. During an interview on 4/15/26 at 4:21 p.m. with Director of Nursing (DON), DON stated the alleged abuse occurred on 4/3/26. DON stated the abuse allegations were not reported to the facility until 4/9/26. DON stated the investigation did not start until 4/9/26 (6 days after the alleged abuse was reported to facility's staff).During a review of the facility's policy and procedure (P&P)…

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

Based on observation, interview, and record review, the facility failed to ensure allegations of abuse were reported timely for one of three sampled residents (Resident 81). This failure resulted in Resident 81's abuse allegation not being reported timely and delaying the investigation.Findings:During a review of Resident 81's Minimum Data Set, (MDS - an assessment tool) dated 2/1/26, the MDS indicated, Resident 81's BIMS (Brief Interview for Mental Status- standardized assessment tool used to evaluate the mental processes that allow individuals to think, learn, and remember) score was 15 (13 to 15 points indicates the resident has cognitive intactness).During a concurrent observation and interview on 4/9/26 at 2:17 p.m. with Resident 81, outside of Resident 81's room, Resident 81 stated that his roommate hit him last week. Resident 81 stated he blocked the hit from Resident 109 with his right forearm and he sustained a bruise to his right forearm; several bruises were observed on right forearm of various stages of healing. Resident 81 stated he informed his Certified Nursing…

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

Based on interview, and record review, the facility failed to accurately complete the Pre-admission Screening and Resident Review (PASRR - federal requirement to help ensure that individuals are not incorrectly placed in nursing homes or long-term care instead of a psychiatric setting), for one of two sampled residents (Resident 4). This failure had the potential for Resident 4 to be placed in an inappropriate setting and not receive required services.Findings:During a review of Resident 4's Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 2/20/24, the PASRR indicated, Level I- Positive.During a concurrent interview and record review on 5/13/26 at 10:34 a.m. with Quality Assurance (QA) Nurse, Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 2/20/24 was reviewed. QA Nurse stated Resident 4's PASRR was positive for mental health evaluation but there was no Level II PASRR completed for Resident 4.During a review of Resident 4's admission Record (AR), dated 5/14/25, the AR indicated Resident 4 had diagnosis of Bipolar disorder (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 implement care plans for two of 53 sampled residents (Resident 51 and Resident 70). This failure had the potential for Resident 51 and Resident 70's safety to be at risk.Findings:During a review of Resident 51's care plan (a comprehensive, personalized document that outlines the specific needs of an individual requiring care, detailing the type of support, how it will be provided, and the goals of the care) with the focus on Falls: (Resident 51) is at risk for falls, initiated 3/23/26. The care plan indicated a few of the interventions were Floor mat to left and right side, initiated 4/2/26 and Keep call light within reach. initiated 3/23/26. During a concurrent observation and interview on 4/16/26 at 9:43 a.m. with Certified Nursing Assistant (CNA) 3, inside Resident 51's room. Resident 51 was sleeping in bed. CNA 3 located Resident 51's call light pad on his nightstand approximately three feet from the bed. CNA 3 stated Resident 51 would not been able to reach his call light.During a concurrent observation…

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

Based on observation, interview, and record review, the facility failed to administer medication according to the physician order for one of six sampled residents (Resident 23) when Resident 23 had an order for the administration of one inhalation (drawing the medication into the lungs) of Trelegy Ellita inhalation Aerosol Powder (a medication to treat inflammation of the lungs) 100-62.5-25 MCG (micrograms-unit of measurement)/ACT (actuation - refers to a single spray, puff, or activation of an inhaler) and Resident 23 did not receive the medication. This failure had the potential for Resident 23 to experience negative health outcomes due to breathing problems.Findings:During a review of Resident 23's Order Summary Report (OSR), dated 3/25/26, the OSR indicated, Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 100-62.5-25 MCG/ACT I inhalation inhale orally one time a day.During a review of Resident 23's Communication Result Report (CRR), dated 5/12/26 at 2:47 p.m., the CRR indicated Trelegy was reordered from the pharmacy on 5/12/26.During a concurrent observation 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 one of 53 sampled residents (Resident 51) was turned and repositioned every two hours. This failure had the potential for delayed wound healing and worsening of pressure injuries (localized injury to the skin and/or underlying tissue usually over a bony prominence, from pressure, or pressure in combination with shear and/or friction) for Resident 51.Findings:During an interview on 4/23/26 at 1:27 p.m. with Treatment Nurse (TN), TN stated turning and repositioning every two hours was the facility's standard for residents with pressure injuries. TN stated everyone with a pressure injury should have a care plan for turning and repositioning every two hours. During a review of Resident 51's Minimum Data Set (MDS - an assessment tool), dated 3/27/26, the MDS indicated, Resident 51 was dependent (helper does all the effort) for rolling left and right (the ability to roll from lying on back to left and right side and return to lying on back on the bed), sit to lying (the ability to move from sitting on side of bed to lying…

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 assessment was accurate for one of two sampled residents (Resident 11). This failure had the potential for Resident 11 to not meeting her nutritional needs.Findings:During an observation on 5/11/26 at 8:50 a.m. in Resident 11's room, Resident 11 was lying in bed with a feeding tube (a soft, flexible, medical device used to deliver liquid nutrition, fluids, and medications directly into the stomach or small intestine) attached to a pole. Resident 11's feeding tube was connected to a bottle with a label of Jevity 1.5 (liquid nutrition formula).During a review of Resident 11's Dietitian Note (DN), dated 4/9/26, the DN indicated, Enteral [the administration of food, fluids, or medication directly into the stomach, typically through the mouth via a feeding tube]: Jevity 1.2 @ [at] 72 ml [milliliter]/hr [hour] x [times] 20 hrs [hours] provides 1440 ml/day, 1728 kcal [kilocalorie]/day, 80 gm [gram] protein/day, 1152 ml FW [free water]/day.During a review of Resident 11's Medication Administration…

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 physician progress notes (PPN) were completed for the months of February, March, and April 2026 for one of three sampled residents (Resident 90). This failure had the potential for a change in condition to go unnoticed and a delay in care.Findings:During a review of Resident 90's admission Record (AR), undated, the AR indicated Resident 90 was admitted to the facility on [DATE].During a concurrent interview and record review on 5/13/26 at 3:41 p.m. with Medical Records Director (MRD), Resident 90's PPN dated 2026 were reviewed. MRD stated there were no PPN for the months of February, March, and April 2026. MRD stated, They (physicians) usually fax them (PPN).During an interview on 5/14/26 at 9:16 a.m. with Minimum Data Set Nurse (MDSN), MDSN stated she could not find the PPN for the last three months. MDSN stated PPN should be completed monthly. During a review of the facility's policy and procedure (P&P) titled, Physician Visits, dated April…

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 their policy and procedure (P&P) titled, MedBank [automated medication dispensing system] Policies & Procedures when narcotic medications (controlled drugs - those drugs highly regulated by the government that carry a high potential for abuse, addiction or physical and psychological dependence) were not counted and documented consistently. This failure had the potential for the facility not to have prompt identification of loss or diversion of narcotic medication.Findings:During an interview on 5/12/26 at 11:31 a.m. with Director of Nursing (DON), DON stated there was no process in place to count the narcotics in MedBank. DON stated facility was not counting the narcotics daily in the MedBank. DON stated MedBank narcotics should be counted daily.During a review of facility's P&P titled MedBank Policies & Procedures, dated 10/2025, the P&P indicated, b. The DON [Director of Nursing] is responsible for ensuring that the cycle counting of controlled drugs in the MedBank system is performed and documented on a daily…

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

Based on interview and record review, the facility failed to ensure two of six sampled residents' (Resident 51 and Resident 6) clinical documentation was complete and accurate. This failure resulted in Resident 51 and Resident 6's clinical records to be incomplete and inaccurate.Findings: 1.During a review of Resident 51's Minimum Data Set (MDS - an assessment tool), dated 3/27/26, the MDS indicated, Resident 51's Brief Interview for Mental Status (BIMS - standardized assessment tool used to evaluate the mental processes that allow individuals to think, learn, and remember) score was 15 (13 to 15 points indicates the resident has cognitive intactness). During an interview on 4/15/26 at 1:58 p.m. with Resident 51, Resident 51 stated he was dropped by a Certified Nursing Assistant (CNA 14) on Monday (4/13/26). Resident 51 stated he was supposed to be transferred with the use of a Hoyer lift (mechanical lift) and there should always be two CNAs but on Monday CNA 14 came in and transferred him alone. Resident 51 stated the Hoyer lift tipped over and he hit his head and neck on the foot…

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 flu vaccines (an immunization to protect from the flu) were offered to two of five sampled residents (Resident 11, Resident 60). This failure had the potential for the flu spreading to all the residents in the facility due to not receiving immunizations.Findings:During a concurrent interview and record review on 5/13/26 at 1:45 p.m. with IP, IP reviewed Resident 11's immunization record. IP stated Resident 11 did not receive a flu vaccine. IP stated there was no documentation of Resident 11 was offered the flu vaccine. IP stated, Resident [11] missed the flu shot.During a concurrent interview and record review on 5/13/26 at 1:49 p.m. with IP, IP reviewed Resident 60's immunization record. IP stated Resident 60 has no record of immunization. IP stated, I missed it [to record Resident 60's immunization]. I did not get to verify.During the review of the facility's policy and procedure (P&P) titled, Influenza Vaccine, dated March 2022, the P&P indicated, All residents and employees who have no medical contraindications…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of two Hoyer lift (equipment used to safely lift a person with limited mobility) battery chargers were working correctly affecting two of five sampled residents (Resident 1 and Resident 2) safety using the Hoyer lift when:1. One of two Hoyer lift battery chargers was not charging the Hoyer lift batteries2. Maintenance logs and records were not being kept for the maintenance of the Hoyer lifts and Hoyer lift batteries These failures had the potential to result in the Hoyer lift batteries not working and placing residents at risk for injuries and accidents.Findings:1. During an interview on [DATE] at 1:27 p.m. with Resident 1, Resident 1 stated in the past (date unknown) while she was in bed in a full body sling (a medical transfer device that attaches to a Hoyer lift and supports the entire body when lifting or moving a person with limited body movement), the Hoyer lift had gone dead (battery died) with her in it several…

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 three of three sampled residents (Resident 1, Resident 2, and Resident 3) call lights were answered timely. This failure resulted in a negative psychosocial effect for Resident 1, Resident 2, and Resident 3.Findings:During a review of Resident 1's Minimum Data Set, (MDS - an assessment tool) dated 2/1/26, the MDS indicated, Resident 1's BIMS (Brief Interview for Mental Status- standardized assessment tool used to evaluate the mental processes that allow individuals to think, learn, and remember) score was 15 (13 to 15 points indicates the resident has cognitive intactness). Resident 1 was dependent (helper does all the effort) sit to stand (the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed) and for chair/bed to chair transfers (the ability to transfer to and from bed to chair or wheelchair).During a review of Resident 1's care plan with the focus on ADL (activities of daily living- bathing, dressing, toileting, transferring/mobility, 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 medications were:1) Administered timely for one of three sampled residents (Resident 1).2) Medications were administered per physicians' orders for one of three sampled residents (Resident 2).These failures had the potential for Resident 1 and Resident 2 to suffer adverse outcomes. Findings:1.During a review of Resident 1's Minimum Data Set, (MDS - an assessment tool) dated 2/1/26, the MDS indicated, Resident 1's BIMS (Brief Interview for Mental Status- standardized assessment tool used to evaluate the mental processes that allow individuals to think, learn, and remember) score was 15 (13 to 15 points indicates the resident has cognitive intactness).During an observation and interview on 2/25/26 at 2:09 p.m. with Resident 1, Resident 1 stated medications vary sometimes he get them timely and sometimes he does not. Resident 1 stated he has pain in his arm and leg. Resident 1 stated when he must wait for medications it is terrible, he stated it makes his pain worst.During a review of Resident 1's Physicians Orders,…

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 able to make and receive phone calls privately. This failure had the potential to violate Resident 1's rights. Findings: During a review of Resident 1's Minimum Data Set, (MDS - an assessment tool) dated 11/3/25, the MDS indicated, Resident 1's BIMS (Brief Interview for Mental Status- standardized assessment tool used to evaluate the mental processes that allow individuals to think, learn, and remember) score was 15 (13 to 15 points indicates the resident has cognitive intactness). During an interview on 1/27/26 at 11:40 a.m. with Resident 1, Resident 1 stated he has been at the facility for about six years. Resident 1 stated up until about six months ago the facility used to have land line phones in the rooms, but now there are no phones in the rooms anymore. He stated the facility will not allow him to set up a land line phone in his room. Resident 1 stated, I am . years old and blind I cannot use…

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 plan of care for one of two sampled residents (Resident 1) when Resident 1 was at risk for contracting head lice after her roommate (Resident 2) contracted head lice. This failure had the potential for Resident 1 to contract head lice and spread infection.Findings:During a review of Resident 2's Change in Condition Evaluation (CCE), dated 12/22/25, the CCE indicated, resident [2] observe [sic] with hair lice.During a review of Resident 1's CCE, dated 12/24/25, the CCE indicated, Resident [1] observed with three counts of live head lice at scalp. One scab noted r/t [related to] Hx [history] of generalized itching.During a concurrent interview and record review on 12/26/25 at 3:37 p.m. with Infection Preventionist (IP), Resident 1's Care Plan (CP), dated 12/24/25, was reviewed. The CP indicated, Resident [1] has head lice. IP stated there was no care plan developed for Resident 1 when her roommate (Resident 2) contracted head lice on 12/22/25. IP stated Resident 1 should have had a care plan developed for at risk…

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 call lights were answered timely for two of five sampled residents (Resident 4 and Resident 5). This failure had the potential to result in unmet care needs, and to negatively impact the physical, mental, and psychosocial well-being for Resident 4 and Resident 5.Findings:During a concurrent observation and interview, on 11/19/25 at 1:23 p.m. with Resident 4 in his room, Resident 4 stated he uses the call light to request water and to be changed. Resident 4 stated he looks at the clock observed across from his bed to calculate his wait time. Resident 4 stated his best wait time is 30 minutes, but he has waited an hour for his call light to be answered. Resident 1 stated the call light wait time makes him just want to leave the facility.During a review of Resident 4's Minimum Data Set, (MDS - an assessment tool) dated 9/16/25, the MDS indicated, Resident 4's BIMS (Brief Interview for Mental Status) score was 15 (13 to 15 points indicates 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 interview and record review, the facility failed to ensure one of three sampled licensed staff (Certified Nursing Assistant [CNA] 2) had the skills and abilities necessary to provide adequate nursing care to the facility's residents. This failure had the potential for CNA 2 to be unable to appropriately care for residents, not meeting residents' needs. Findings:During a concurrent interview and record review, on 11/19/25 at 2:06 p.m. with the Administrator, CNA 2's employee file was reviewed. CNA 2's Job Description, signed on 12/13/23 by CNA 2 was reviewed. CNA 2's CNA Skills Checklist -Performance Objectives, (CNASCPO) dated 12/7/24 was reviewed. CNA 2's CNASCPO, indicated there were no completed skills competency check off. The Administrator confirmed the findings.During review of the facility's policy and procedure (P&P) titled, Competent Nursing, revised August 2022, the P&P indicated, 1. Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions…

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 responsible party (RP) and hospice provider for one of three sampled residents (Resident 1) were notified when a psychotherapeutic medication (a class of drugs that alter brain chemistry to treat cognitive, emotional, and behavioral conditions) was discontinued. This failure resulted in Resident 1's RP and hospice provider not to be part of the decision-making process. Findings:During a review of Resident 1's admission Record, (AR) the AR indicated, Resident 1 was admitted on [DATE], with diagnoses included senile degeneration of the brain (a syndrome of progressive decline in mental functions; impacting memory, reasoning, and the ability to perform everyday activities, caused by an underlying disease of the brain), Dementia (a decline in mental ability that affects a person's daily life; characterized by a loss of cognitive functioning, such as thinking, remembering, and reasoning, that worsens over time), and major depressive disorder 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 follow its policy and procedure for Access to Personal and Medical Records, for one of three sampled residents (Resident 1). This failure resulted in violation of Resident 1's rights. Findings: During a concurrent interview and record review, on 4/15/25 at 12:39 p.m. with Medical Records Director (MRD), Resident 1's Authorization to Release Medical Records, (ARMR) dated 3/31/25 (Monday), signed by Resident 1 was reviewed. MRD stated the ARMR did not indicate the request was for legal reason and the medical records request was made by Resident 1. Resident 1's Certified Mail Receipt, dated 4/15/25 (15 days after ARMR was submitted) was reviewed. MRD stated Resident 1's medical record should been provided to Resident 1 within two business days. During a review of the facility's policy and procedure (P&P) titled, Access to Personal and Medical Records, revised May 2017, the P&P indicated, Each resident has the right to access and /or obtain copies of his or her personal and medical records upon request. 5. The resident may…

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 sufficient staffing for one of three sampled residents (Resident 2), when call lights were not answered timely. This failure resulted in delay in meeting Resident 2's basic needs and potential for emotional distress. Findings: During a review of Resident 2's Minimum Data Set, (MDS - an assessment tool) dated 3/10/25, the MDS indicated Resident 2's BIMS (Brief Interview for Mental Status) score was 15 (13 to 15 points indicates the resident has cognitive intactness). The MDS indicated Resident 2 needed substantial/maximal assistance (helper does more than half the effort) for toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement) and Resident 2 was dependent (helper does all the effort) for toilet transfer (the ability to get on and off the toilet or commode). The MDS indicated Resident 2 was always continent (the ability to control one's bladder) of urine. During a review of Resident 2's care plan with the focus on ADL/Mobility, revised 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 interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) medical records were accurate. This failure had the potential to affect the continuity of care for Resident 2. Findings: During an interview on 4/16/25 at 3:14 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 2 had a green sticker on his door and the green sticker indicated Resident 2 was on fluid restriction (limiting the amount of fluids a person can drink). During a review of Resident 2's active care plan with the focus on The (Resident 2) has fluid overload (occurs when there is too much fluid in the body, leading to swelling and other complications), revised on 11/14/23. The care plan indicated interventions were, Fluid restriction 1500ml (milligram-unit of measure) per day. During a concurrent interview and record review, on 4/22/25 at 2:15 p.m. with Director of Nursing (DON), Resident 2's active orders were reviewed. DON stated Resident 2 did not have an active order for fluid restriction. DON stated Resident 2's fluid restrictions order was…

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

Based on interview and record review, the facility failed to ensure medications were administered according to the physician's orders (PO) for one of three sampled residents (Resident 1) when: 1. Resident 1's Docusate Sodium (medication for constipation [problem with passing stool]) was not held for episodes of loose stools. 2. Resident 1 was not administered Imodium or Loperamide (medications to treat diarrhea [loose stools]) for episodes of loose stools. These failures had the potential for Resident 1 to develop skin breakdown due to episodes of loose stools. Findings: 1. During a review of Resident 1's PO, dated 4/10/25, the PO indicated, Docusate Sodium. Give 1 capsule by mouth two times a day for constipation. Hold for loose stool. During an interview on 4/21/25 at 12:50 p.m. with Resident 1, Resident 1 stated she has been having diarrhea since 4/11/25, and the licensed nurses and CNAs (Certified Nursing Assistants) have been aware. During a concurrent interview and record review on 4/21/25 at 4:00 p.m. with Director of Nursing (DON), Resident 1's ADL (Activities of Daily…

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

Based on interview and record review, the facility failed to ensure medications were administered according to the physician's orders (PO) for one of three sampled residents (Resident 1) when Resident 1 did not receive two medications on time. This failure had the potential to result in Resident 1 developing adverse health outcomes due to delay in receiving his medications. Findings: During a review of Resident 1's Order Summary Report, dated 3/26/25, the OSR indicated, Apixaban (medication that helps the blood flow more easily). two times a day for ATRIAL FIBRILLATION (irregular, often rapid heart rhythm) . Metoprolol (medication to treat high blood pressure). two times a day for HYPERTENSION (high blood pressure). During a review of Resident 1's Brief Interview for Mental Status (BIMS), dated 3/20/25, the BIMS indicated Resident 1 had a score of 15 (cognitively intact). During an interview on 3/26/25 at 2:34 p.m. with Resident 1, Resident 1 stated on 3/16/25, he was supposed to be administered his Metoprolol and Apixaban at 9 a.m. but were administered to him at around 12:30 p.m.…

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 the allegation of sexual abuse for one of three sampled residents (Resident 1) was reported timely to California Department of Public Health (CDPH-local stated agency) and local ombudsman (representatives assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences). This failure had the potential for Resident 1 not to be protected from further abuse and resulted in emotional distress. Findings: During a review of the facility provided document titled, Incident Investigation For (Resident 1), dated 2/25/25, the document indicated, Interview conducted by Director of Nursing (DON) on 2/24/25 with (Resident 1) .(Resident 1) has a BIMs (Brief Interview for Mental Status) of 15 (a score of 13 to 15 suggests the resident is cognitively intact). (Resident 1) reported on the night of 02/19/2025 (Licensed Vocational Nurse [LVN] 1) went into her room and kissed her on the corner of her mouth. (Resident 1) stated, It made me feel uncomfortable and very unsafe.…

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 seven sampled residents (Resident 1) was protected from physical and verbal abuse. This failure had the potential to result in physical and psychosocial harm for Resident 1. Findings: During a review of Resident 1's Minimum Data Set, (MDS - an assessment tool) dated 11/28/24, the MDS indicated, Resident 1's BIMS (Brief Interview for Mental Status) score was 3 (a score of 0-7 suggests the resident has severely impaired cognition). The MDS indicated Resident 1 needed substantial/maximal assistance (helper does more than half the effort) with sit to stand (the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed) and chair/bed to chair transfers (the ability to transfer to and from bed to a chair or wheelchair). During a review of Resident 2's Minimum Data Set, 12/12/24, the MDS indicated, Resident 2's BIMS score was 15 (a score of 13 to 15 suggests the resident is cognitively intact). The MDS indicated Resident 2 needed partial/moderate assistance helper does…

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 their policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, when the facility failed to: 1. Submit the SOC 341(Report of Suspected Dependent Adult/Elder Abuse) timely to California Department of Public Health (CDPH-local stated agency) and local ombudsman for two of four sampled residents (Resident 1 and Resident 2). This failure resulted in the allegation of abuse not being reported to CDPH and the local ombudsman timely. 2. Thoroughly investigate resident to resident physical abuse for two of four sampled residents (Resident 1 and Resident 2). This failure had the potential to result in an incomplete investigation. Findings: 1. During a concurrent interview and record review on 2/24/25 at 11:53 a.m. with Director of Nursing (DON), DON confirmed a Resident-to-Resident physical abuse between Resident 1 and Resident 2 happened on 1/31/25. DON was unable to provide evidence the SOC 341 was submitted to CDPH and local ombudsman within 24 hours. During a…

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

Based on interview and record review, the facility failed to consistently implement Interdisciplinary Team (IDT- a group of health care professionals with various areas of expertise who work together to improve patient safety and outcomes) recommendation for two of four sampled residents (Resident 1 and Resident 2). This failure had the potential for Resident 1 and Resident 2's physical and psychosocial needs to be unmet. Findings: During a review of the facility provided document titled, Resident to Resident (Resident 1 and Resident 2) Altercation Investigation, dated 1/31/25, the document indicated, 5-Day Follow-Up (February 05, 2025) . 3. Monitor for mood and delayed signs/symptoms of injury related to altercation. During a review of Resident 1's IDT Note, dated 1/31/25, the IDT note indicated Resident 1 was involved in a Resident-to Resident physical altercation with Resident 2. The IDT note indicated, the IDT recommendation: . Monitor for mood and delayed signs/symptoms of injury related to altercation. During a concurrent interview and record review, on 2/24/25 at 11:53 a.m.…

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 their policy and procedure (P&P) titled, Change in Condition or Status when facility did not complete assessments for three of four sampled residents (Resident 2, Resident 3, and Resident 4) after a verbal altercation incident. This failure had the potential for residents not being assessed and monitored for psychosocial distress. Findings: During a review of Resident 1's Progress Notes (PN), dated 2/13/25 at 12:15 a.m. the PN indicated, [Resident 1] heard [Resident 2] tell her to go to bed. [Resident 1] entered [Resident 2]'s room and told him [Resident 2] to Get out of bed and say that to my face, I'll kick your ass. Resident 1's PN dated 2/13/25 at 1:05 a.m. indicated, [Resident 1] had a verbal altercation with another female resident [Resident 3] regarding waiting for her turn for call light to be answered which escalated to [Resident 1] allegedly threatening the other female resident [Resident 3]. [Resident 1] also allegedly threatened 2 other male residents [Resident 2 and Resident 4] on the night of 2/12/2025.…

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

Based on interview and record review, the facility failed to provide sufficient staffing for three of five sampled residents (Resident 1, Resident 2, and Resident 3), when call lights were not answered timely. This failure resulted in residents' increased wait times for basic needs to be met and had the potential for emergent needs not attended. Findings: During a concurrent observation and interview, on 1/8/25 at 1:52 p.m. with Resident 1 Resident 1 stated call lights take longer at night to be answered. Resident 1 stated she calculates the wait time by looking at the clock observed across from Resident 1's bed. Resident 1 stated she usually call the staff to change her adult briefs (when soiled) and request for pain medications. Resident 1 stated the wait time is 30 to 45 minutes but worst wait time was two hours. Resident 1 stated the long wait time happens two to three nights a week. Resident 1 stated, Makes me feel very disrespected #1, very unsafe #2, and not being treated like I am human, not shown compassion or empathy that to me is inhuman. 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.

Based on interview and record review, the facility failed to ensure professional standards were followed when medications and treatments were not administered according to physicians' orders for two of four sampled residents (Resident 4 and Resident 5). These failures had the potential for worsening skin breakdown and infection to Resident 4 and Resident 5. Findings: During a concurrent interview and record review, on 1/23/25 at 3:49 p.m. with Director of Nursing (DON), DON stated medications and treatment should be administered per physician's orders. DON stated the expectation is the medications and treatment should be documented in the medical record once administered. Resident 4 and Resident 5's Treatment Administration Record, (TAR) for January 2025 were reviewed. DON confirmed the following: Resident 4's TAR, dated January 2025, the TAR indicated, MASD (moisture-associated skin damage- is the general term for inflammation or skin caused by prolonged exposure to a source of moisture such as urine, stool, sweat) to coccyx (tailbone) area, cleanse with NS (normal saline), pat…

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 infection control practices were implemented when: 1. The treatment nurse had long artificial nails. 2. One of one linen cart cover was a mesh (uniform small openings) material, and the mesh cover was frayed in the center. 3. Two of two housekeeping carts trash bins did not have lids. 4. Three of four sample resident rooms (Resident 36, Resident 14 and Resident 133) who were on Enhanced Barrier Precaution (EBP-infection control strategy that uses PPE to reduce the spread infections) had no Personal Protective Equipment supplies (PPE-equipment worn to minimize exposure to a variety of hazards). These failures had the potential to spread infections to residents, staff, and visitors. Findings: 1. During an observation on 11/18/24 at 11:45 a.m. in the hallway, Treatment Nurse (TN) 1 was going in resident's room to provide wound care. TN 1 had long, artificial nails. During an interview on 11/18/24 at 12:20 p.m. with Infection Preventionist Nurse (IPN), IPN stated staff providing direct resident care should…

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 their Advanced Directive (AD - legal document which indicates a person's wishes for medical treatment) policy and procedure (P&P) for three of three sampled Residents (Resident 32, Resident 40, and Resident 28) to provide AD information and obtain a signed or declined AD. This failure had the potential for the facility to be unaware of Resident 32's, Resident 40's, and Resident 28's wishes for treatment. Findings: During a concurrent interview and record review on 11/20/24 at 10:46 a.m. with Director of Admissions (DA), Resident 32's Advance Directive Acknowledgement (ADA), dated 9/9/24, was reviewed. The ADA indicated, I HAVE NOT executed an Advance Directive. DA stated they do not have any documentation that assistance to develop an AD was offered to the resident and declined or accepted. DA stated they don't have a process and their form does not have anywhere to indicate if assistance was offered, accepted or declined. During review of Resident 40's ADA, dated 1/31/24, the ADA indicated, I HAVE NOT executed 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 ensure one of three sampled residents (Resident 19) had informed consent (resident recieves enough information regarding treatment risk and benefits to accept or reject treatment) forms for physician ordered psychotropic (drug that affects behavior, mood, thoughts or perception) medications. This failure had the potential for Resident 19 to be unable to make an informed decision regarding medications. Findings: During a review of Resident 19's admission Record (AR), dated 11/21/24, the AR indicated Resident 19 was admitted to the facility on [DATE] with diagnoses including major depressive disorder (sad mood) and anxiety disorder (feelings of worry). During an interview on 11/18/24 at 8:25 a.m. with Resident 19, Resident 19 stated she had not been included in the decision making regarding the medications prescribed to her for anxiety and depression. During a review of Resident 19's Order Details (OD), dated 7/17/23, 7/18/23 and 1/31/24, the OD…

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 three sampled residents (Resident 3), was treated with dignity while assisting with meals. This failure had the potential to negatively impact emotions, behavior and social needs for Resident 3. Findings: During a concurrent observation and interview on 11/18/24 at 7:49 a.m. with Certified Nursing Assistant (CNA) 5 in Resident 3's room, Resident 3 was laying in bed in an upright position. CNA 5 was standing over Resident 3 while assisting Resident 3 with her meals. CNA 5 stated, I should not be standing over resident while assisting her [Resident 3] with feeding and I should have been at level of resident [3] by sitting down on a chair. During a review of Resident 3's Minimum Data Set (MDS-Assessment Tool), dated 10/18/24, the MDS indicated, Resident 3 required the assistance of one staff with meals. During a review of Resident 3's Care Plan (CP), dated 3/7/24, the CP indicated, ADL [Activities of Daily Living-basic tasks]/Mobility: Resident is at risk for ADL/mobility decline and requires…

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 call light were within reach for two of 48 sampled residents (Resident 186 and Resident 13). This failure had the potential for not meeting the psychosocial and physical needs of Resident 186 and Resident 13 . Findings: During an observation on 11/18/24 at 7:52 a.m. in Resident 186's room, Resident 186 was laying in bed. Resident 186's call light was clipped on the curtain. Resident 186 was unable to reach the call light. During an interview on 11/18/24 at 7:58 a.m. with Certified Nursing Assistant (CNA) 6, CNA 6 stated, Sorry the call light is clipped on resident's [186] curtain. During a review of Resident 186's Minimum Data Set (MDS-Assessment Tool), dated 9/1/24, the MDS indicated, Resident 186 required the assistance of one staff with toileting transfer and toileting hygiene. During a review of Resident 186's Care Plan (CP), dated 11/14/24, the CP indicated, ADL/Mobility: Resident is at risk for ADL/mobility decline and requires assistance related to generalized weakness, abnormal gait, requires…

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 their policy and procedure (P&P) titled, Personal Property, for one of six sampled residents (Resident 50) when Resident 50's belongings were not inventoried and documented on admission. This failure had the potential to result in lack of reimbursement for lost belongings. Findings: During an interview on 11/18/24 at 10:57 a.m. with Resident 50, Resident 50 stated he was missing a grey jacket, blue sweater, and black sweater. During a concurrent interview and record review on 11/20/24 at 1:50 p.m. with Social Services Director (SSD) 1, the facility's record of 2024's loss reports and Resident 50's Personal Belonging Inventory Checklist (PBIC), dated 2/2022 were reviewed. The facility's loss reports for 2024 indicated Resident 50 had not reported any missing clothing items. Resident 50's PBIC was blank. SSD 1 stated when an item of clothing was missing, the facility checked the resident's room, laundry, and surrounding rooms for the missing item. SSD 1 stated if the item was on the resident's inventory sheet, then…

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 three sampled residents (Resident 66) change of condition assessment was completed and the physician was notified of Resident 66's significant weight loss. This failure resulted in Resident 66's physician was not notified of the change in condition and continued weight loss. Findings: During a concurrent interview and record review on 11/21/24 at 3:35 p.m. with Registered Dietitian (RD), Resident 66's Weights and Vitals Summary (WVS), was reviewed. The WVS indicated, Resident 66's weights: 5/6/24 139 lbs (pounds) 6/5/24 134.6 lbs (down 4.4 lbs) 7/2/24 129.6 lbs (down 5 lbs) 8/5/24 129.8 lbs 9/2/24 124.4 lbs (down 5.4 lbs) 10/5/24 119.4 lbs (down 5 lbs) 11/5/24 116.6 lbs (down 2.8 lbs) RD stated Resident 66's weight loss from 6/5/24 to 7/2/24 was 5% and considered significant weight loss. RD stated the three month lookback from 7/2/24 to 10/5/24 was 7.7% and considered significant weight loss. RD stated the six month lookback from 5/6/24 to 11/5/24 was 16% and considered significant weight loss. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of three sampled residents (Resident 10 and Resident 12) had a care plan for preferred activities and interests. These failures had the potential for unmet pyschosocial needs when Resident 10 and Resident 12 were not be provided activities of their choice. Findings: During a review of Resident 10's admission Record (AR), dated 11/21/24, the AR indicated Resident 10 was admitted to the facility on [DATE]. During a concurrent interview and record review on 11/20/24 at 10:41 a.m. with Director of Activities (DOA), Resident 10's medical record (MR) was reviewed. DOA stated Resident 10 did not have an individualized activities care plan and needed one. During a review of Resident 12's AR, dated 11/21/24, the AR indicated Resident 12 was admitted to the facility on [DATE]. During a concurrent interview and record review on 11/20/24 at 10:55 a.m. with DOA, Resident 12's MR was reviewed. DOA stated Resident 12 did not have an individualized…

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 their policy and procedure (P&P) titled, Sensory Impairments- Clinical Protocol, for one of three sampled residents (Resident 50) when staff did not assist resident to obtain hearing aids. This failure resulted in unmet communication needs. Findings: During an interview on 11/18/24 at 11:03 a.m. with Resident 50 and Resident 52 (roommate/spouse), Resident 50 stated the facility had checked his hearing a long time ago. Resident 52 stated Resident 50 needed hearing aids. During a review of Resident 50's Pure Tone Audiogram (PTA- a hearing test that measures how well you can hear sounds at different frequencies and intensities), dated 3/25/24, the PTA indicated, The patient has hearing loss significant enough to qualify for hearing aids and is eligible for them under their Medicare Plan. During a review of Resident 50's Care Plan (CP), dated 5/3/22, the CP indicated, (Resident 50) looks for things to be offended by and people talking about him, but is hard of hearing and misses what is being said. During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure policy and procedure (P & P) titled, Podiatry [treatment of the feet] Services were provided timely for one of three sampled residents (Resident 79) when Resident's 79's thicken toe nails were overgrown. This failure had the potential for Resident 79 to experience podiatric complications. Findings: During a review of Resident 79's admission Record (AR), dated 9/17/24, the AR indicated, Resident 79 was admitted on [DATE] with diagnoses of metabolic encephalopathy (brain dysfunction caused by chemical imbalance in the brain), type 2 diabetes mellitus (high blood sugar), end stage renal disease, (kidneys lose the inability to remove waste), dependence on renal dialysis (process of removing water, and toxins when kidneys no longer perform this function), neuromuscular dysfunction of bladder (when nerves and muscles don't work together properly), and hypertension (high blood pressure). During a review of Resident 79's Order Summary…

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 three sampled residents (Resident 19) was provided social services (SS) assistance with changing her Power of Attorney (POA - legal document that allows someone else to act on your behalf). This failure resulted in Resident 19 experiencing frustration and emotional distress related to lack of assistance from facility to change her POA. Findings: During an interview on 11/18/24 at 8:25 a.m. with Resident 19, Resident 19 stated she did not keep money at the facility, her brother was her POA and had control of her finances. Resident 19 stated she wished she had not given her brother POA. Resident 19 stated she cannot spend money without getting his approval and was not sure if she even had any money left. Resident 19 stated she was upset that her brother had so much control over her and her money. During a concurrent interview and record review on 11/21/24 at 12:22 p.m. with Social Services Assistant (SSA), Resident 19's IDT [interdisciplinary team - team of healthcare providers] Conference Summary (CS), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their policy and procedure (P & P) titled, Controlled Medications to ensure controlled medications (drugs that are regulated by federal laws and have a high risk for dependence) for one of eight sampled residents (Resident 385) were accounted when one tablet of Hydrocodone (opioid pain medication) was missing. This failure had the potential for drug diversion. Findings: During a concurrent observation and interview on [DATE] at 11:18 a.m. with the Director of Nursing (DON), in the DON's office, DON unlocked the file cabinet and pulled out the controlled medications to be destroyed. DON stated they account for all controlled medications in the facility before they disposed of. DON stated the nurses return the controlled medications to her once the residents had been discharged , a medication had expired, or the order was changed. During a concurrent interview and record review on [DATE] at 11:20 a.m. with DON, in DON's office, 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 implement their policy and procedure (P&P) titled, Medication Storage for one of three sampled residents (Resident 284) when two 50 ml (milliliters) of expired (less effective) IV (intravenous - in the vein) were not removed from medication storage. This failure had the potential for expired medication to be administered to Resident 284 resulting in a negative health outcome. Findings: During a concurrent observation and interview on [DATE] at 9:50 a.m. with the Director of Nursing (DON), in the IV medication storage room, two 50 ml of Daptomycin (antibiotic) Intravenous Solution dated [DATE] and [DATE] were in the refrigerator. DON stated the expired Daptomycin should not be stored in the refrigerator. DON stated the expired medication should be in the medication dispensing bin. DON stated the nurses are to look at the expiration date prior to giving medications. DON stated they had no process of surveillance of outdated medications 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 ensure one of three sampled residents (Resident 66), was provided dental services in a timely manner when significant weight loss was identified. This failure had the potential for Resident 66 to have difficulty eating and continued weight loss due to ill fitting dentures. Findings: During a concurrent interview and record review on 11/21/24 at 9:39 a.m. with Social Services Director (SSD) 1, Resident 66's medical record (MR) was reviewed. The MR indicated a SS note dated 7/3/24 for denture evaluation and treatment per RD. SSD 1 stated Resident 66 had a dental exam on 10/22/24 (three and a half months after referral was made). SSD 1 stated when a dental referral was made for resident weight loss the expectation would be to have the resident evaluated as soon as possible to help prevent further weight loss. During a concurrent interview and record review on 11/21/24 at 3:35 p.m. with Registered Dietitian (RD), Resident 66's Weights and Vitals Summary (WVS), was reviewed. The WVS indicated, Resident 66's weights were: 5/6/24…

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 follow their policy and procedure (P&P) titled Administering Medications, for one of three sampled residents (Resident 51) when topical medication was administered without a physician's order by unlicensed staff. This failure resulted in physician and licensed staff being unaware of Resident 51's skin condition which had the potential for an adverse health outcome. Findings: During an interview on 11/18/24 at 2:46 p.m. with Resident 51, Resident 51 stated Certified Nursing Assistants (CNAs) put ointments under his belly to help heal his wounds. During a concurrent interview and record review on 11/20/24 at 2:14 p.m. with Minimum Data Set Nurse (MDSN), Resident 51's medical record (MR) was reviewed. MDSN stated there was no documentation in the MR indicating Resident 51 had wounds under his abdominal folds and there was no order for any topical ointment. MDSN stated, We don't let CNAs put anything on the patient. Any kind of ointment is locked in the med cart. During an interview on 11/20/24 at 3:09 p.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 follow its policy and procedure (P&P) titled, Administering Medication, to ensure one of 48 sampled residents (Resident 133) medication administration was documented. This failure resulted in Resident 133's medication administration record (MAR) being inaccurate and incomplete. Findings: During an observation on 11/18/24 at 8 a.m. in Resident 133's room, Resident 133 was sitting in her wheelchair with her intravenous (IV - in the vein) pole (a device that you hang IV medication on) behind her and a peripherally inserted central catheter (PICC - a thin flexible tube inserted into the vein) dressing to the upper right arm. During an interview on 11/18/24 at 8:05 a.m. with Infection Preventionist Nurse (IPN), IPN stated Resident 133 was diagnosed with Methicillin-Resistant Staphylococcus Aureus (MRSA - a germ that is resistant to some antibiotics). During a concurrent interview and record review on 11/21/24 at 9:24 a.m. with Director of Nursing (DON), Resident 133's MAR, dated November 2024 was reviewed. The MAR 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.

Based on interview and record review, the facility failed to follow the physician's order for one of four sample residents (Resident 1) to provide treatment for Resident 1's right lower extremities (RLE) cellulitis [infected/swollen inflamed area of skin]. This failure had the potential to result in Resident 1's worsening of skin condition. Findings: During an interview on 10/17/24 at 12:36 a.m. with Resident 1, Resident 1 stated, There was no one to take care of my treatment for five days in September. During a review of Resident 1's Treatment Administration Record (TAR), dated September 2024, the TAR indicated, To RLE cellulitis cleanse with house wound cleanser pat dry and apply diphenhydramine HCL [medication cream for irritated skin] and zinc acetate ointment [prevents skin infection] and wrap with kerlix [gauze bandage roll] every day shift for 14 Days. The TAR indicated there were no documentations of treatments provided on 9/11/24, 9/12/24, 9/14/24, and 9/15/24. During a review of Resident 1's TAR, dated September 2024, the TAR indicated, Methol-Zinc Oxide External Ointment…

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

Based on observation, interview, and record review, the facility failed to ensure an effective implementation of pest control when there were cockroaches found in the facility ' s staff break room. This failure had the potential for placing residents at risk for infectious disease and foodborne illnesses. Findings: During an observation on 9/3/24 at 12:35 p.m. in the staff break room, one cockroach approximately 0.5 inches in size was crawling on the wall, one cockroach approximately 0.5 inches in size was crawling on the countertop, one dead cockroach approximately one inch in size was inside the cabinet under the sink, and one cockroach approximately 0.5 inches was crawling inside the cabinet under the sink. During an interview on 9/3/24 at 1:37 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, I saw one cockroach by the microwave and one cockroach crawling on the table. LVN 1 stated, I told [Registered Nurse Supervisor] verbally on Sunday [there were cockroaches in the break room]. During an interview on 9/3/24 at 1:45 p.m., with Certified Nurse Assistant (CNA) 1, CNA 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of four sampled residents ' (Resident 2 and Resident 4) call lights were answered timely. This failure had the potential for residents not being assisted with their activities of daily living (ADL). Findings: During a concurrent observation and interview on 9/3/2024 at 1:16 p.m. with Resident 2 in Resident 2 ' s room, Resident 2 was lying in bed with covers on. Resident 2 stated his call light was being answered by staff up to an hour. During a review of Resident 2 ' s Minimum Data Set (MDS-assessment tool), dated June 5, 2024, the MDS indicated Resident requires the assistance of one staff with transfer from bed to a wheelchair and with toileting. The MDS indicated Resident 2 had a BIMS (Brief Interview for Mental Status) score of 15 (score of 13-15 means cognitively intact). During a concurrent observation and interview on 9/3/2024 at 3:39 p.m., with Resident 4 in Resident 4 ' s room, Resident 4 was sitting in her wheelchair…

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

Based on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) on Abuse, Neglect, Exploitation and Misappropriation Prevention Program for one of four sampled residents (Resident 1) when an alleged abuse incident was not investigated within five working days. This failure had the potential for Resident 1 to suffer further physical and psychosocial harm. Findings: During a concurrent observation and interview on 7/18/24 at 1:29 p.m. with Resident 1 in Resident 1's room, Resident 1 had a dime-sized purple discoloration on his left upper arm. Resident 1 stated Caregiver (CG) 1 grabbed his left arm and caused the discoloration. During an interview on 7/18/24 at 1:38 p.m. with CG 2, CG 2 stated Resident 1 said, [CG 1] grabbed me on my arm. During a review of Resident 1's SBAR (Situation, Background, Assessment, Recommendation), dated 7/6/24, the SBAR indicated, [Resident 1] was grabbed by the arm and woken up during the night by [CG 1]. During an interview on 7/18/24 at 3:54 p.m. with DON, DON stated she is the abuse coordinator…

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 four of four sampled residents' (Resident 1, Resident 2, Resident 3, and Resident 4) call lights were answered timely. This failure had the potential for residents not being assisted with their activities of daily living (ADL) affecting their quality of life. Findings: During an interview on 6/14/24 at 10:29 a.m., with Resident 1, Resident 1 stated, When I use the call light for assistance, the longest I wait is an hour until someone comes to my room to help me, and I couldn't wait that long to use the bathroom. During a review of Resident 1's Minimum Data Set (MDS-Assessment Tool), dated 5/4/24, the MDS indicated Resident 1 requires the assistance of one staff with transfer from bed to a wheelchair and with toileting. The MDS indicated Resident 1 had a (BIMS- Brief Interview for Mental Status) score of 14 (score of 13-15 means cognitively intact). During a review of Resident 1's Care Plan (CP), dated 5/02/24, the CP indicated, ADL/Mobility [the ability of a resident to change and control their 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure three of nine sampled residents (Resident 3, Resident 7, and Resident 8) received the necessary care and assistances needed for showers/baths. This failure resulted in Resident 3, Resident 7, and Resident 8, not receiving appropriated care and services to maintain cleanliness and prevent infection. Findings: During an interview on 4/10/24 at 12:51 p.m. with Certified Nursing Assistant (CNA 2), CNA 2 stated short staffing happened four out of seven days. CNA 2 stated when she had 20 residents no one get a shower. During a review of Resident 3's Minimum Data Set, (MDS - an assessment tool) dated 4/9/24, the MDS indicated, Resident 3's BIMS (Brief Interview for Mental Status) score was 15 (13 to 15 points indicates cognitive intactness). The MDS indicated Resident 3 was dependent (helper does all of the effort) for shower/bathe self (The ability to bathe self, including washing, rinsing, and drying self). During a review of Resident 3's Activity'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 provide sufficient staffing for eight of nine sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 7, Resident 8, and Resident 9) when call lights were not answered timely. This failure had the potential to result in the residents' needs not being met in a timely manner, and to result in physical and/or psychosocial harm. Findings: During a review of Resident 1's Minimum Data Set, (MDS - an assessment tool) dated 1/31/24, the MDS indicated, Resident 1's BIMS (Brief Interview for Mental Status) score was 15 (13 to 15 points indicates cognitive intactness). The MDS indicated Resident 1 needed setup and clean up assistance (helper sets up or cleans up; residents' complete activity, helper assists only prior to or following the activity) for eating, substantial/maximal assistance (helper does more than half the effort) for toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement). During an interview on 4/10/24 at 10:58…

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 bed hold (holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization) was offered to one of nine sampled residents (Resident 8). This failure had the potential for Resident 8 and Resident 8's Representative not to be informed of the rights and benefits of bed hold and return policy of the facility. Findings: During a review of Resident 8's SBAR (situation, background, appearance, and review) Communication Form, dated 5/8/24, the SBAR indicated Resident 8 was sent to the hospital for evaluation and treatment for abnormal laboratory results. During a review of Resident 8's Minimum Data Set, (MDS - an assessment tool) dated 3/11/24, the MDS indicated, Resident 3's BIMS (Brief Interview for Mental Status) score was 15 (13 to 15 points indicates cognitive intactness). During an interview on 5/15/24 at 12:38 p.m. with Resident 8, Resident 8 stated he was sent to the hospital on 5/8/24. Resident 8 stated he returned to the facility on 5/10/24. When he…

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 three of three sampled Licensed Vocational Nurses (LVN 1, LVN 2, and LVN 3) were competent in the application and operation of a Bi-Level Positive Airway Pressure (BIPAP- a machine that helps you breathe). This failure resulted in incorrect application of the BIPAP machine on Resident 8. Findings: During a review of Resident 8's Minimum Data Set, (MDS - an assessment tool), dated 3/11/24, the MDS indicated, Resident 3's BIMS (Brief Interview for Mental Status) score was 15 (13 to 15 points indicates cognitive intactness). During an interview on 5/15/24 at 12:38 p.m. with Resident 8, Resident 8 stated some of the nurses were not trained on the application of the BIPAP machine. Resident 8 stated one nurse put the machine on its side and water got into the hose and I choked and coughed due to the water. During a review of Resident 8's Order Summary Report, (OSR) active orders as of 5/15/24, the ORS indicated, Bipap [sic] Nursing staff to assist patient with application of equipment at 11 pm and removal at 0700 [7 a.m.]…

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 four of five sampled employees' (Certified Nursing Assistant [CNA 2], CNA 3, Licensed Vocational Nurse [LVN 1], and LVN 2) had the required screening prior to their date of hire. This failure had the potential to expose the facilities resident to abuse. Findings: During a concurrent interview and record review on 5/2/24 at 4:20 p.m. with Minimum Data Set Nurse (MDSN), CNA 2's employee file was reviewed. CNA 2 was hired on 1/19/23. MDSN confirmed CNA 2 did not have a criminal background check prior to the date of hire. CNA 3's employee file was reviewed. CNA 3's date of hire was 1/19/23. MDSN reviewed CNA 3's criminal background check ordered 3/1/23 (approximately 6 weeks after hire date). LVN 1's employee file was reviewed. LVN 1's date of hire was 4/2/24. LVN 1's reference checks was not completed before the date of hire. LVN 2's employee file was reviewed. LVN 2's date of hire was 5/10/23. MDSN confirmed LVN 2 reference checks was not completed before the date of hire. MDSN stated the required screening should be…

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 when: 1. Registered Nurse (RN 1) was not wearing the appropriate PPE (personal protective equipment) while providing direct care for one of 11 sampled residents (Resident 1) on contact precautions. 2. Phlebotomist 1 and Phlebotomist 2 did not perform hand hygiene prior to donning (put on) and doffing (removing) gloves and did not perform hand hygiene in between rooms for one of 11 sampled residents (Resident 8). 3. Certified Nursing Assistant (CNA 1) did not perform hand hygiene before donning gloves for two of 11 sampled residents (Resident 2 and resident 3). These failures had the potential for the spread of infectious diseases to all residents, staff, and visitors. Findings: 1. During a concurrent observation and interview, on 1/17/24 at 10:53 a.m. with RN 1 in Resident 1 ' s room. RN 1 was observed wearing N95 mask (respiratory protective device designed to achieve a very close facial fit and very…

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 three of five sampled residents (Resident 5, Resident 6, and Resident 7) were offered and educated on the COVID- 19 (coronavirus disease- is an illness caused by a virus that spreads most commonly through the air in tiny droplets of fluid between people in close contact, can cause mild to severe acute respiratory infection) vaccination. These failures had the potential for Resident 5, Resident 6, and Resident 7, acquiring, transmitting, or experiencing complications from COVID- 19. Findings: During a concurrent interview and record review, on 1/17/24 at 2:53 p.m. with Infection Preventionist Nurse (IPN), IPN stated the admissions nurse should offer the seasonal vaccines. IPN stated if the resident refuses the vaccine there should be a refusal documentation in the resident ' s medical record. IPN reviewed the medical records for Resident 5, Resident 6, and Resident 7. IPN confirmed there was no evidence Resident 5, Resident 6, and Resident 7, were offered and educated the COVID -19 vaccine. IPN stated if it is not…

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 its policy and procedure to complete skin assessments and shower sheets for three of four sampled residents (Resident 2, Resident 3, and Resident 4). These failures had the potential for Resident 2, Resident 3, and Resident 4, to develop skin injuries and delay treatment. Findings: 1. During a concurrent interview and record review on 2/5/24 at 1:15 p.m. with Director of Staff Development (DSD), the facility ' s policy and procedure (P&P) titled, Prevention of Pressure Injuries, dated April 2020, was reviewed. The P&P indicated, Risk Assessment 1. Assess the resident on admission (within eight hours) for existing pressure injury risk factors. Repeat the risk assessment weekly and upon any changes in condition. Skin Assessment 1. Conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment, as indicated according to the resident ' s risk factors, and prior to discharge. DSD stated a skin assessment was to be completed weekly by licensed nurses for each resident. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure showers or baths were provided to three of four sampled residents (Resident 1, Resident 3, and Resident 4). Theses failures had the potential for Resident 1, Resident 3, and Resident 4, to have delayed identification of skin issues and negative health outcomes. Findings: During an interview on 12/27/23 at 11:30 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the CNAs filled out shower sheets when residents received or refused shower, and the nurse signed the shower sheets so any issues with the resident ' s skin or refusal of care was communicated. During an interview on 12/27/24 at 10:00 a.m. with Resident 1, Resident 1 stated she was admitted to the facility on [DATE]. Resident 1 stated she begged to get a shower for six days after coming to the facility. During a review of Resident 1 ' s Minimum Data Set (MDS – assessment tool), section C, dated 12/17/23, the MDS indicated Resident 1 ' s Brief Interview for Mental Status (BIMS)…

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 develop an individualized care plan for refusal of care for one of four sampled residents (Resident 4). This failure had the potential for Resident 4 to have adverse health outcomes. Findings: During a concurrent observation and interview on 1/9/24 at 11:49 a.m. with Resident 4, in Resident 4 ' s room, Resident 4 was lying flat in bed on his back with covers pulled up to his waist. Resident 4 stated he was legally blind and his left leg was amputated so he cannot stand on his own. Resident 4 stated he only takes bed baths. During a review of Resident 4 ' s Minimum Data Set (MDS- a comprehensive assessment tool), section C, dated 1/3/24, the MDS indicated Resident 4 ' s BIMS (Brief Interview for Mental Status) a score of 14, (score of: 13-15 means cognition is intact). The MDS section GG indicated, Resident 4 ' s functional status for E. Shower/bathe self required partial/moderate assistance (helper does more than half the effort). During an interview on 12/27/23 at 11:10 a.m. with Certified Nurse Assistant…

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 administer a blood pressure medication on time for one of three sampled residents (Resident 2). This failure had the potential to negatively affect Resident 2's medical condition. Findings: During an interview on 12/27/23 at 10:55 a.m. with Resident 2, Resident 2 stated she attends resident council meetings, and one of the recent concerns brought up during those meetings was medications not being given on time. Resident 2 stated she sometimes had to get up and ask the nurse when her medications will be given. During an interview on 12/27/23 at 11:30 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on busy days, she may be assigned up to 33 residents to care for. LVN 1 stated those days were very busy, and she had to prioritize care to get medications passed on time. During an interview on 12/27/23 at 11:55 a.m. with LVN 2, LVN 2 stated sometimes she has 30 or more residents assigned to her care. LVN 2 stated she had to be very organized and manage her time to get medications passed on time. During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement the safe use of a Hoyer lift (a mechanical lift device designed to assist caregivers in safely transferring patients or individuals with limited mobility) for one of three sampled residents (Resident 1). This failure had the potential for physical harm. Findings: During a review of Resident 1 ' s Minimum Data Set (MDS- a comprehensive assessment tool) under BIMS (Brief interview for mental status- an assessment tool for cognition), dated 11/23/23, the BIMS indicated Resident 1 had a score of 15 out 15 (cognition is intact). During an interview on 1/9/24 at 2:49 p.m. with Resident 1, Resident 1 stated on 1/1/24, Certified Nursing Assistant (CNA) 1 transferred him out of bed with a Hoyer lift but had no other staff assisting her. During an interview on 1/9/24 at 3:07 p.m. with Director of Staff Development (DSD), DSD stated on 1/1/24, Resident 1 submitted a complaint CNA 1 used the Hoyer lift on him without any other staff assistance. DSD…

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 sufficient staffing for three of three sampled residents (Resident 1, Resident 2 and Resident 3) who required two persons physical assists with transfers. This failure had the potential to place Resident 1, Resident 2, and Resident 3 at risk for accidents and injuries. Findings: During an interview on 10/27/23 at 10:31 a.m. with Resident 1, Resident 1 stated she must use Hoyer lift (equipment which allow a person to be lifted and transferred with a minimum of physical effort) to transfer. Resident 1 stated occasionally it is just one person. During a review of Resident 1's Minimum Data Set, (MDS – an assessment tool) dated 8/23/23, the MDS indicated, Resident 1's BIMS (Brief Interview for Mental Status with a range of 0-15) score was 15 (a score of 13 to 15 suggests the resident is cognitively intact). During a review of Resident 1's care plan with the focus on ADL [activities of daily living ]/Mobility, initiated 6/29/23, the care plan indicated Resident 1 was dependent and required transfer with Hoyer lift.…

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 honor the preferences for two of three sampled resident (Resident 1 and Resident 2) when a bariatric (person classified as obesity- disorder involving excessive body fat) shower bed (specialized bed designed to support more than 300 pounds of evenly distributed weight to allow easy patient transfer to and from the shower room) with adjustable headrest was not repaired or replaced. This failure resulted in Resident 1 unable to maintain his independence and Resident 2 not receiving a shower for approximately 70-days. Finding: During a review of Resident 1 ' s admission Record (AR), the AR indicated, Resident 1 was admitted on [DATE], with diagnoses included hemiplegia (paralysis of partial or total body function on one side of the body) and hemiparesis (characterized by one-sided weakness) following cerebral infarction (occurs because of disrupted blood flow to the brain due to problems with the blood vessels) affecting left non-dominant side, 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 resolve a grievance for one of three sampled residents (Resident 1). This failure resulted in Resident 1 care needs to go unresolved for 2 months. Findings: During a concurrent interview and record review on 9/27/23, at 4:06 p.m. with the Director of Nursing (DON), DON reviewed Resident 1's Resident Grievance Form, (RGF) dated 7/21/23, the RGF indicated, Investigation: One shower bed (with adjustable headrest) broke & a second (shower bed without an adjustable headrest) is available. Resolution: Respond to resident or designee within 7 working days of concern with resolution: interventions/Action: Resident verbalized wants the old shower bed fixed. Resident was informed a second shower bed without an adjustable headrest) is available and verbalized he does not care & wants that one (shower bed with adjustable headrest) fixed. Date Follow-Up to Resolution Occurred: 10 working days after resolution/action plan was implemented: [Blank] DON stated the grievance was communicated to MD. DON confirmed Resident 1's grievance has…

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 a care plan for one of three sampled residents (Resident 2) when needed equipment was not provided. This failure resulted in Resident 2 refusing showers for approximately 70-day, the refusals were not documented, and Resident 2's doctor was not notified. Findings: During a review of Resident 2's Minimum Data Set (MDS – an assessment tool), dated 6/13/23, the MDS indicated, Resident 2's BIMS (Brief Interview for Mental Status with a range of 0-15) score was 15 (a score of 13 to 15 suggests the resident is cognitively intact). During an interview on 9/27/23, at 12:21 p.m. with Resident 2, Resident 2 stated she has not had a shower in 70 days, since July 17, 2023. Resident 2 stated her skin feels dry itchy. Resident 2 stated the shower bed with the adjustable headrest, she was able to sit at an incline, so the side bar came up enough for her to support her arm. Resident 2 stated, she refused showers because the other bed (shower bed without…

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 medications were administered according to physician's order for one of three sampled resident (Resident 1). This failure resulted in medications not administered as ordered and had the potential for adverse outcome due to Resident 1 not receiving medications. Findings: During a concurrent interview and record review on 10/17/23, at 11:03 a.m. with Director of Nursing (DON) and Director of Staff Development (DSD), Resident 1's Medication Administration Record, (MAR) and Location of Administration Report (LAR) dated 9/1/23- 9/30/23 was reviewed, and indicated the following: Resident 1's MAR Ketoconazole Cream 2% [a drug used in the management and treatment of fungal infections] Apply to back topically every day shift for fungal infection -Start Date- 12/28/2022 0700 [7 a.m.] 9/8/23, day shift, not documented as administered (blank). Levemir [medication used to treat high blood sugar] . inject [act of administering into the body] 30 units subcutaneously [the injection is given in the fatty tissue, just under the skin]…

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 shower documentation was complete and accurate for two of three sampled resident (Resident 1 and Resident 2). This failure resulted in Resident 1 and Resident 2 medical records to be inaccurate. Findings: During an interview on 9/27/23, at 12:08 p.m. with Certified Nursing Assistant (CNA 1) CNA 1 stated shower/baths should be documented on shower sheets and in PCC (Point Click Care- electronic medical records). During a concurrent interview and record review on 9/27/23, at 2:20 p.m. Director of Nursing (DON), DON reviewed Resident's PPC ADL [activities of daily living]- Bathing/Shower, for last 30-days. DON confirmed Resident 1 only had four shower and one bed bath documented in last 30-days. DON reviewed Resident 2's PCC ADL-Bathing/Shower, for last 30-days. DON confirmed Resident 2's had no documentation of bathing/showers for last 30-days. DON stated showers should be given as scheduled and documented. During a review of the facility's policy and procedure (P&P) titled, Bath, Shower/Tub, the P&P indicated, The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide scheduled showers for four of four sampled residents (Resident 1, Resident 2, Resident 3, and Resident 4) when there were no documented showers for these residents (Resident 1, Resident 2, Resident 3, and Resident 4). This failure had the potential for Resident 1, Resident 2, Resident 3, and Resident 4 to have skin break down, skin infections, and affect their quality of life. Findings: During an interview on 8/31/23 at 10:30 a.m. with Resident 1, Resident 1 stated there have been shortage of staff and he had not had a shower in two weeks. During a review of Resident 1's Shower Sheets (SS) , dated August 2023, the SS indicated Resident 1 did not receive showers on August 3, 7, 16, 21, 24 and 28. During a concurrent interview and record review on 8/31/23 at 11:41 a.m. with the Director of Staff Development (DSD), the facility's Shower Binder (SB), dated August 2023 was reviewed. The SB indicated Resident 1 was scheduled to get…

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 RNA (Restorative Nursing Assistant -nursing care designed to improve or maintain the functional ability of residents, so they can achieve their highest level of well-being possible) program for one of four sampled residents (Resident 4) according to the physician's order. This failure had the potential for Resident 4 to have a decline in mobility. Findings: During a concurrent observation and interview on 8/31/23 at 10:57 a.m. with Resident 4 in his room lying in bed, his hand was unsteady grabbing his remote control. Resident 4 stated he does not get exercise anymore and his last exercise was two weeks ago. During a record review of Resident 4's Task Flowsheet (TF-log to document RNA program were performed) dated August 2023, the TF indicated Resident 4 had two physician orders for RNA program exercises. The TF indicated, RNA 3X [times] a week for BUE [both/bilateral upper extremities] strengthening BUE strengthening in various planes using 2+ weights or NuSTep [exercise machines used in senior living or physical…

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 its policy and procedure on hand hygiene (cleaning one's hands that substantially reduces potential pathogens [harmful microorganisms] on the hands. Hand hygiene is considered a primary measure for reducing the risk of transmitting infection among residents and health care personnel) for three of three sampled residents (Resident 1, Resident 2, Resident 3). This failure had the potential to spread infection amongst the residents and staff and result in negative consequences up to and including death. Findings: During an observation on 8/16/23 at 11:28 a.m. in the facility 200 hall, Certified Nursing Assistant (CNA) 1 was observed exiting resident room [ROOM NUMBER] and doffing her PPE (PPE – personal protective equipment - protective clothing, goggles, and other garments or equipment designed to protect the wearer's body from injury or infection). CNA 1 completed removing her PPE and did not perform hand hygiene. CNA 1 was…

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

Based on interview and record review, the facility failed to ensure call light was answered timely for two of five sampled residents (Resident 2 and Resident 3). This failure had the potential to result in unmet care needs, and negatively impact safety, physical, mental, and psychosocial well-being for Resident 2 and Resident 3. Findings: During an interview on 7/24/23, 1:52 p.m. Resident 2, Resident 2 stated she waited three hours on Saturday for her call light to be answered. During a review of Resident 2's Minimum Data Set, (MDS – an assessment tool) dated 6/15/23, the MDS indicated, Resident 2's BIMS (Brief Interview for Mental Status with a range of 0-15) score was 15 (a score of 13 to 15 suggests the resident is cognitively intact). During an interview on 7/24/23, 2:08 p.m. with Resident 3, Resident 3 stated it takes 15 minutes to 2 hours for the staff to answer her call light. Resident 3 also stated this morning it took 2 hours for her call light to be answered. Resident 3 stated she calculated the time on the clock in front of her bed. During a review of Resident 3's 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 ensure direct care daily staffing information was posted in a visible and prominent place. This failure had the potential for residents, families, and visitors not to be aware of the numbers of staff and titles, caring for residents on that day. Findings: During a concurrent observation and interview on 7/24/23, at 3:17 p.m. with Director of Nursing (DON), DON observed the facility's postings and was unable to locate where the direct care daily staffing hours for 7/24/23 were posted. DON confirmed there was no direct care daily staffing hours posted they should be posted. During a review of the facility's policy and procedure (P&P) titled, Posting Direct Care Daily Staffing Numbers, revised August 2022, the P&P indicated, Our facility will post on a daily basis for each shift nurse staffing data, including the number of nursing personal responsible for providing direct care to residents. 1. Within two (2) hours of the beginning of each shift, the number of licensed nurses . and the number of unlicensed…

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 medications were administered according to physician's order for one of five sampled resident (Resident 2). This failure resulted in medications not administered as ordered and had the potential for adverse outcome due to not receiving medications. Findings: During a concurrent interview and record review on 8/10/23, at 2:08 p.m. with Director of Nursing (DON), Resident 2's Medication Administration Record, (MAR) dated 6/1/23- 6/30/23 was reviewed, and indicated the following: Escitalopram Oxalate [medication used to treat depression] Oral Tablet 20 MG [milligram- unit of measure] . Give 2 tablet by mouth one time a day for m/b [manifested by] sad mood -Start Date- 06/13/2023 2000 [8 p.m.]. 6/12/23, at 8 p.m., 9 (9=Other/See Nurse Notes) was documented. MS Contin [medication use to treat severe chronic pain] Tablet Extended Release 30 MG . Give 1 tablet by mouth two times a day for pain . Start Date 06/11/2023 0800 [8 a.m.] 6/11/23, at 8 a.m., 9 was documented. 6/11/23, at 8 p.m., 9 was documented.…

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 an ensure effective pain management for two of five sampled residents (Resident 2 and Resident 3). This failure resulted in unrelieved pain for Resident 2 and Resident 3. Findings: During an interview on 7/24/23, 1:52 p.m. with Resident 2, Resident 2 stated her pain was worse and was at eight out of ten on pain scale (0 means you have no pain; one to three means mild pain; four to seven is considered moderate pain; eight and above is severe pain) and was getting Hydrocodone-acetaminophen ([HA-controlled narcotic – medication regulated by a government] - medication used to treat moderate to severe pain) every four as needed (PRN) for pain. Resident 2 also stated, Calling for it [HA] and getting it [HA] are two different stories. Resident 2 believed the facility's staff were stealing her pain medication and stated, It is unnecessary suffering. During a review of Resident 2's Minimum Data Set, (MDS – an assessment tool) dated 6/15/23, the MDS indicated, Resident 2's BIMS (Brief Interview for Mental Status with a range 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 and record review, the facility failed to ensure medical record were complete and accurate for two of five sampled residents (Resident 2 and Resident 3). This failure resulted in inaccurate medical records for Resident 2 and Resident 3. Findings: During an interview on 8/10/23, at 12:22 p.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 stated, she is popping the controlled narcotic medication from the card and sign the narcotic out on the controlled drug count sheet. LVN 4 also stated once the narcotic is administered to the resident she documents on EMAR (electronic medication administration record). During a review of Resident 2's Order Summary Report, (OSR) active orders as of 7/24/23, the OSR indicated Hydrocodone-acetaminophen (controlled substance - medication used to treat pain) tablet 10-325 MG (milligram-unit of measure) give one tablet by mouth every 4 hours as needed for pain, start date 6/30/23. During a review of Resident 3's OSR active orders as of 7/24/23, the OSR indicated Hydrocodone-acetaminophen tablet 5-325 MG give one tablet by mouth every 4…

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. Assess one of three sampled residents (Resident 1) immediately after a fall incident. This failure had the potential for a delay in treatment and care for Resident 1. 2. Complete a fall risk assessment on admission for one of three sampled residents (Resident 2). This failure had the potential for Resident 2 to have unmet care needs. Findings: 1. During an interview on 7/10/23, at 2:40 p.m. with Certified Nursing Assistant (CNA 1), CNA 1 stated if a resident had a fall incident I will not move the resident, I will get the nurse to assess the resident. During an interview on 7/10/23, at 3:03 p.m. with CNA 2, CNA 2 stated if she noted a resident on the floor or witness a fall incident, I will not move the resident and I will call the nurse to assess the resident. During a review of Resident 1 ' s SBAR [situation, Background, appearance, review, and notify] Communication From, dated 6/23/23, at 2:30 p.m., the SBAR indicated, Witnessed fall was…

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

Based on interview and record review, the facility failed to follow their policy and procedure to ensure the Dietary Manager was certified and had a competency skills checklist completed. This failure had the potential to affect all residents nutrition status when served the wrong food consistency, or unpalatable (unpleasant to taste) food. Findings: During an interview on 2/27/23, at 9:09 AM, with Resident 14, Resident 14 stated, she did not like the facility's food including the alternative menu. Resident 14 stated, her family brings her food. During a concurrent observation and interview on 2/27/23, at 12:56 PM, in Resident 29's room, Resident 29 was not served a lunch tray. Resident 29 stated, she refused to get a lunch tray and just wanted to eat her oatmeal. Resident 29 stated, she did not like the food the facility was serving and that's why her daughter buys her the oatmeal. During a concurrent dining observation and interview on 2/27/23, at 1:06 PM, with Resident 44, in Resident 44's room, Resident 44 had a lunch tray on his overbed table. Resident 44 was not touching his…

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 its policy and procedure (P&P) to provide annual training on Abuse Prohibition & Prevention to all facility staff. This failure had the potential for exposing all residents to abuse and neglect while residing in the facility. Findings: During a concurrent interview and record review on 3/1/23, at 9:15 AM, with Director of Staff Development (DSD), three in-service binders were reviewed. DSD stated, I was the DSD since January, and my responsibilities were to provide in-service orientation for new hires and for current staff. DSD stated, all employees should be provided the in-services for abuse prevention and dementia care upon hire and annually. DSD stated, The in-service binders for the annual training were filed in the binders for the following years: 2019, 2020, 2022 but 2021 was missing and I could not find it. During a review of the facility's P&P titled Abuse Prohibition & Prevention Policy and Procedure and Reporting Reasonable Suspicion of a Crime Policy and Procedure, dated 8/2022, the P&P indicated,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure call lights were answered timely for six of 58 sampled residents (Resident 66, Resident E, Resident J, Resident D, Resident B, and Resident G). This failure had the potential for delayed provision of care affecting residents' health and safety. Findings: During an interview on 2/27/23, at 9:02 AM, with Resident 66, Resident 66 stated, Call lights were not answered for one to two hours and depends on who's on duty. During an interview on 2/27/23, at 3 PM, with RN 1, RN 1 stated, We have been short staffed for the past three months and at least two to three times a week I pass medications. RN 1 stated, there should be six CNAs from 2 PM to 10:30 PM, but only five CNAs are here today. During a group interview on 2/28/23, at 10 AM, with Resident E, Resident E stated, Some staff ignore you. They don't care. During a review of Resident E's Minimum Data Set (MDS-assessment tool), dated 12/6/22, the MDS indicated, Resident E had a Brief Interview 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: 1. Follow their Advanced Directive (legal document which indicates a person's wishes for medical treatment) policy and procedure (P&P) for two of six sampled Residents (Resident 37 and Resident 48) to provide AD information and obtain a signed or declined AD. This failure had the potential for the facility to be unaware of residents' wishes for treatment. 2. Ensure one of five sampled residents (Resident 42), with mental capacity to make medical decisions, was able to make his own healthcare decisions. This failure had the potential for competent residents not being allowed to make their own healthcare decisions. Findings: 1. During a concurrent interview and record review, on 3/1/23, at 11:38 AM, with admission Assistant (AA), Resident 37's Advance Directive Acknowledgement (ADA), dated 9/23/22, was reviewed. The ADA indicated, Family Member (FM) 1 E-signed (electronically signed) the form and AA witnessed the signature. AA stated, she assumed FM 1 had power of attorney (POA- a legal document that allows an individual to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide assistance with activities of daily living (ADL) when: 1. Facility did not provide showers to two of five sampled residents (Resident 46 and Resident 27). 2. Facility did not assist four of five sampled residents (Resident 7, Resident 27, Resident 30, and Resident 85) to trim their fingernails and toenails. 3. Facility did not provide grooming assistance to one of five sampled residents (Resident 7). These failures resulted in residents not receiving assistance with their personal hygiene which negatively affected their quality of life. Findings: 1. During an interview on 2/28/23, at 2:42 PM, with Resident 46, Resident 46 stated, she does not remember when the last time she was moved out of her bed to get showered. Resident 46 stated she gets wiped but wished she could have showers. During a review of the facility's Shower List, undated, the Shower List indicated, Resident 46 was to receive showers every Tuesday and 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.

Based on observation, interview, and record review, the facility failed to: 1. Complete an assessment for one of five sampled residents (Resident 46's) foot drop (difficulty lifting the front part of the foot). This failure had the potential for Resident 46 to experience worsening of foot contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). 2. Ensure one of 58 sampled residents (Resident 37) had a proper fitting wheelchair. This failure had the potential to result in Resident 37 falling or slipping out of her wheelchair. Findings: 1. During an observation on 2/28/23, at 9:18 AM, in Resident 46's room, Resident 46 was in bed. Resident 46 had left sided weakness, left hand contracture, and both feet had foot drop. During a concurrent interview and record review on 2/28/23, at 4:18 PM, with Director of rehabilitation (DOR-person who provides therapy to improve or maintain body function). DOR reviewed Resident 46's therapy notes. DOR stated, There were no assessments or treatment for [Resident 46'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 observation, interview, and record review, the facility failed to provide Restorative Nursing Assistant (RNA - person-centered nursing care designed to improve or maintain the functional ability of residents, so they can achieve their highest level of well-being possible) services for three of five sampled residents (Resident 46, Resident 29, and Resident 28). This failure had the potential for residents' worsening of contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), decline in mobility, and range of motion. Findings: During a concurrent observation and interview on 3/1/23, at 9 AM, with Resident 46, in Resident 46's room. Resident 46 was in bed, awake, and watching people walk by. Resident 46 stated, nobody had assisted her with exercise and was never offered to get up. Resident 46 was asked when was the last time she was assisted to get up and she stated, Never. Resident 46 was asked if she would like to get up, she stated, That would be nice. During a review of Resident 46'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 follow its Dialysis policy (procedure to remove waste products and excess fluids) for three of three sampled residents (Resident 5, Resident 70 and Resident 83). This failure had the potential for the residents to suffer complications from dialysis which may lead to hospitalization and death. Findings: During a concurrent interview and record review, on 3/1/23, at 11:52 AM, with Licensed Vocational Nurse (LVN) 6, Resident 5's Order Summary Report (OSR), dated 3/1/23, was reviewed. The OSR indicated, Resident 5's Hemodialysis (HD a machine that filters wastes, salts and fluid from the body when kidneys are no longer healthy enough to work adequately) vital signs pre (before) and post (after) dialysis. LVN 6 stated, the nurses should check Resident 5's dialysis access site if there was bleeding, edema (swollen) and if vital signs were okay. LVN 6 stated, the nurse who assessed should document on Resident 5's Dialysis Communication Record (DCR) for post dialysis assessment every time Resident 5 returns to the facility from…

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: 1. Ensure sufficient nursing staff to meet the needs of 87 out of 87 residents. 2. Ensure the Federally mandated Direct Care Service Hours Per Patient Day (DHPPD - actual hours of work performed per patient day by a direct caregiver. The total number of hours worked per patient day divided by the average daily census) were met. These failures had the potential for all residents in the facility to not receive timely and necessary nursing care and related services, to assure the residents' safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being. Findings: 1. During a concurrent observation and interview on 2/27/23, at 8:21 AM, with Certified Nursing Assistant (CNA) 3, in Resident 17's room, CNA 3 assisted Resident 17 was observed being assisted with breakfast. CNA 3 stated, Four nurses called-off sick today. I belong to the shower team with another CNA, but today instead of taking care of 9-10…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of six sampled staff had the skills (specific abilities to perform their job) and competency (knowledge, skills, abilities, and behaviors) to provide care and services to the residents. This failure had the potential for all residents to be exposed to negligent care and compromised safety. Findings: During an concurrent interview and record review, on [DATE], at 10:33 AM, with Licensed Vocational Nurse (LVN) 6, Certified Nursing Assistant (CNA) 4's personnel files was reviewed. LVN 6 stated, CNA 4's certification expired on [DATE]. LVN 6 stated, CNA 4 did not have an updated certification. LVN 6 stated, CNA 4's personnel file did not include reference checks or a background screening. During a review of the facility's policy and procedure (P&P) titled, Knowledge and Skills Competency Evaluation, dated [DATE], the P&P indicated, In an effort to provide optimal clinical care, direct care nursing staff are required to meet minimum standards…

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 a medication error rate of less than five percent (%) when there were three errors out of 33 opportunities (9.09 %). This failure had the potential for residents not receiving the full therapeutic effects of the medication and potential for adverse health outcomes. Findings: During an observation of medication administration on 2/28/23, at 8:14 AM, in the hallway, Licensed Vocational Nurse (LVN) 4 was passing medications. LVN 4 did not administer Cyanocobalamin (supplement) 1000 mcg (microgram-unit of measurement) tablet and Apremilast (medication for Psoriatric Arthritis - skin disease with joint pain, stiffness, and swelling) 30 mg (milligram-unit of measurement) tablet to Resident 25. During a review of Resident 25's Order Summary Report (OSR), dated 12/2/22, the OSR indicated, a physician's order of Apremilast Tablet 30 mg, give one tablet by mouth two times a day related to Psoriatric Arthritis and Cyanocobalamin Tablet 1000 mcg by mouth one time a day. During a concurrent interview and record…

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

Based on observation and interview, the facility failed to: 1. Ensure discontinued medications were removed from the medication cart. This had the potential for medications administered to the wrong resident. 2. Ensure medications were stored in appropriate compartments. This failure had the potential for contamination and medication errors. 3. Ensure expired medications were discarded. This failure had the potential for toxic, expired medications to be administered to residents and had the potential for adverse health outcomes. 4. Ensure medications were labeled with open and discard date according to pharmacy recommendation. This failure had the potential for medications to lose their potency and had the potential for residents to not receive the full therapeutic effect. Findings: 1. During a concurrent observation and interview on 3/1/23, at 10:37 AM, by the nurses' station, with Licensed Vocational Nurse (LVN) 2, the medication cart number four contained the following discontinued medications: a) A bag of several Lovenox (blood thinner) 40 mg (milligram-unit if measure)…

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 food served was palatable (pleasant to taste) for 13 of 13 sampled residents (Resident 14, Resident 29, Resident 44, Resident A, Resident B, Resident C, Resident D, Resident E, Resident F, Resident G, Resident H, Resident I, and Resident J). This failure had the potential for residents to not eat and not meet their nutrional needs. Findings: During an interview on 2/27/23, at 9:09 AM, with Resident 14, Resident 14 stated, she did not like the facility's food including the alternative menu. Resident 14 stated, her family brings her food. During a concurrent observation and interview on 2/27/23, at 12:56 PM, in Resident 29's room, Resident 29 was not served a lunch tray. Resident 29 stated, she refused to get a lunch tray and just wanted to eat her oatmeal. A big box of oatmeal was on her night stand. Resident 29 stated, she did not like the food the facility was serving and that's why her daughter buys her the oatmeal. During a concurrent dining observation and interview on 2/27/23, at 1:06 PM, 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 observation, interview, and record review, the facility failed to provide three of three sampled residents (Resident 20, Resident 28, and Resident 52) with a properly prepared pureed (food that is smooth and lump free, not firm or sticky, requires no chewing) diet. This failure had the potential for three residents diagnosed with Dysphagia (difficulty with swallowing that can lead to inhaling food and liquid into the lungs) to suffer from choking or inhaling the food. Findings: During a concurrent observation and interview on 2/28/23, at 1:13 PM, with Director of Nursing (DON), in the conference room, a pureed lunch tray was observed. DON stated, the ham looked like a fine chop consistency, and the bread looked like a ball of dough. DON tasted the ham and the bread and stated, they were not a puree consistency. During a concurrent observation and interview on 2/28/23, at 2:16 PM, with the consulting Registered Dietician (RD) 1, in the conference room, a pureed lunch tray was observed. RD 1 stated, the ham looked like a fine chop consistency, and the bread looked like a ball…

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

Based on observation, interview, and record review, the facility failed to follow its policy and procedure on Water Pitchers to provide clean water pitchers and fresh water daily to four of 26 sampled residents (Resident E, Resident A, Resident B, and Resident 14). This failure had the potential for resident hydration needs to not be met. Findings: During a group interview on 2/28/23, at 10 AM, with Resident E, Resident E stated, she was not provided a clean water pitcher and fresh water every day. Resident E stated, We do not get water unless we ask. They should routinely provide us water. During a group interview on 2/28/23, at 10 AM, with Resident A, Resident A stated, Years ago it was routine for [staff providing] water. Now there's no more water, it's very frustrating, the pitchers are empty. During a group interview on 2/28/23, at 10:17 AM, with Resident B, Resident B stated, My observation in the night shift, I used to get water without request, automatic. Now, we only get it when I remember to ask it. I wake up middle of the night without water. About three years, we have…

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 standards when: 1. Certified Nursing Assistant (CNA) 1, passed meal trays to multiple residents in multiple rooms without performing hand hygiene. 2. Licensed Vocational Nurse (LVN) 4 did not perform hand hygiene and was wearing long artifical nails while providing direct patient care. These failures had the potential for spread of infectious diseases to all residents, staff, and visitors. Findings: 1. During a concurrent observation and interview on 2/27/23, at 12:22 PM, in the facility's 400 hallway, CNA 1 removed a meal tray from the tray cart and went into room [ROOM NUMBER] and set up the resident's meal tray on the overbed table. CNA 1 then came out of room [ROOM NUMBER] and removed another meal tray from the cart without performing hand hygiene. CNA 1 then entered room [ROOM NUMBER] and set up the meal tray. CNA 1 then came out of room [ROOM NUMBER] and removed another meal tray from the cart without…

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 a clean and orderly physical environment when two of 55 rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) had a cracked-opened ceiling and a paint-patched fire sprinkler. This failure had the potential for the risk of the health and safety of two residents in room [ROOM NUMBER] and two residents in room [ROOM NUMBER]. Findings: During a concurrent observation and interview on 3/1/23, at 8:39 AM, with Maintenance Supervisor (MS), the ceilings in the two-person shared room [ROOM NUMBER] and in the two-person shared room [ROOM NUMBER] were observed. MS stated, the cracked-open ceiling with dry wall hanging from it, in room [ROOM NUMBER] leaked due to last year's rain. MS stated, the ceiling from the roof had been patched and it stopped leaking, but due to several recent rainstorms the ceiling began leaking again. MS stated, I have been asking [for financial] support from the management since February which is why I cannot fix it. MS…

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 58 sampled residents (Resident 54) had access to his facility managed funds after 5 PM, weekends, or holidays. This failure had the potential for residents to not have access to their funds when needed. Findings: During an interview on 2/28/23, at 9:51 AM, with Resident 54, Resident 54 stated, the facility managed his personal funds. Resident 54 stated, he can only withdraw money from his facility managed account during the week but not on the weekends. During an interview on 3/1/23, at 9:05 AM, with Social Services Assistant (SSA), SSA stated, residents whose funds are managed by the facility only have access to their funds during business hours. SSA stated, business hours are Monday through Friday from 8 AM to about 5:30 PM. During an interview on 3/1/23, at 9:11 AM, with Business Office Manager (BOM), BOM stated, residents whose funds are managed by the facility have access to their funds Monday through Friday from 8 AM to 5 PM, no weekends or holidays. During a review of the facility's policy and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 42), his family, or the ombudsman (person in a government agency whom people can go to for assistance with navigating the programs or policies of a long-term care agency) was notified, in writing, of Resident 42 transfer to the hospital. This failure resulted in Resident 42, his family, and the ombudsman to be not fully informed of Resident 42's physical location. Findings: During an interview on [DATE], at with Director of Nursing (DON), DON stated, Resident 42 had been hospitalized several times for ileus (temporary lack of the normal muscle contractions of the intestines). During a concurrent interview and record review on [DATE], at 1:43 PM, with Director of Staff Development (DSD), Resident 42's clinical record was reviewed. DSD stated, the Physician Order (PO), dated [DATE], indicated, may transfer to [local hospital] ER [emergency department] for further evaluation. DSD stated, the SBAR (Situation,…

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 sampled residents (Resident 42) was: 1. Assessed for abdominal distention (abnormally swollen outward). 2. Assessed for unexpected weight loss. These failures resulted in Resident 42's physical condition and weight loss not being reported to the physician and for physician orders for laboratory and diagnostic testing to be delayed. Findings: 1. During an observation on 2/27/23, at 11:07 AM, in Resident 42's room, Resident 42 was laying in his bed. Resident 42 answered a few questions about the taste and temperature of the facility's food. Resident 42's abdomen was very distended. During a concurrent observation and interview on 2/28/23, at 10:10 AM, with Resident 42, in Resident 42's room. Resident 42 was groggy but able to answer two questions and fell to sleep. Resident 42's abdomen remained very distended. During an observation on 2/28/23, at 11:29 AM, in Resident 42's room, Resident 42 remained sleeping in his bed. During an interview on 2/28/23, at 12:22 PM, with Resident 42's Family…

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 Interdisciplinary Team (IDT-members from various disciplines who review and discuss information and make plans to meet residents' needs) care conferences were completed at least quarterly for two of five sampled residents (Resident 42 and Resident 54). This failure had the potential for comprehensive care needs to go unmet. Findings: During a concurrent interview and record review, on 3/1/23, at 11:43 AM, with Director of Staff Development (DSD), Resident 42's clinical record was reviewed. DSD stated, the last IDT care conference for Resident 42 was conducted on 7/13/22. DSD stated, two IDT conferences were not held for Resident 42 as required. During a concurrent interview and record review, on 3/2/23, at 10:41 AM, with DSD, Resident 54's clinical record was reviewed. DSD stated, the last IDT care conference for Resident 54 was conducted on 4/27/22. DSD stated, three IDT care conferences were not held for Resident 54 as required. During an interview on 3/2/23, at 3:01 PM, with Director of Nursing (DON), DON 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.