Bayshire Riverwalk Post-Acute

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive care plan (CP) for one of 46 sampled residents (Resident 12). This failure had the potential to result in Resident 12 having an unrecognized change in condition and adverse health outcomes. Findings:During an observation on 12/1/25 at 9:29 a.m. with Resident 12, in Resident 12's room. Resident 12 was receiving intravenous (into the vein) Total Parenteral Nutrition (TPN - a method of delivering complete nutrition directly into the blood stream via an intravenous when the person's digestive system can not absorb nutrients from food).During a review of Resident 12's CP, dated 11/25/25, the CP indicated, [Resident 12] with TPN orders with oral gratification.During a concurrent interview and record review on 12/4/25 at 11:56 a.m. with Registered Nurse (RN) 2, Resident 12's clinical records was reviewed. Resident 12's clinical record indicated there was no record of monitoring Resident 12 receiving TPN. RN 2 stated they (staff) were not checking Resident 12's blood sugar and had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 46 sampled resident (Resident 119) had dentures in place and assisted with meals. This failure had the potential for Resident 119 not being assisted with activities of daily living and not meeting her nutritional needs. Findings:During a concurrent observation and interview on 12/1/25 at 12:54 p.m. with Resident 119, in Resident 119's Room, Resident 119's lunch was provided. Resident 119's dentures were in a container on her bedside table. Resident 119 stated she could not open and clean her dentures. Resident 119 stated her food was not cut up for her to eat. Resident 119 stated she needed help and there was no staff present to assist.During a concurrent observation and interview on 12/1/25 at 12:56 p.m. with Registered Nurse (RN) 1, RN 1 stated Resident 119 needs help with her dentures to eat her lunch, Resident 119 said she can't do it, her lunch was just put on the tray without her dentures being in her mouth for her to eat. RN 1 was observed leaving the room without assisting Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to assess and complete the Skilled Nursing Dialysis Center Communication Form (SNDCCF - a communication tool to be completed by the nursing home and sent with each resident hemodialysis [a treatment that filters waste and excess fluid from your blood when your kidneys are failing] treatment) for one of two sampled residents (Resident 131). This failure had the potential for a change in condition to not be identified and delay in provision of care for Resident 131 who was receiving hemodialysis treatments.Findings:During a review of Resident 131's Order Summary Report (OSR), dated [DATE], the OSR indicated, Dialysis Evaluation Form Post Treatment every Mon [Monday], Wed [Wednesday], Fri [Friday].During a review of Resident 131's Care Plan Report (CPR), dated [DATE], the CPR indicated, [Resident 131] needs hemodialysis. Interventions/Tasks: Monitor for redness, swelling, or drainage, tunneled dialysis catheter [flexible tube tunneled under the skin (usually…

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

Based on observation, interview, and record review, the facility failed to ensure a meal was served at a palatable and appetizing appearance for one of 30 sampled residents (Resident 74). This failure resulted in Resident 74 not eating her meals and potential for not meeting her nutritional needs.Findings:During a concurrent observation and interview on 12/1/25 at 12:44 p.m. with Resident 74, in Resident 74's room, Resident 74's meal tray was on her overbed table. Resident 74's food was untouched. The plate contained mixed green and brown food. Resident 74 stated, Would you eat that? [pointing to the plate with food]. It looks like someone had a sick stomach and threw up.During a review of Resident 74's Meal Ticket, dated 12/1/25, the Meal Ticket indicated, Broccoli Chicken Casserole.During an interview on 12/2/25 at 11:31 a.m. with Certified Dietary Manager (CDM), CDM stated the food could have been presented better. CDM stated, It's a casserole, when it scooped, it mixes, the food should be in a small boat [bowl] to look better. CDM stated the facility had no policy and procedure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a care plan (a detailed, written document created by facility staff that outlines all the medical, physical, emotional, and social care a resident will receive to improve or maintain their quality of life) for one of three sampled residents (Resident 1) with visual hallucinations (the experience of sensing something that is not actually there, even though it seems very real). This failure had the potential to result in Resident 1's care needs to not be met and/or result in psychological harm.Findings:During a review of Resident 1's admission RECORD (AR), dated 7/30/25, the AR indicated, Resident 1 was admitted to the facility on [DATE] with a diagnosis of unspecified dementia (a decline in mental ability severe enough to interfere with daily activities and decision-making, impacting core cognitive functions like memory, language, attention, reasoning, and social skills) unspecified severity with other behavioral…

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

Based on interview and record review, the facility failed to implement their policy and procedure (P&P) titled, Abuse, Neglect & Exploitation Policy, when: 1. The allegation of psychological/mental abuse was not reported timely to the California Department of Public Health (CDPH the state survey and certification 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) for one of three sampled residents (Resident 1). This failure had the potential for Resident 1 not to be protected from further abuse. 2. A 5-day investigation report (written report of the results of abuse investigation) was not sent to CDPH or local ombudsman within 5-days of the incident for one of three sampled residents (Resident 1). This failure had the potential for an incomplete investigation for Resident 1. Findings: 1. During a review of Resident 1 ' s Report of Suspected Dependent Adult/Elder Abuse, (SOC – a written report of suspected of abuse or neglect of elders or dependent adults) dated…

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

Based on interview and record review, the facility failed to ensure the facility controlled medication (medications that have the potential for abuse and addiction and are therefore regulated by the government) drug record was accurate for one of three sampled residents (Resident 1). This failure had the potential for unaccounted for and/or diversion of controlled medications. Findings: During a review of Resident 1's, Physician Order Report (POR), the POR dated 1/12/25, indicated, Resident 1 had an order for Percocet (strong pain medication) oral tablet 5-325 MG (milligram) (Oxycodone w/ Acetaminophen) give one tablet by mouth every six hours as needed for moderate to severe pain 4-10/10 (pain level 0-10 when 10 is the worst). Acetaminophen NTE (not to exceed) 3gms (grams)/24 hours. During a review of the facility's Summary of Incident (SI) , dated 2/3/25, the SI indicated, . she [Resident 1] received an extra Percocet at the end of the previous week [1/23/25] . made a medication error and gave [Resident 1] a PRN [as needed] Percocet and did not document. During an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an allegation of abuse to the California Department of Public Health (CDPH-state agency) for one of three sampled residents (Resident 1). This failure resulted in delayed investigation of the allegation of abuse and potential for continued abuse towards Resident 1. Findings: During a review of Resident 1's admission Record (AR), dated 11/7/24, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including, fracture [broken] of thoracic [upper spine] vertebra [spine bone], muscle weakness and history of falls. During a review of Resident 1's Minimum Data Set (MDS – assessment tool), dated 10/8/24, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS - assessment of cognitive function) score was 15 (a score of 13-15 suggests resident is cognitively intact). During an interview on 11/05/24 at 9:15 a.m. with Resident 1 and Resident 1's Family Member (FM) 1, Resident 1 stated she told her daughter…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 their policies for cleaning, drying, and storing clean dishes. This failure had the potential for contaminating food placing residents at risk for foodborne illnesses. Findings: During a concurrent observation and interview on 11/5/24 at 10:53 a.m. with the Certified Dietary Manager (CDM) in the kitchen, on the clean side of the dish washing area, there were two plastic bins without lids, filled with plastic dessert dishes. The dessert dishes were piled up in the bins and not upside down. One of the dessert dishes on top of the pile had some debris inside. Some of the dessert dishes had dark debris on the rims. CDM stated the dessert dishes had been through the dish washer and should be clean. CDM stated the dark color on the rims looked like it was from the blueberry dessert served the previous night. CDM stated the dessert dishes should have been air dried upside down then stored upside down in a clean area. CDM stated the dishes needed to go through the dishwasher again. During a concurrent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and interview the facility failed to implement infection control practices when: 1. The facility's policy & procedure (P&P) for hand hygiene was not followed when two staff members did not perform hand hygiene before entering and after exiting residents' rooms. 2. The facility's P&P for laundry and bedding was not followed when the cover to the clean linen cart was ripped and unable to cover the clean linen completely for transport. 3. The facility's P&P for enhanced barrier precautions (EBP - measures to prevent infection which involves wearing gowns and gloves) was not followed for one of six sampled residents (resident 268) who had an indwelling foley catheter (flexible tubing that drains urine from the bladder into a collection bag). These failures had the potential to spread infectious diseases to residents, staff, and visitors. Findings: 1. During a concurrent observation and interview on 11/04/24 at 9:47 a.m. with Certified Nursing Assistant (CNA) 3, CNA 3 was observed coming 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.

Based on observation, interview, and record review, the facility failed to ensure three of three sampled residents (Resident 364, Resident 33 and Resident 3) were assessed for self administration of medications. This failure had the potential for the facility not to identify and resolve any risks for self administration of medications for Resident 364, Resident 33, and Resident 3, and the potential to place mobile residents at risk for harm. Findings: a. During a concurrent observation and interview on 11/04/24 at 11:34 a.m. with Resident 364, a box labeled Lidocaine Viscous 2% (medication used to numb the mouth) was on Resident 364's bedside table. Resident 364 stated he had thrush (fungal infection) in his mouth which made it painful to eat, so he used the Lidocaine Viscous to rinse his mouth before each meal. During an interview on 11/07/24 at 8:53 a.m. with Clinical Manager (CM) 2, CM 2 stated if a resident wanted to self administer medications a Physician's order for self administration of the medication would be needed. CM 2 stated a Self Administration of Medication Data…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Ensure proper accommodations were made for one of 25 sampled residents (Resident 269) when Resident 269 was given a call bell that could not be heard at the nurse's station. 2. Implement its policy and procedure (P&P) titled, Call System, Residents for 8 of 25 sampled residents (Resident 48, Resident 18, Resident 8, Resident 31, Resident 92, Resident 34, and Resident 67) when call lights were not answered within 5 minutes. These failures contributed to residents not being assisted timely which negatively affected their psychosocial and personal hygiene needs. Findings: 1. During a review of Resident 269's admission Record (AR), dated 10/21/24, the AR indicated, Resident 269 is a [AGE] year-old admitted to the facility after a fall that resulted in a right hip fracture requiring physical therapy and a leg brace to be worn 24 hours a day. Resident 269 also has diagnoses of abnormalities of gait and mobility with history of falling.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 six sampled residents (Resident 93, Resident 414, Resident 76, and Resident 164) had an Advance Directive (AD- a legal document that provides instructions for medical care and only go into effect if the individual is unable to make decisions for themselves) in the medical record. This failure had the potential for responsible parties and/or medical professionals to not honor resident's healthcare wishes and to not provide appropriate treatment in the event of an emergency medical situation. Findings: a. During a review of Resident 93's Social Services Progress Notes (SSPN), dated 7/3/24, the SSPN indicated, There is a DPAHC [Durable Power of Attorney for Health Care- advance directive] in place. During a concurrent interview and record review on 11/5/24 at 10:26 a.m. with Social Services Director (SSD), Resident 93's medical record (MR) was reviewed. SSD stated there was no copy of DPAHC in Resident 93's MR. b. During a review of Resident 414's SSPN, dated 10/28/24, the SSPN indicated, There is a DPAHC in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure three of five medication carts did not contain controlled medications (medications with high potential for abuse and addiction) that were unaccounted for. This failure had the potential for drug diversion (illegal use of prescription drugs) and inaccurate documentation of controlled medication disposal. Findings: During a concurrent observation and interview on [DATE] at 1:55 p.m. with Registered Nurse (RN) 2, at nursing station medication cart 2, contained 18 sealed envelopes in the controlled medication drawer dated from [DATE] through [DATE]. RN 2 stated the envelopes contained wasted [not administered] controlled medications and should have been given to the Director of Nursing (DON) for disposal. RN 2 stated the wasted medications were not counted and documented each shift. During a concurrent observation and interview on [DATE] at 2:11 p.m. with RN 1, at nursing station two medication cart 2, contained two sealed envelopes 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 implement an effective antibiotic (range of powerful medications that kill bacterial infections) stewardship program (the practice of ensuring antibiotics are used appropriately and only when necessary) when antibiotic use was not monitored for three of three sampled residents (Resident 414, Resident 164, and Resident 57) . This failure had the potential for unnecessary use of antibiotics which could contribute to negative health outcome for residents. Findings: During a review of the facility's Order Listing Report (OLR-list of residents on antibiotic), dated 11/6/24, the OLR indicated, [Resident 414] Order Summary: Vancomycin HCl Intravenous Solution [strong antibiotic to treat infections] Use 750 gram intravenously [medications administered through the veins] two times a day related to Urinary Tract Infection [bladder infection]. During an interview on 11/6/24 at 1:35 p.m. with Infection Preventionist Nurse (IPN), IPN stated Resident 414's antibiotic use is not currently on her tracking sheet (log for monitoring the…

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

Based on observation, interview, and record review, the facility failed to ensure three of three sampled resident's rooms (Resident 10, Resident 51, Resident 56) were maintained in good repair. This failure had the potential to impact residents' psychosocial needs and quality of life. Findings: During an observation on 11/5/24 at 11:06 a.m. in Resident 10's room, Resident 10 was lying in bed. The ceiling tiles in Resident 10's room had large round patches of brownish discolorations in four areas. During an interview on 11/5/24 at 11:44 a.m. with Maintenance Director (MD), MD stated he had not seen the large brownish round discolorations in the ceiling tiles of Resident 10's room. MD stated the large round patches of brownish discolorations were not reported and not listed in the computer for repairs. MD stated he does daily rounds with maintenance assistants (MA) but was not sure if they (MA) had seen it (large round patches of brownish discolorations in Resident 10's ceiling tiles). During a review of the facility's Tasks Due This Week (list of locations for maintenance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 25 sampled residents (Resident 84) personal preference was honored when Certified Nurse Assistant (CNA) 2 was assigned to care for Resident 84 after Resident 84 requested CNA 2 not be assigned to her care. This failure resulted in Resident 84 experiencing emotional distress. Findings: During an interview on 11/05/24 at 9:15 a.m. with Resident 84 and Resident 84's family member (FM) 1, FM 1 stated CNA 2 was rude to Resident 84. FM 1 stated on 10/30/24 a request was made for CNA 2 not be assigned to care for Resident 84. Resident 84 stated CNA 2 had continued to be assigned to care for her. During an interview on 11/07/24 at 10:37 a.m. with Clinical Manager (CM) 2, CM 2 stated Resident 84's FM 2 stated CNA 2 had an attitude and requested CNA 2 not be assigned to care for Resident 84. CM 2 stated on 10/30/24 he contacted Scheduler and requested CNA 2 be removed from caring for Resident 84. CM 2 stated it was expected that Scheduler would not assign CNA 2 to care for Resident 84 in the future. CM 2 stated he did…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care plans were developed and implemented for two of five sampled residents (Resident 18 and Resident 268). This failure resulted in Resident 18 and Resident 268 having unmet care needs. Findings: a. During an observation on 11/04/24 at 9:15 a.m. in Resident 18's room, Resident 18 was lying in bed without her legs elevated. During an interview on 11/05/24 at 12:25 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated, Resident 18's heel should be floated [legs elevated so heel does not touch surface] but they are not. During an interview on 11/07/24 at 8:29 a.m. with Resident 18, Resident 18 stated, I have pain in my feet. I'm supposed to have them elevated but they [staff] don't do it. My pain is constant, but elevating does help with the pain. During a review of Resident 18's Minimum Data Set (MDS-assessment tool), dated 11/1/24, the MDS indicated, Resident 18's Brief Interview for Mental Status (BIMS - cognition assessment tool, 15-point scale: 13-15 cognitively intact) score was 14. 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 observation, interview, and record review, the facility failed to ensure one of 25 sampled residents (Resident 1) received the necessary care and services to prevent the development and promote healing of pressure ulcers (open wounds caused by consistent pressure on the skin). This failure had the potential to cause Resident 1 to experience development or deterioration of pressure ulcers. Findings: During a review of Resident 1's admission Record (AR), dated 10/4/24, the AR indicated, Resident 1 has diagnoses of Diabetes Mellitus (DM- disease that causes abnormal blood sugars) with foot ulcer (an open sore that can be shallow or deep), Peripheral Vascular Disease (PVD- abnormal circulation to the extremities), difficulty in walking, and history of falling. During a concurrent observation and interview on 11/4/24 at 11:55 a.m. with Resident 1 in resident's room, Resident 1 had multiple open sores on both of his legs, dried black colored wounds on 2nd, 3rd, and 4th left toes, black colored wounds on both sides of the left foot, and a black colored wound to bottom of his left…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 for one of five sampled residents (Resident 48) fall precautions were in place. This failure had the potential for Resident 48 to fall and sustain injuries. Findings: During an observation on 11/04/24 at 8:53 a.m. in Resident 48's room, Resident 48 was lying in bed and fall mat was folded up next to nightstand. During a concurrent observation and interview on 11/04/24 at 3:03 p.m. with Licensed Vocational Nurse (LVN) 1, in Resident 48's room, one fall mat was folded and placed behind Resident 48's bed, and one (mat) was folded next to the nightstand. LVN 1 stated, they [fall mats] should be placed on the floor next to each side of the bed. During a review of Resident 48's Physician Order (PO), dated 9/1/23, the PO indicated, bilateral [both sides] floor matts [sic]. During a review of the facility's policy and procedure (P&P) titled, Falls Prevention Policy, dated 8/2023, the P&P indicated, The safety precautions for high-risk residents may include, but are not limited to the following: review 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 follow their policy and procedure titled, Medication and Treatment Orders to ensure the physician orders for two of two sampled residents (Resident 164 and Resident 57) included the clinical condition or symptoms for its use. This failure had the potential for residents to be taking unnecessary medications with potential for experiencing adverse health outcomes. Findings: 1. During a review of Resident 164's Medication Administration Record (MAR), dated 11/7/24, the MAR indicated, Meropenem [strong antibiotic to treat infections] Intravenous Solution Reconstituted [mixed with liquid] 500 mg [milligram] Use 500 mg intravenously [given via the veins] two times a day for Infection for 7 days. During an interview on 11/6/24 at 1:35 p.m. with Infection Preventionist Nurse (IPN), IPN stated, The physician's order [for Resident 164] should have the type of infection. IPN stated she had not reviewed the antibiotic order. 2. During a review of Resident 57's MAR, dated 11/7/24, the MAR indicated, Cefepime [strong antibiotic to treat…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 25 sampled residents (Resident 87) was free from significant medication errors. This failure had the potential for Resident 87 to have adverse health outcomes. Findings: During a concurrent observation and interview on [DATE] at 2:51 p.m. with Licensed Vocational Nurse (LVN) 6 at Station 1 Medication Cart 3 contained a bag labeled [Resident 87's name] Morphine Sulf [sulfate - MS - pain medication] 20mgs [milligrams]/1ml [milliliter] Sol [solution] Discard After [DATE] in the controlled medication (medications with high potential for abuse and addiction) drawer. Inside the bag were two syringes each with Resident 87's name, medication name, medication dose, and discard date. LVN 6 stated the label on each syringe indicated a discard date of [DATE]. During a review of Resident 87's [Facility name] Order Audit Report (OAR), dated [DATE], the OAR indicated, Morphine Sulfate (Concentrate) Oral Solution 20mg/ml Give 5mg by mouth…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. Ensure dental services were provided for one of two sampled Residents (Resident 18). 2. Implement care plan interventions for one of two sampled Residents (Resident 18). This failure had the potential for Resident 18 to experience difficulty maintaining nutritional needs and could result in unintended weight loss. 1. During an interview on 11/05/24 at 12:23 p.m. with Resident 18, Resident 18 stated, my teeth are rotting in the back. I told them I needed to see a dentist at least 4 months ago. During an interview on 11/06/24 at 2:35 p.m. with Social Service Director (SSD), SSD stated Resident 18 had a dental consult sent on 9/12/24. No follow-up to this consult as of today (11/6/24). Resident 18 saw a dental hygienist on 9/4/24 for cleaning. She (Resident 18) gets referred to the dentist after a dental hygienist appointment. Last annual checkup from the dentist was on 5/7/24 (lost a tooth). I did not follow up. During an interview on 11/07/24 at 8:29 a.m. with Resident 18, Resident 18 stated, My teeth are hurting this…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 25 sampled resident's (Resident 269) meal tray ticket (MTT - guidance to staff on what to serve for a meal to a resident) was accurate and followed. This failure had the potential to result in a negative health outcome. Findings: During a review of Resident 269's admission Record (AR), dated 10/21/24, the AR indicated, Resident 269 had a diagnosis of Gout (inflammatory arthritis caused by high levels of uric acid [waste product created when the body breaks down a chemical compound]] in the body). During an interview on 11/4/24 at 10:11 a.m. with Resident 269, Resident 269 stated she gets a glass of tomato juice with every meal. Resident 269 stated, I have told staff several times I can't have it because I have Gout and can't have acidic juices but staff bring it to me anyway's. During a concurrent observation and interview on 11/4/24 at 12:26 p.m. with Resident 269 in Resident's room, Resident 269 was eating lunch and got a glass of tomato juice with her meal. Resident 269 stated, See, I told…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the call light system was working properly for one of 25 sampled residents (Resident 269). This failure resulted in delayed care and unmet needs of Resident 269. Findings: During a concurrent observation and interview on 11/4/24 at 10:07 a.m. with Resident 269 in Resident's room, a call bell was on Resident 269's bedside table. The call light was tested and not functioning. Resident 269 stated she does not have a call light that works and was given a call bell to ring instead. Resident 269 stated she can't reach it sometimes; staff can't hear the bell and it takes hours for staff to come. Resident 269 stated she has been without a call light for days. During an interview on 11/4/24 at 10:36 a.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated, Resident 269's call light has not been functioning for a few days and the staff gave her a call bell to use. During an interview on 11/4/24 at 10:40 a.m. with Certified Nursing 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 observation, interview, and record review, the facility failed to ensure comprehensive care plan for one of three sampled residents (Resident 1) impaired skin integrity were developed and implemented. This failure had the potential for worsening of Resident 1's impaired skin integrity. Findings: During an observation on 6/28/24 at 9:31a.m. in Resident 1's room, Resident 1 was lying on his right side. During a review of Resident 1's TAR, dated March 2024, the TAR indicated, Skin care: Right hip – Cleanse, pat dry, & apply foam dressing Q [every] 7 days & PRN [as needed] to maintain skin integrity.Skin care: Cleanse redness on scrotum with soap and water pat dry BID [twice a day] and apply house supply skin protectant cream.Skin care: Right elbow -Cleanse, pat dry, & apply foam dressing Q7 days & PRN to maintain skin integrity. During a concurrent interview and record review on 7/8/24 at 12:25 p.m. with Director of Nursing (DON), Resident 1's nursing care plans for March 2024, April 2024, and May 2024 were reviewed. DON stated, I don't not know why there are no care plans for…

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

Based on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) titled, Routine Clinical Documentation for one of three sampled residents (Resident 1). This failure had the potential not to meet the resident needs. Findings: During an observation on 6/28/24 at 9:31a.m. in Resident 1's room, Resident 1 was lying on his right side. During a review of Resident 1's BD Braden Scale [BDBS – assesses the risk for pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) development], dated 5/22/24, the BDBS indicated, Score: 13 [Moderate risk: 13 to 14]. During a concurrent interview and record review on 7/8/24 at 11:03 a.m. with Director of Nursing (DON), Resident 1's Documentation Survey Report [DSR], dated June 2024 was reviewed. The DSR indicated, Turned and Repositioned – Starting at midnight turn patient to right side. 2:00am turn resident to back, 4:00am turn resident on back, 6am turn resident to right side, 8am turn resident to back, 10am turn resident to right, 12pm turn to back, 2pm turn…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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) on weight management guidelines when one of four sampled residents (Resident 1's) weight was not monitored weekly as ordered. This failure had the potential for Resident 1 to continue losing weight due to weight changes not being monitored and addressed in a timely manner. Findings: During a review of Resident 1's Order Summary Report (OSR), dated 5/11/24, the OSR indicated Resident 1 had an order of Weekly wts [weights] x [for] 1 month. During a review of Resident 1's Weights and Vitals Summary (WVS), dated 6/5/24, the WVS indicated the following weight summary: a. 4/29/24 – 138.4 lbs. (pounds/unit of measuring weight) b. 5/5/24 –129 lbs. (Resident 1 lost 9.4 lbs. in 6 days.) c. 5/6/24 – 128.8 lbs. d. 5/12/24 – 126.2 lbs. There were no weights checked on 5/19/24 and 5/26/24 as indicated in the OSR to complete the weekly weights. e. 6/2/24 – 126.6 lbs. (Resident 1 lost 11.8 lbs. in 30 days from 4/29/24 to 6/2/24) During a review of Resident 1's Weight Change Note (WCN), dated 5/8/24,…

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

Based on observation, interview, and record review, the facility failed to: 1. Ensure the dry food storage room in the kitchen was maintained in a sanitary condition when lifeless roaches were found on the floor and the drain. 2. Ensure the clean water pitcher storage cabinets were cleaned and free from pest. These failures had the potential for contaminating the dry food and clean water pitchers, placing residents at risk for foodborne illnesses. Findings: 1. During an observation on 5/24/24 at 10:41 a.m. in the kitchen, the dry food storage room drain had three lifeless roaches approximately 0.5 inches in size and two lifeless roaches approximately 0.5 inches in size, in the corner of the dry storage room. During an interview on 5/24/24 at 10:47 a.m., with Assistant Dining Supervisor (ADS), ADS stated she saw few roaches last week. ADS stated she reported it (roaches) to the maintenance (department). During an interview on 5/24/24 at 10:49 a.m., with Dietary Dining Supervisor (DDS), DDS went to see the lifeless roaches in the drain and in the corner of the dry storage room. DDS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medications were administered according to the physician order(s) for one of four sampled residents (Resident 1) when: 1. Resident 1's Sodium Chloride (salt-based solution to provide hydration) Intravenous (IV-medication administration route into a vein of a person's body) solution was not administered as ordered. 2. Resident 1's Amiodarone (antiarrhythmic medication-prevents and treats a fast or irregular heartbeat [arrhythmia] by slowing down overactive electric signals in the heart, which stabilizes heart rate and rhythm [strong sound]) was not administered as ordered. These failures had the potential to cause adverse health outcomes. Findings: 1. During an interview and record review on 3/18/24 at 4:58 p.m. with Clinical Nurse Specialist (CNS), Resident 1's Medical Record (MR) was reviewed, the MR indicated the following: Physician Order [PO] dated 11/2/23 indicated, Start IV fluids Now: IV NS[normal saline] 0.9% @[at] 75 cc [cubic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. Notify the physician of a change in condition and increasing oxygen administered for one of four sampled residents (Resident 1) when Resident 1 ' s oxygen saturation (oxygen level in the blood) went below normal, and staff increased the oxygen without a physician's order. This failure had the potential to contribute to Resident 1's decline in health condition. 2. Follow their policy and procedure on Neurological Checks (assessment of sensory and motor responses, especially reflexes, to determine whether the nervous system is impaired) for one of four sampled residents (Resident 1) when the neurological check results were inaccurately documented. This failure resulted in Resident 1 having inaccurate clinical records and potential for unidentified neurological decline. Findings: 1. During a concurrent interview and record review on 3/5/24 at 4:34 p.m. with Director of Clinical Services (DCS), Resident 1 ' s Progress Notes, dated 2/24/24 at 11:45 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 observation, interview, and record review, the facility failed to ensure its policy and procedure (P&P) titled, Resident Call System and Door Alarm Response- EME-1 was followed for one of two sampled residents (Resident 2). This failure resulted in Resident 2 to have a delay in positioning of his therapeutic knee pillow. Findings: During a concurrent observation and interview on 2/13/24 at 1:18 p.m. with Resident 2, in Resident 2's room, Resident 2 was in a side-lying position in bed with his knees bent, and a wall clock was noted across from his bed. Resident 2 stated he had contractures (the shortening or tightening of tissues that reduces movement affecting skin, muscles and often causes pain in addition to decreased range of motion) to his legs/knees and required positioning assistance with the use of a therapeutic knee pillow placed in between his knees to help with his painful contractures. Resident 2 stated on 2/6/24, he waited for A really long time felt like hours and expected his call light to be answered approximately within a few minutes. Resident 2 stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure pain medications were administered as ordered for one of two sampled residents (Resident 1). This failure resulted in Resident 1 ' s delay in receiving his pain medication. Findings: During an interview on 2/13/24 at 12:55 p.m. with Resident 1, in Resident 1's room. Resident 1 stated on 2/6/24, he had back pain and was admitted to the facility from the hospital after he received an epidural (an injection in the back for pain relief) to help with his back pain. Resident 1 stated he did not receive his pain medications Dilaudid (Schedule II- controlled narcotic medication for the treatment of pain) and Morphine Sulfate (Schedule II- controlled narcotic medication for the treatment of pain) until 2/7/24 and was offered non-pharmacological care interventions which included repositioning. During a review of Resident 1's Medical Record (MR), Resident 1's Minimum Data Set (MDS) dated [DATE], indicated, Section C- Cognitive Patterns. C0500. BIMS [Brief…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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) on Resident Grievance Procedure for one of three sampled residents (Resident 1). This failure had the potential for grievances to go unresolved and result in negative consequences. Findings: During a concurrent interview and record review on 12/12/23 at 2:59 p.m. with Director of Staff Development (DSD), the facility grievance forms were reviewed. DSD stated on 11/27/23, she spoke with Resident 1 ' s family regarding him being left wet with urine throughout the previous night. DSD stated she spoke with the facility Administrator regarding Resident 1 ' s family concern and she was instructed to document in a grievance form. DSD reviewed the grievance form regarding Resident 1 and stated it was left blank. DSD stated she was not aware of the facility policy and procedure for grievances that indicated they must be addressed within a specific amount of time. DSD stated she was not aware of the expectation regarding grievance reports. During a review of the facility ' s policy and procedure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 change one of three sampled residents (Resident 1) after an episode of urinary incontinence (inability to control urine or feces). This failure had the potential to result in infection, skin issues, wounds, and low self-esteem. Findings: During an interview on 12/12/23 at 8:38 a.m. with Complainant, Complainant stated the Monday after Thanksgiving (11/27/23) she had visited Resident 1 and noticed his room stunk like urine and feces. Complainant stated staff (unidentified) were in the process of changing Resident 1's brief. Complainant stated Resident 1 had a soiled brief of urine and feces. Complainant stated she spoke with Resident 1, and he stated he had not been changed since 4 p.m. the prior day. Complainant stated she gathered all the nurses (unidentified) (undisclosed time) in the area and let them know it was unacceptable. Complainant stated the nurses informed her the night shift nurses were lazy and the reason why Resident 1 was not changed. Complainant stated Resident 1 was dependent on care by staff to change…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a clean environment for one of three sampled residents (Resident 1). This failure had the potential for Resident 1 to feel undervalued, not cared for and have a negative effect on his self-respect. Findings: During a review of Resident 1 ' s Minimum Data Set (MDS- comprehensive assessment tool) under BIMS (Brief interview for mental status - an assessment tool for cognition), dated 11/22/23, the BIMS indicated Resident 1 had a score of 15 out 15 (cognition is intact). During a concurrent observation and interview on 12/12/23 at 12:18 p.m. with Resident 1, in Resident 1 ' s room, Resident 1's linen and pillowcases were noted to have red to brownish stains scattered throughout. Resident 1 stated he had scraped his right elbow three or four days ago in which it was bleeding. Resident 1 was observed to have a dressing on his right elbow with red to brownish stains on it. During a concurrent observation and interview on 12/12/23 at 12:38 p.m. with Executive Director (ED) in Resident 1 ' s room, ED observed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pain medications were administered according to physicians ' orders for six of nine sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, and Resident 6). These failures had the potential for Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, and Resident 6 to have ineffective pain management. Findings: During an interview on 12/20/23 at 3:49 p.m. with Resident 6, Resident 6 stated she currently has 7/10 pain to her leg and back. Resident 6 stated she was requesting pain medications every six hours. Resident 6 stated she could not have her pain medications until 4 p.m. During an observation and interview on 12/20/23 at 4 p.m. with Resident 2 in Resident 2 ' s room. Resident 2 stated she currently has pain from her hip down to her leg and right now it is a 10/10. Resident 2 was observed wincing and moaning in pain. Resident 2 stated she was requesting pain medication every 4 hours and the medication brings her pain down to 5 or 6. Resident 2 stated the medication only…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an effective pain management for six of nine sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, and Resident 6). These failures had the potential for delay in the residents treatment and improper pain management causing discomfort to the residents. Findings: During an interview on 12/20/23 at 3:49 p.m. with Resident 6, Resident 6 stated she currently has 7/10 pain to her leg and back. Resident 6 stated she was requesting pain medications every six hours. Resident 6 stated she could not have her pain medications until 4 p.m. During an observation and interview on 12/20/23 at 4 p.m. with Resident 2 in Resident 2 ' s room. Resident 2 stated she currently has pain from her hip down to her leg and right now it is a 10/10. Resident 2 was observed wincing and moaning in pain. Resident 2 stated she was requesting pain medication every 4 hours and the medication brings her pain down to 5 or 6. Resident 2 stated the medication only last about 3 hours. During an interview on 12/21/23…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, Controlled Substances Policy, for six of nine sampled residents (Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, and Resident 7). This failure had the potential for pain medications to be diverted and Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, and Resident 7 ' s pain to be ineffectively managed. Findings: During an interview on 12/20/23 at 3:14 p.m. with Interim Director of Nurse of Nursing (IDON), IDON stated the issue with controlled narcotic was brought to her attention yesterday (12/19/23). IDON stated she conducted a review of PRN (as needed medications) narcotics. IDON stated she found two nurses were documenting on Control Drug Record (CDR) but not documenting on Medication Administration Record (MAR). IDON stated the nurses had stated they signed the medications out on the CDR, but they were busy and just forgot to document on the MAR. During an interview on 12/21/23 at 3:34 p.m. with Registered Nurse (RN 1), RN 1 stated he and the oncoming…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 four sampled residents (Resident 1) was promptly assisted with toileting. This failure resulted in Resident 1 not receiving timely assistance and not treated with dignity. Findings: During an interview on 10/19/23 at 11:47 a.m. with Resident 1, Resident 1 stated she cannot get out of bed to use the restroom, she uses a bed pan to go to the restroom. Resident 1 stated on Tuesday night she had to call the office; she stated she was left on the bedpan for about 30 minutes. Resident 1 stated on Monday night I was told if I had to go just go. She stated she felt like I wanted to get up and slapped her (staff) During a review of Resident 1's Minimum Data Set, (MDS – an assessment tool) dated 10/20/23, the MDS indicated, Resident 1's BIMS (Brief Interview for Mental Status) score was 14 (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] Self Care Preformance Deficit, initiated 10/17/23, the care plan…

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

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) pain medication was administered timely. This failure resulted in Resident 1's pain to not be treated effectively and timely. Findings. During an interview on 10/19/23 at 11:47 a.m. with Resident 1, Resident 1 stated pain medications can take anywhere from ten minutes to two hours to be administered. Resident 1 stated, Last night, I ring the bell informed the CNA [certified nursing assistant] and waited two hours, the Nurse stated the CNA never told her, so I don't know who dropped the ball on that one. During a review of Resident 1's Minimum Data Set, (MDS – an assessment tool) dated 10/20/23, the MDS indicated, Resident 1's BIMS (Brief Interview for Mental Status with a range of 0-15) score was 14 (a score of 13 to 15 suggests the resident is cognitively intact). During a review of Resident 1's Care Plan, (PC) initiated on 10/16/23, with the focus on risk for pain, the CP indicated, Interventions/Tasks Monitor/document/report to Nurse any s/sx [signs and symptoms] 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 pain management was effective for two of five sampled residents (Resident 2 and Resident 4) when: 1. Resident 2 was crying and waited for more than one hour for pain medication to be given. 2. Resident 4's pain was not followed up after administering pain medication. These failures had the potential for residents suffering in pain affecting their quality of life. Findings: 1. During an interview on 10/31/23 at 10:10 a.m. with Family Member (FM) 1, FM 1 stated Resident 2 gets pain medication every four hours. FM 1 stated on 10/21/23, Resident 2 did not receive her pain medication (Norco -medication to treat moderate to severe pain) for 10 hours. On that day, the p.m. nurse gave Resident 2's pain medication at 4 a.m. and told her (Resident 2) that it (Norco) was her last pain medication, and the a.m. nurse would need to re-order her pain medication. FM 1 stated the Assistant Director of Nursing (ADON) told her Resident 2's room was shared with two medication carts and that is why the medication was taught to 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.

During an interview and record review, the facility failed to ensure one of five sampled residents (Resident 5) was free from a medication error when Resident 5 received a discontinued pain medication. This failure resulted in Resident 5 having sudden and unexpected inability to perform usual activities, onset of confusion, and hallucinations (perception of something not present) and potential for adverse unfavorable health consequences including death. Findings: During an interview on 11/14/23 at 3:52 p.m. with Resident 5, Resident 5 stated her care was awful . Resident 5 stated, The facility did not read the instructions from the ER [Emergency Room] and overdosed me with Morphine [medication to treat severe pain], twice. Resident 5 stated her family (Family Member/FM 3) realized she was overdosed. Resident 5 stated she was not good . During a review of Resident 5's Brief Interview for Mental Status (BIMS), dated 10/26/23, the BIMS indicated, Resident 5 had a BIMS of 15 (score of 13-15 means cognitively intact). During an interview on 11/15/23 at 1:13 p.m. with FM 3, FM 3 stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care and services for one of three sampled residents (Resident 1) to ensure: 1. Physician's order was obtained for the left knee splint (LKS-device that hinders mobility causing atrophy [decrease in size of a body part] and range of motion [maximum amount of joint movement] loss) prior to applying on Resident 1's left knee. This failure resulted in Resident 1's above the left knee discoloration and unstageable (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer [damaged skin due to constant pressure] cannot be confirmed because it is obscured by slough a [dead tissue appearing as while/yellow in the wound bed that's needed to be removed to promote healing] or eschar [death of body tissue]) pressure injury (a localized damage to the skin and underlying soft tissue, usually over a bony prominence or related to a medical device) to the left side of his left knee. 2. Accurate Change of Condition…

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

Based on interview and record review, the facility failed to provide sufficient staffing to accommodate residents needs by not answering call lights timely for one of four sampled residents (Resident 1). This failure had the potential for Resident 1 to not receive timely care and unmet care needs. Findings: During an interview on 7/13/23, at 5:57 p.m. with Resident 1, Resident 1 stated the call lights take anywhere from 30 minutes to three hours to be answered by staff. Resident 1 stated the Certified Nursing Assistant (CNAs) answered the call light and say they will be right back but do not return for an hour sometimes three hours. Resident 1 stated she was taking a water pill, and usually calling because she needed to be changed, but she was not getting the help on time. Resident 1 stated she calculated the wait time by the clock on the wall. During a review of Resident 1 ' s Minimum Data Set, (MDS – an assessment tool) dated 4/26/23, the MDS indicated, Resident 1's BIMS (Brief Interview for Mental Status with a range of 0-15) score was 13 (a score of 13 to 15 suggests the…

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

Based on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) titled, Supporting Activities of Daily Living to provide grooming, personal and oral hygiene assistance for two of 31 residents (Resident 190 and Resident 239). This failure resulted in physical and psychosocial distress for Resident 190 and Resident 239. Findings: During an interview on 12/5/22, at 10:48 AM, with Resident 190, Resident 190 stated, she relied on the facility staff to assist her with showers. Resident 190 stated, she had not had a shower since 11/27/22. Resident 190 stated, her scheduled shower days were Tuesdays and Fridays. Resident 190 stated, on Tuesday 11/29/22, when she returned from therapy, the Certified Nursing Assistant (CNA) told Resident 190 she had missed her shower time. Resident 190 stated, she asked for a bath every day and asked for a towel to try and clean herself, but she was never bathed or provided a towel to clean herself. Resident 190 stated, not being bathed for so many days made her feel yucky and uncomfortable. During an…

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

Based on observation, interview, and record review, the facility failed to implement their policy and procedure (P&P) for securing the medication cart and medication. This failure had the potential for unauthorized access to medications by residents, staff, and visitors. Findings: During an observation on 12/7/22, at 9:55 AM, in the hallway outside Resident 28's room, an unattended and unlocked medication cart was observed. A bubble pack (pre-packaged medication) individualized for Resident 28, labeled glycopyrrolate (medication to decrease saliva) was observed unattended on top of medication cart. During an interview on 12/7/22, at 9:58 AM, with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, she should not have left the medication cart unlocked and medication unattended at any time. During a review of the facility's P&P titled, General Dose Preparation and Medication Administration, dated 1/13, the P&P indicated, 3.9 Facility staff should not leave medications or chemicals unattended. 7. Facility should ensure that medication carts are always locked when out of sight or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) titled, Storage of Perishable Food when: 1. Condiments were not discarded by their use by date 2. All food was not covered in the refrigerator and freezer units 3. Opened products were not labeled with an opened date or a use by date 4. Refrigerator Temperature logs were not maintained. These failures had the potential to result in decreased food quality, loss of nutrients, and foodborne illness. Findings: 1. During a concurrent observation and interview, on 12/5/22, at 8:23 AM, with Cook, in the kitchen, the labels on condiments in the refrigerator were observed. The following products and use by dates were observed: Italian Salad Dressing, use by 12/1/22 Thousand Island Salad Dressing, use by 12/1/22 Ketchup, use by 12/4/22 Ranch Salad Dressing, use by 12/4/22 [NAME] Real Mayonnaise, use by 11/29/22 Yellow Mustard, use by 12/1/22 Blue Cheese Salad Dressing, use by 12/1/22 Romaine Caesar Salad…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ice machines was maintained in a safe and sanitary condition. This failure had the potential to result in food-borne illness to residents and staff. Findings: During an observation on 12/7/22, at 10:28 AM, with Regional Director (RD), in Nurses' Station 1's ice machine room, the ice machine was observed with a puddle of water on a top ledge above the ice storage bin and water dripping from the left side of the ice machine at the bottom edge. An ice machine maintenance log, dated 11/25/22, was observed on the wall indicating the ice machine had been deep cleaned on 11/25/22. During a concurrent observation and interview on 12/7/22, at 10:39 AM, with Maintenance Supervisor (MS) and RD, in Nurses' Station 1's ice machine room, the ice machine was observed with a puddle of water on a top ledge above the ice storage bin. The front panel and evaporator cover, allowing observation of the water distribution system and ice curtain (where the ice cubes are made), were removed by MS. Drops of water…

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

Based on observation, interview, and record review, the facility failed to ensure a call light was easily accessible for two of 31 sampled residents (Resident 239 and Resident 13). This failure resulted in Resident 239 and Resident 13 unable to call staff for assistance and unmet needs. Findings: During a review of Resident 239's admission Record (AR), dated 9/28/22, the AR indicated, Resident 239's primary admitting diagnosis was a Cerebral Infarction (Stroke- damage to brain tissue) with Hemiplegia (paralysis, muscle weakness) affecting the right dominant side of her body (resident was right handed). During a concurrent observation and interview on 12/6/22, at 11:05 AM, with Resident 239, at Resident 239's bedside, Resident 239 was unable to move her right arm and spoke in a whisper. Resident 239's call light was under the pillow next to the right side of her head. Resident 239 was searched with her left hand for the call light. Resident 239 stated, she could not find the call light and she did not know what she would do if she needed help. 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 observation, interview, and record review, the facility failed to provide a homelike environment for one of 31 sampled residents (Resident 239) when drawers were missing in the chifforobe (closet-like piece of furniture over two drawers). This resulted in the potential for lack of storage for personal belongings and did not provide a homelike environment. Findings: During a concurrent observation and interview on 12/6/22, with Maintenance Supervisor (MS), at 11:15 AM, at Resident 239's bedside, the room's chifforobe was missing the two drawers. The open space for the top drawer contained a plastic bag with Resident 239's belongings. MS stated, missing drawers in the facility's furniture did not promote a homelike environment. During an interview on 12/8/22, at 9:26 AM, with Resident 239, Resident 239 stated, it was important to her to have a homelike environment. During a review of the facility's policy and procedure (P&P) titled Quality of Life- Homelike Environment, dated 4/14, the P&P indicated, Residents are provided with a safe, clean, comfortable and homelike…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide vision screening for one of 31 sampled residents (Resident 36). This failure had the potential for Resident 36 to have worsening vision. Findings: During a review of Resident 36's admission Record (AR), readmitted [DATE], the AR indicated, Resident 36 was originally admitted to the facility on [DATE]. Resident 36's admission diagnosis included Diabetes Mellitus (disease that affect how the body uses blood sugar/glucose. When not treated effectively, can lead to blindness, heart disease, and other ailments). During an interview on 12/6/22, at 2:42 PM, with Resident 36, Resident 36 stated, he needed glasses. Resident 36 stated, he lost his prescription glasses and had been buying over the counter glasses at various places. Resident 36 stated, he could not remember when he was last seen by an eye doctor for glasses. During an interview on 12/7/22, at 2:06 PM, with Social Services Director (SSD), SSD stated, he was unable to provide written…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were free from a medication error rate of greater than five percent for one of four sampled residents (Resident 26) when two medication errors occurred within 30 opportunities for errors. This failure had the result of the facility medication error rate of 6.67 %. Findings: During a review of Resident 26's Order Summary Report (OSR), dated 12/7/22, the OSR indicated, Flurometholone Ophthalmic Suspension [[NAME]- medicated eyes drops] 0.1 % . Instill (to drop in) one drop in both eyes two times a day for dry eyes and Refresh Liquigel Gel [RLG - eye drops] 1% . Instill two drops in both eyes three times a day for Dry Eyes. During a medication pass observation on 12/7/22, at 9:40 AM, with Licensed Vocational Nurse (LVN) 1, LVN 1 instilled two drops of [NAME] in Resident 26's right and two drops of [NAME] in Resident 26's left eye. LVN 1 instilled one drop of RLG in Resident 26's right and one drop of RLG in Resident 26'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.