Parkview Julian Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy and procedure (P&P) on Fall Management Program, Refusal of Treatment, and Continence Management Guideline when:1. Certified Nursing Assistant (CNA) 1 did not notify a licensed nurse when one of three sampled residents' (Resident 1) refused to have her soiled brief changed.2. CNA 1 did not check and offer to change Resident 1's soiled brief after a refusal for one hour and 45 minutes.3. CNA 1 did not check and offer to change Resident 1's brief every two hours.These failures had the potential to result in Resident 1 falling from trying to go to the bathroom and sustaining right distal femur (lower part of the right thigh bone) fracture (broken bone) requiring hospitalization and surgery.Findings:During a review of Resident 1's admission Record [AR], dated 1/6/26, the AR indicated, DIAGNOSIS. MUSCLE WEAKNESS (GENERALIZED). NEED FOR ASSISTANCE WITH PERSONAL CARE. HISTORY OF FALLING. DISPLACED INTERTROCHANTERIC FRACTURE [a break in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Documentation - Nursing, for one of three sampled residents (Resident 1) when Resident 1's Nurse Advance Skilled Evaluation ([NAME]) documentation was inaccurate. This failure had the potential for Resident 1 to receive inappropriate care.Findings:During a concurrent interview and record review on 1/5/26 at 1:01 p.m. with Registered Nurse (RN), Resident 1's [NAME], dated 11/24/25 at 3:34 p.m. was reviewed. The [NAME] indicated, Respiratory: Difficulty breathing noted. Resident [1] reported respirations shallow. Nurse observed sternal retractions [a visible sign of respiratory distress] present. Shortness of breath noted. Resident [1] reported Shortness of breath (while lying flat). Nurse observed Shortness of breath (while lying flat). RN stated she documented in error. RN stated the documentation was for another resident (unknown).During an interview on 1/20/26 at 12:20 p.m. with Director of Nursing (DON),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 four sampled residents (Resident 1, Resident 30 and Resident 75) had comprehensive activities assessments and activities care plans developed specific to the preferences and interests of Resident 1, Resident 30 and Resident 75. This failure resulted in Resident 1, Resident 30 and Resident 75 not receiving activities specific to their preference or interests. This failure resulted in a decreased quality of life for Resident 1, Resident 30, and Resident 75.Findings: a. During an observation on 12/17/25 at 2:23 p.m. outside of Resident 1's room, activities staff (AS) was pushing a cart to resident rooms. AS visited multiple resident's rooms but did not attempt to enter Resident 1's room. During an interview on 12/18/25 at 8:45 a.m. with AS, AS stated she assumed Resident 1's son was in the room visiting the day before (12/17/25) and did not go in Resident 1's room. AS stated she does not go into Resident 1's room normally, because Resident 1 refuses activities. During a concurrent interview 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 ensure professional standards for food service safety and sanitary kitchen conditions were followed when: 1. Two opened boxes of vegetables in the refrigerator in the dry storage room were not labeled with a received, opened and use by date. This had the potential for residents to be served unpalatable food.2. An opened unlabeled box of butter was stored in one of one refrigerator in the dry storage room. This had the potential for residents to be served unpalatable food.3. Food scoops were stored inside two of four dry good food containers. This failure had the potential to cause foodborne illnesses (illness caused by the ingestion of contaminated food) for residents.4. One of one sampled ice cream scoop was not cleaned prior to being stored with clean utensils. This failure had the potential to cause foodborne illnesses (illness caused by the ingestion of contaminated food) for residents.5. Two rolls of unlabeled meat were stored in one of one of the freezers in the hallway outside the kitchen. This had 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 its policy and procedure (P&P) titled Miscellaneous Areas when one of three trash bins could not be closed. This failure had the potential to attract flies, vermin, and rodents that carry diseases which could infect the residents and cause an infestation in the facility.Findings:During a concurrent observation and interview on 12/15/25 at 8:25 a.m. with Certified Dietary Manager (CDM) in the outside area where the trash bins are located. One of three trash bins had the lid open, and the trash bags were overflowing from the top of the bin. CDM stated the staff should have put the trash in the trash bin that was empty. CDM stated staff know that they must be able to close the lid, to prevent attracting flies or rodents.During a review of the facility P&P titled, Miscellaneous Areas, dated 2023, the P&P indicated, Garbage and trashcans must be inspected daily that no debris is on the ground or surrounding area, and that the lids are closed. The trash collection area is a potential feeding ground for vermin…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 sanitary disposal of three used trash bags. This failure had the potential to result in the spread of infection to residents, staff, and visitors. During an observation on 12/15/25 at 8:38 a.m., in room [ROOM NUMBER]'s bathroom, a plastic trash bag containing trash was on the floor next to a trash can inside the resident's bathroom. During a concurrent observation and interview with Licensed Vocational Nurse (LVN) 2, in Resident 30's bathroom, trash was on the floor. LVN 2 stated, the certified nurse assistant should have placed the bag in the trash can, it should not be there on the floor.During an observation on 12/15/25, at 10 a.m., in Resident 52's room, looking out onto the patio area outside, a clear plastic bag was seen on the ground across the courtyard in the resident's patio area. The plastic trash bag contained a brown substance. During a concurrent observation and interview on 12/15/25 at 10:10 a.m., with…

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

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan (CP) for one of six sampled residents (Resident 89). This failure had the potential to result in Resident 89 having an unrecognized change in condition and adverse health outcome.Findings:During an observation on 12/16/25 at 8:58 a.m. with Resident 89, in Resident 89's room. Resident 89 was receiving oxygen though a nasal cannula (A lightweight tubing device that is placed in the patient's nose to deliver supplemental oxygen).During a review of Resident 89's Clinical Record (CR), the CR indicated Resident 89 had a Physician Order (PO) for Oxygen-continuously to start at 5 LPM (liters per minute) via nasal cannula to maintain Oxygen [O2]) sat [saturation - level of O2 in the blood] above 92% [percent] notify MD [Medical Doctor] if O2 drops below 92 %.During a concurrent interview and record review on 12/18/25 at 10:15 a.m. with Minimum Data Set Coordinator (MDSC), Resident 89's Care Plan (CP), was reviewed. MDSC stated Resident 89 was receiving…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 75) was provided quality health care when: a. Resident 75's laboratory results were not reviewed and reported to the physician in a timely manner. This failure had the potential to result in delayed treatment and worsening of Resident 75's infection. b. Interdisciplinary Team (IDT - a group of health care providers) did not develop an individualized care plan (CP) for Resident 75's contact isolation (CI - infection control process for preventing germs from spreading through direct touch or contaminated surfaces). This failure resulted in staff not being aware of Resident 75's infection and the potential for the infect to spread to staff and other residents in the facility. c. Resident 75 was kept on contact isolation for 13 days after the physician order for contact isolation was discontinued. This failure resulted in unnecessary isolation had the potential to result in emotional distress for Resident 75. Findings: a. During a concurrent interview and record review on 12/18/25…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 annual competencies were completed for one of six sampled employees (Certified Nursing Assistant [CNA] 1) was completed. This failure had the potential for the staff not be aware of their need for improvement in certain areas, which could affect resident care.During a concurrent interview and record on 12/18/25 at 10:48 a.m. with Director of Staff Development (DSD), Certified Nursing Assistant (CNA) 1's personal file (PF), [undated] was reviewed. The PF indicated CNA 1 was hired on 6/5/24. The PF indicated there was no annual competency completed for CNA 1. DSD stated there should have been annual competency done in June of 2025 but there was none completed.During a review of the facility's P&P titled, Care Standards, dated 11/1/17, the P&P indicated, V. The DNS or designee evaluates staff competency in skills and techniques necessary to care for residents assessed needs.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure patio area located between Station B and Station C was maintained in a clean and sanitary manner. This failure had the potential to result in the spread of infection to residents, staff and visitors.During an interview on 12/15/25 at 10 a.m. with Resident 52, in Resident 52's room. Resident 52 stated he would like to have a cover or umbrella on the patio area to sit with family or children who visit on the patio area outside his room. During an observation on 12/15/25, at 10:02 a.m. in Resident 52's room, on to the patio area, a plastic bag was on the ground across the courtyard in the resident's patio area. The plastic trash bag contained a brown substance. During a concurrent observation and interview on 12/15/25 at 10:10 a.m., with Transportation/Help and Maintenance Supervisor (MS), Transportation/Help put on gloves and open the plastic trash bag, Transportation/Help stated, it's poop [feces - human waste product]. MS stated he was not sure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, Grievance and Complaints for one of three sampled residents (Resident 1) when the facility did not inform Resident 1of the outcome of the investigation and actions taken to resolve the grievance. This failure had the potential for Resident 1 to feel his grievances were not investigated or resolved.Findings:During an interview on 8/12/25 at 11:53 a.m. with Resident 1, Resident 1 stated he asked a certified nursing assistant (CNA) to speak to the administrator on Friday (8/8/25). Resident 1 stated the Administrator still has not come to talk to him (on 8/12/25). Resident 1 stated he wanted to speak to the Administrator about noise. Resident 1 stated his roommate next to him is only Spanish speaking and his TV is loud. Resident 1 stated no one comes. Resident 1 stated, For breakfast it says orange juice I am really particular about juice, but I still get pineapple juice. Resident 1 stated he recently asked to speak to someone in the kitchen on Friday and no one has been out yet.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accommodate residents needs when call lights were not answering timely for one of three sampled residents (Resident 1). These failures had the potential for Resident 1 not to receive timely nursing care and maintain the highest practicable physical well-being.Findings:During an interview on 6/30/25 at 1:42 p.m. with Resident 1, Resident 1 stated she use the call light to be changed after having a bowel movement. Resident 1 stated she has to wait sometimes up to 40 minutes for her bowel movement to be changed. Resident 1 stated she is prone to Urinary Tract Infections (UTI-start when bacteria get into the tube through which urine leaves the body) and has had a two UTI's since being in the facility.During a review of Resident 1's Minimum Data Set (MDS - an assessment tool), dated 2/19/25, the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS- standardized assessment tool used to evaluate the cognitive processes that allow individuals to think, learn, and remember) score was 15 (score of 13 to 15 indicates…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, Abuse Prevention and Prohibition Program, when the facility failed to: 1. Report and investigate misappropriation of property to the California Department of Public Health (CDPH - local state agency) and local ombudsman for one of four sampled residents (Resident 1). This failure had the potential for Resident 1 to experience further abuse. 2. Develop and implement a care plan to protect one of four sampled residents (Resident 1), when financial abuse was discovered. This failure resulted in Resident 1 not to be protected from further abuse, and the potential for Resident 1 ' s mental or psychosocial needs to go unmet. Findings: 1. During an interview on 4/21/25 at 12:32 p.m. with Behavioral Health Worker (BHW), BHW stated Resident 1 ' s reported that he gave his bank card to his brother and he gave his brother permission to use $300 and his brother had not returned the card. BHW stated Resident 1 only get $316 monthly and he had 3 months on the card…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Prevention and Prohibition Program, when the facility failed to: 1. Submit the SOC 341 (California Report of Suspected Dependent/Elder Abuse) to the California Department of Public Health (CDPH - local state agency) and local ombudsman for two of five sampled residents (Resident 1 and Resident 2). This failure had the potential for Resident 1 and Resident 2 to experience further abuse. 2. Submit the 5-day investigation report to the local ombudsman and the CDPH within 5-days of the incident for one of five sampled residents (Resident 3). This failure had the potential for an incomplete investigation for Resident 3. 3. Notify the attending physician (AP) for one of five sampled residents (Resident 3) allegation of financial abuse. This failure resulted in Resident 3's AP to be unaware of the financial abuse. 4. Develop a care plan for one of five sampled residents (Resident 3) when the financial abuse was discovered. This failure had the potential for Resident 3 mental…

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

Based on interview and record review, the facility failed to ensure an antibiotic (medication used to treat infections) order was given as ordered by the Medical Doctor (MD) for one of five sampled residents (Resident 1). This failure had the potential to result in delayed healing of Resident 1's infection. Findings: During a review of Resident 1's admission Record (AR), dated 2/28/25, the AR indicated, Diagnosis. Encounter for other specified surgical aftercare (care provided after surgery). During a review of Resident 1's Medication Administration Record (MAR), dated February 2025, the MAR indicated Resident 1 received Keflex (antibiotic) every eight hours from 2/13/25 to 2/20/25 for surgical wound infection. During a concurrent interview and record review on 3/6/25 at 2:59 p.m. with Treatment Nurse (TN), Resident 1's Change in Condition Evaluation (CCE), dated 2/12/25, and Order Summary (OS), dated 2/13/25 were reviewed. The CCE indicated, Resident's dressing was noted to have a large amount of drainage (fluid that leaks out of the wound) . MD notified, new orders were entered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assessment and management of resident weights for one of three sampled residents (Resident 1) when Resident 1 did not have his weight taken for three months. This failure had the potential to result in inaccurate nutrition assessment due to using outdated weights. Findings: During a review of Resident 1's admission Record (AR), dated1/31/25, the AR indicated, Diagnosis. Mild Protein-Calorie Malnutrition (condition where someone does not get enough protein and energy). Onset Date. 11/26/2024. During a review of Resident 1's Minimum Data Set (MDS – an assessment tool), dated 1/7/25, the MDS indicated Resident 1 had a BIMS (Brief Interview for Mental Status) of 12 (score of 8 to 12 means moderately impaired cognition). During a review of Resident 1's Documentation Survey Report (DSR – activities of daily living [basic personal tasks performed daily] flowsheet), dated January 2025, the DSR indicated Resident 1 had multiple meal refusals on: a. 1/4/25 dinner, b. 1/5/25 breakfast 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 three sampled residents (Resident 1) was involved in the comprehensive person-centered care planning process. This failure resulted in violation of resident's rights. Findings: During an interview on 12/23/24 at 12:42 p.m. with Resident 1, Resident 1 stated he was told by the facility staff he could no longer be transferred via sheet from his bed to the shower bed. Resident 1 stated No reason was given, they (facility staff) have been transferring me like that since I have been here, since January 2024. During a concurrent interview and record review, on 12/23/24 at 3:34 p.m. with Administrator, Resident 1's care plan with the focus on (Resident 1) is persistent on having staff transfer him with a sheet to shower bed . initiated 12/21/24 was reviewed. Administrator stated the facility discussed the reasons staff could no longer transfer Resident 1 using a sheet, with Resident 1 a few months ago. Administrator stated he was not sure if it was in a care conference or IDT (a group of healthcare professionals who…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident (Resident 1) transportation was scheduled for doctor's appointment. This failure resulted in Resident 1 missing a necessary doctor's appointment. Findings: During an interview on 12/23/24 at 12:42 p.m. with Resident 1, Resident 1 stated he recently missed a doctor's appointment due to transportation not being scheduled. Resident 1 stated the appointment was for medications to treat his valley fever (a serious lung infection). During a review of Resident 1's Order Details, (OD) order date 12/4/24, the OD indicated Resident 1 had a doctor's appointment scheduled on 12/16/24. During a review of Resident 1's Social Services, (SS) note dated 12/16/24, the SS note indicated, [Resident 1] didn't have transport for his appt (appointment) at the (hospital name), Appt rescheduled so that ss can set up transport. During an interview on 12/23/24 at 4:05 p.m. with Social Services Director (SSD), SSD stated she did not receive a transportation request and I cannot schedule transportation without one.…

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

Based on interview and record review, the facility failed to implement a care plan for one of three sampled residents (Resident 1) when the facility did not monitor Resident 1 after a fire. This failure had the potential for Resident 1 to develop adverse health outcomes from exposure to fire. Findings: During a review of Resident 1's Change in Condition Evaluation (CCE), dated 12/21/24, the CCE indicated, CNA came rushing to nursing station informed that resident has fire in her room. resident c/o (complained of) throat and lungs hurting, chest pain and difficulty breathing. During a review of Resident 1's Minimum Data Set (MDS – an assessment tool), dated 9/14/24, the MDS indicated Resident 1 had a BIMS (Brief Interview for Mental Status) of 12 (score of 8 to 12 indicates moderate cognitive impairment). During an interview on 12/24/24 at 9:19 a.m. with Resident 1, Resident 1 stated, Something was on fire. They said it was my charger and there was a lot of smoke in here. It happened last week (12/21/24). Resident 1 stated she breathed in the smoke in her room, and it made her chest…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policy and procedure (P&P) titled, Resident Access to PHI (protected health information), when three of four sampled residents (Resident 1, Resident 2, and Resident 3) medical records request (MRR) were not logged. This failure had the potential for MRR not to be reviewed and acted upon timely for Resident 1, Resident 2, and Resident 3. 2. Follow their P&P titled Third Party Disclosures of Protected Health Information, when communication for request were not acted upon timely for three of four sampled residents (Resident 1, Resident 2, and Resident 3). This failure resulted in a violation of Resident 1, Resident 2, and Resident 3's rights for MMR to be acted upon timely for Resident 1, Resident 2, and Resident 3. Findings: 1. During a concurrent interview and record review on 12/23/24 at 3:04 p.m. with Medical Records (MR), MR stated she received an MMR for Resident 1, Resident 2, and Resident 3. MR stated she does not keep a log to track the MRR. During a review of the facility's P&P titled, Resident…

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

Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 1 and Resident 2) personal items were inventoried upon admission. This failure had the potential for personal items to be unaccounted for Resident 1 and Resident 2 and the use of dangerous materials in the facility. Findings: During a concurrent observation and interview on 12/6/24 at 12:45 p.m. in Resident 1's room. Resident 1 stated he was a smoker. Resident 1's lighter was observed on his bedside table. Resident 1stated he was allowed to keep lighter and cigarettes upon admissions. Resident 1 stated he was storing his cigarettes in his nightstand next to his bed. During a concurrent observation and interview on 12/6/24 at 1 p.m. in Resident 1's room. with Certified Nursing Assistant (CNA) 1. CNA 1 confirmed Resident 1 had possession of a lighter and a pack of cigarettes. CNA 1 stated residents should not have lighters or smoking materials in their possession. CNA 1 stated lighter and cigarettes should be with a nurse or activity staff in a locked box at all…

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

Based on interview and record review, the facility failed to ensure: 1. Six of 20 sampled residents (Resident 58, Resident 87, Resident 193, Resident 22, Resident 17, Resident 70) had a signed and dated 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) 2. Document five of 20 sampled residents (Resident 344, Resident 4, Resident 68, Resident 60, and Resident 45) were informed about their right to complete and Advance Directive or had evidence of declining to complete an Advance Directive. These failures 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: 1. During a concurrent interview and record review on 11/20/24 at 9:53 a.m. with Social Service Director (SSD), Resident 58's MR was reviewed. SSD stated there was a copy of the AD in Resident 58's MR, but it was not signed and dated. 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 interview and record review, the facility failed to follow their policy and procedure (P&P) titled Smoking, for ten of 11 sampled residents (Resident 42, Resident 17, Resident 24, Resident 42, Resident 43, Resident 62, Resident 78, Resident 89, Resident 243, and Resident 245), who smoked independently on the smoking patio, when a smoking assessment was not completed. This failure resulted in residents not being assessed for safety while smoking and the potential residents to be burned while smoking. Findings: During a concurrent interview and record review on 11/20/24 at 2:33 p.m. with Minimum Data Set Coordinator (MDSC), Resident 42's Smoking and Safety undated was reviewed. Reident 42's admission records indicated Resident 42 was re-admitted on [DATE] and smoking assessment was done on 1/28/24. MDSC stated there should have been a smoking assessment done upon re-admission. During a review of Resident 17's Smoking Assessment (SA), dated 11/15/24, the SA indicated, Resident 17 uses tobacco products 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 in interview and record review the facility failed to: 1. Ensure medications were administered according to physicians' order for one of two sampled residents (Resident 82). This failure had the potential for Resident 82's infection to worsen. 2. Ensure three of eight sampled employees (Registered Nurse [RN] 1, Director of Staff Development [DSD], and Director of Nursing [DON]) had current educational training and demonstrated knowledge in cardiopulmonary resuscitation (CPR-life saving intervention during medical emergency). This failure had the potential to staff would not be able to perform life-saving procedures in the event of a heart or respiratory emergency. 3. Provide 57 of 57 Certified Nursing Assistants (CNA) and 27 of 27 Licensed Nurses the required Personnel Educational Program (required employee competencies). This failure had the potential for staff to not have the knowledge and skills necessary to perform their jobs, which could be detrimental to patient safety and patient care. 4. Ensure one…

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

Based on observation, interview, and record review, the facility failed to maintain an environment free of accident hazards for 12 of 22 sampled residents when: 1. One of one sampled resident (Resident 58), at risk for choking, was unsupervised in the dining room. This failure resulted in Resident 58 putting sugar packets into her mouth and chewing on them. 2. 10 of 16 residents that smoke (Resident 17, Resident 24, Resident 42, Resident 43, Resident 48, Resident 62, Resident 78, Resident 89, Resident 243, and Resident 245) were not monitored with smoking materials and supervised during smoking times. This failure had the potential for residents to be burned while smoking. 3. Two of two sampled residents (Resident 17 and Resident 62) had space heaters in their rooms without authorized approval. This failure had the potential for an electrical failure or fire. 4. One of one sampled residents (Resident 58) who was at risk for wandering/elopement (leave a medical facility without permission), had an unlocked and unalarmed screened door in her room. this failure had the potential for…

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NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Transfer and Discharge, when the facility did not send a notice of transfer to the ombudsman (representatives who assist residents in long-term care facilities with issues related to day-day care, health, safety, and personal preferences) for two of two sampled residents (Resident 42, and Resident 50). This failure had the potential to result in Resident 42, and Resident 50 not having an advocate who could inform them of their admission, transfer, and discharge rights and options. Findings: During a review of Resident 42's medical record (MR), undated, the MR indicated, Resident 42 was transferred to the hospital on [DATE], 2/5/24, and 7/22/24. There was no indication in Resident 42's medical record that Ombudsman was notified. During an interview on 11/20/24 at 3:46 p.m. with Minimum Data Set Coordinator (MDSC), MDSC stated, there was no Ombudsman notification done on hospital transfer. 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 follow their policy and procedure (P&P) titled, Food Preparation when one of one sampled cooks (Cook 1) did not follow the facility's standardized recipe for puree (smooth texture) food preparation to maintain nutritive value. This failure had the potential for residents on a pureed diet to be at risk for nutritive impairment. Findings: During a concurrent observation and interview on 11/18/24, at 9:40 a.m. with [NAME] 1, in the kitchen, [NAME] 1 prepared the puree meat sauce for lunch. [NAME] 1 stated she was using the 12 servings portion in the recipe book for the meat sauce. [NAME] 1 stated 10 residents were on a puree diet. [NAME] 1 stated she would put three cups of water to blend into the meat and sauce. [NAME] 1 stated she was using the casserole menu from the recipe book. [NAME] 1 put in three (3) cups of water into the food processor with the meat and sauce. [NAME] 1 then added 3/4 of a cup of thickener. [NAME] 1 proceeded to use the food processor to blend the above items into a puree texture. [NAME] 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.

Based on observation, interview, and record review, the facility failed to store, prepare, and maintain food in a sanitary manner when: 1. Food items were expired in one of one dry storage room. 2. One dented can was not stored separately in one of one dry storage room. 3. Food items in one of one dry storage room were unlabeled and undated. 4. Food item in the one of one freezer was unlabeled and undated. 5. Food items in one of two Refrigerator's were unlabeled and undated. Findings: 1. During a concurrent observation and interview on 11/17/24 at 10:07 a.m. with [NAME] 1 in the kitchen's dry storage room, 11 boxes of baking soda were on the shelf with an expiration date of 9/27/24. [NAME] 1 stated the baking soda boxes were expired and they should not have been on the shelf for use. 2. During a concurrent observation and interview on 11/17/24 at 10:10 a.m. with [NAME] 1 in the kitchen's dry storage room, a dented can of Pork and Beans was on the shelf with other canned foods. [NAME] 1 stated the dented cans should not have been with the regular cans. [NAME] 1 stated the dented can…

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

Findings: 1. During a concurrent observation and interview on 11/19/24 at 10:47 a.m. with Licensed Vocational Nurse (LVN) 2 inside Resident 70 and Resident 29's bedrooms, the ceiling above Resident 29's bed had water stain larger than a dinner plate with black stains in the center about the size of a silver dollar. LVN 2 examined the water stain on the ceiling and stated, I think there's a leak, it looks like water damage. During a concurrent interview and record review on 11/20/24 at 3:19 p.m. with Maintenance Supervisor (MS), MS stated he had seen the visible signs of water damage. MS reviewed the maintenance binder and stated he could not find documentation where staff had notified him of water damage to Resident 70 and Resident 29's bedroom ceiling. During a review of the Division of Occupational Health and Safety (DOHS) Mold and Water Intrusion Program Manager's Standard Operating Procedures [SOP] titled Moisture and Mold Remediation Standard Operating Procedures dated 2023, the SOP indicated The presence of excessive moisture in buildings has been linked with occupant…

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Based on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Informed Consent, for one of two sampled residents (Resident 42) when his informed consent for psychotherapeutic (medication to treat mental disorders) medication was not completed. This failure had the potential for Resident 48 to receive psychotropic medication without knowing the risks and benefits of the medication. Findings: During a concurrent interview and record review on 11/20/24 at 2:15 p.m. with Minimum Data Set Coordinator (MDSC), Resident 42's Informed Consent (IC), dated 11/22/23 was reviewed. Resident 42 was on Amitriptyline (to treat symptoms of depression) 25 mg 1 tablet at bedtime. MDSC stated signature of verification was blank. MDSC stated IC was incomplete. During a review of the facility's P&P titled, Informed Consent, dated 4/1/24, the P&P indicated, The Facility verifies that informed consent was obtained prior to the administration of a medical intervention or change in medical intervention that requires informed consent. .

Based on observation and interview, the facility failed to provide a homelike environemnt for three of three residents (Resident 17, Resident 62 and Resident 75) when: 1. One of one sampled resident (Resident 17) clothing was not laundered correctly. This failure resulted in Resident 17's personal clothing being damaged and thrown away. 2. Two of two sampled residents (Resident 62 and Resident 75) rooms had patched unpainted wall areas, broken baseboard and peeling wallpaper. This failure resulted in a personal environment that was not homelike for Resident 62 and Resident 75. Findings: 1. During an interview on 11/17/24 at 11:11 a.m. with Resident 17, Resident 17 stated he had to throw away several of his personal shirts in the past due to the items having bleach stains. During a concurrent observation and interview on 11/17/24 at 11:13 a.m. at Resident 17's room closet, one black shirt with light gray stain was observed. A second shirt brown in color, Resident 17 stated it had been black. During an interview on 11/20/24 at 2:55 p.m. with Laundry Services (LS), LS stated, They are…

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Based on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Dialysis Care for two of two sampled residents (Resident 67 and Resident 69) when: 1. One of two sampled residents (Resident 69) did not have an order to monitor dialysis access site. 2. Two of two sampled residents' (Resident 67 and Resident 69) dialysis access sites were not assessed according to access type. These failures had the potential for dialysis access sites to not be assessed for correct care and monitoring. Findings: 1. During an interview on 11/19/24 at 8:48 a.m. with Resident 69, she stated her dialysis access was a catheter on her chest. During a concurrent interview and record review on 11/20/24 at 8:27 a.m. with Registered Nurse (RN) 2, Resident 69's Order Summary Report (OSR) dated November 2024 was reviewed. The OSR indicated, there was no order for dialysis access monitoring or what type of dialysis access Resident 69 had. RN 2 stated there should have been an order for monitoring her dialysis access site and there was no order. 2a. 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.

Based on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, 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]), to accurately complete the annual Pre-admission Screening Assessment and Resident Review for two of six sampled residents (Resident 68 and Resident 69). This failure had the potential for Resident 68 and Resident 69 to be placed in an inappropriate setting and not receive required services. Findings: During a review of Resident 68's Pre-admission Screening and Resident Review (PASRR) Level I screening, dated 9/9/24, the PASRR indicated, Level I-positive for SMI [Serious Mental Illness]/Negative for ID [Intellectual Disability]/DD [Developmental Disability]/RC [Related Condition]. During a concurrent interview and record review on 11/20/24 at 1:39 p.m. with Minimum Data Set Coordinator (MDSC), Resident 68's Notice of Attempted Evaluation letter was reviewed. The letter…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 adequate numbers of staff with certain skill set were available to meet one of two sampled resident (Resident 82) care plan needs. This failure resulted in Resident 82 not receiving needed medications. Findings: During a review of Resident 82's care plan with the focus on (Resident 82) is on IV [Intravenous - administration of fluids, medications or nutrients directly into a vein] antibiotics [medication used to treat infections] for Osteomyelitis [inflammation of bones] r/t [related to] Right foot/ankle, initiated 8/20/24. The care plan indicated one of the interventions were to Administer antibiotic per md (medical doctor) orders. During a concurrent interview and record review on 11/6/24 at 3:03 p.m. with Director of Nursing (DON), Resident 82's IV Medication Administration Record, (IV MAR) for October 2024 was reviewed. DON reviewed the following: Unasyn (medication used to treat infection) .Use 3 grams (unit of measure) intravenously (administering medications directly into a vein using a needle or tube) every…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, Food Preference, when two of six sampled residents (Resident 24 and Resident 43) meal preferences were not honored. This failure had the potential for Resident 24 and Resident 43's nutritional needs to not be met and the potential for unintended weight loss due to the food not meeting their nutritional needs. Findings: 1. During a concurrent observation and interview on 11/17/24, at 12 p.m. with Resident 24, in the facility's dining room, Resident 24 was sitting in her wheelchair at the dining room table. Resident 24 was served Mac and Cheese for lunch. Resident 24 stated she does not like pasta. During a concurrent interview and record review on 11/17/24 at 12:05 p.m. with Certified Dietary Manager (CDM), Resident 24's Meal Tray Ticket (MTT), dated 11/17/24 was reviewed. The MTT indicated, Resident 24 disliked pasta. CDM stated Resident 24 was given Mac and Cheese. CDM stated Resident 24 should not have had been given Mac and Cheese since it was pasta 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 reasonable accommodations and follow the care plan for one of one sampled resident (Resident 48) to prevent symptoms of dehydration, poor oral (mouth) moisture and skin elasticity (turgor) This failure had the potential to negatively affect the well-being and the hydration status for Resident 48. Findings: During an interview on 11/19/24 at 9:08 a.m. with Resident 48, Resident 48 stated, The staff will never give me a cup of coffee. They [staff] will either tell me the kitchen is closed or that I am not allowed to have it. I like to drink coffee all day. It is my favorite beverage. During a concurrent observation and interview on 11/19/24 at 2:05 p.m. with Resident 48 and Dietary Supervisor (DS) at the kitchen entrance. Resident 48 stated staff won't let him have a cup of coffee. Resident 48 rang the doorbell at the kitchen entrance. DS came to the door and told him she couldn't give him a cup of coffee, and that he would have to tell his Certified Nursing Assistant (CNA). Resident 48 stated he 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.

Based on interview and record review, facility failed to ensure the Director of Staff Development (DSD) had a minimum of two years of experience as a Licensed Nurse to qualify for the DSD position. This failure had the potential to result in DSD ' s inability to provide education to the nursing staff and negatively impact the residents ' health and safety. Findings: During a concurrent interview and record review on 7/2/24 at 4:10 p.m. with DSD, DSD's Personal File (PF), undated was reviewed. The PF indicated the DSD received her Licensed Vocational Nurse (LVN) license in February 2023. DSD stated, I received my license in February 2023, and I only have about a year and a half of nursing experience. DSD stated she started working as a DSD in June 2024. DSD stated she does not have two years of experience as LVN. During a concurrent interview and record review on 7/2/24 at 5:55 p.m. with Director of Nurses (DON), DSD's Job Description (JD), dated June 2024 was reviewed. The JD indicated, Job Title: Director of Staff Development. Qualifications: Has a minimum of two years experience…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 five sampled residents (Resident 1 and Resident 2) physician's orders were followed. This failure had the potential for Resident 1 and Resident 2 to experience adverse health concerns. Findings: a. During a review of Resident 1's Physician Orders (PO), dated 4/5/24 at 9:44 p.m. the PO indicated, Quetiapine Fumarate (Seroquel) (anti-psychotic medication [medication that affects behavior, mood, thoughts, or perception] used to reduce psychotic symptoms like hallucinations [experience involving the apparent perception of something not present], delusions [a false belief or judgment about external reality], and disordered thinking) Oral Tablet 50 MG (milligrams-unit of measurement) .give 1 tablet by mouth in the evening.Discontinued 4/5/24. Discontinue Date/Reason: change.Order Date: 4/5/24 at 9:52 p.m.Seroquel Oral Tablet 25 MG.give 75 mg by mouth in the afternoon for aggression. During a concurrent interview and record review, on 5/20/24 at 11:40 a.m. with Licensed Vocational Nurse (LVN) 1, 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 behaviors were monitored for one of five sampled residents (Resident 1). This failure had the potential for Resident 1 to receive unnecessary psychotropic (medication that affects behavior, mood, thoughts, or perception) medication. Findings: During a review of Resident 1's Care Plan (CP), undated, the CP indicated, [Resident 1] uses psychotropic medications Quetiapine fumarate (Seroquel) (anti-psychotic medication used to reduce psychotic symptoms like hallucinations (experience involving the apparent perception of something not present), delusions (a false belief or judgment about external reality), and disordered thinking) .r/t (related to) behavior management.interventions.review behaviors interventions and alternate therapies attempted and their effectiveness. During a concurrent interview and record review on 5/20/24 at 11:12 a.m. with Director of Nursing (DON), Resident 1's clinical record was reviewed. DON was unable to provide documentation of the behavior monitoring. DON stated Resident 1's behaviors…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents care planning meetings were completed timely for one of three sampled residents (Resident 1). This failure had the potential for Resident 1 to have unmet care needs. Findings: During a review of Resident 1's admission Record, (AR) the AR indicated, Resident 1 was admitted on [DATE]. During a concurrent interview and record review on 3/6/24 at 12:40 p.m. with Social Services Director (SSD), SSD stated care conferences are completed on admission, quarterly, annually and for discharge planning. SSD reviewed Resident 1's medical record. SSD confirmed Resident 1 most recent Care Conference was completed on 7/13/23. (Care Conference should have been completed in October 2023 and January 2024). During a review of the facility's policy and procedure (P&P) titled, Care Planning, dated 11/1/17, the P&P indicated, I. the facility's Interdisciplinary Team (IDT) will develop a Comprehensive Care Plan for each resident . II. The Care Plan serves as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ordered medications for one of three sampled residents (Resident1). This failure had the potential for adverse outcomes for Resident 1. Findings: During a current interview and record review on 3/6/24 at 11:52 p.m. with Minimum Data Set Nurse (MDS Nurse), MDS Nurse reviewed Resident 1's Medication Administration Record, (MAR) dated 2/2024 and confirmed the following: Klonopin [medication sometimes prescribed to manage severe manic symptoms (increased activity, energy or agitation) associated with bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration)] Oral Tablet 2 MG [milligram- unit of measure] . Give 1 tablet by mouth two times a day for Bipolar D/O [disorder] m/b [manifested by] assaultive behavior informed consent obtained by MD [medical doctor] . -Order Date- 02/21/2024 1643 [4:43 p.m.] -D/C [discontinued] Date 02/27/2024 1109 [11:09 a.m.] 2/22/24 at 5 p.m., there was no documentation the Klonopin was administered (blank). Seroquel…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1) was provided safety to prevent injuries. This failure resulted in Resident 1 sustaining a laceration (cut to skin) to his forehead, which required a hospital medical evaluation and treatment for his injuries. Findings: During a review of Resident 1 ' s hospital record, titled Discharge Instructions Document, dated 2/6/24, indicated, Emergency Department Patient Discharge Instructions. Reason for Visit 1) Assault 2) Scalp laceration Discharge Diagnosis Assault Closed head injury Forehead laceration. Tests Performed. CT [computed tomography- a specialized x-ray to examine body tissues and bones in detail for diagnosis of disease and injury] Head wo [without] Con[Contrast- special solution that provides better x-ray images for the diagnosis of disease and injury]. During a concurrent interview and record review on 2/7/24 at 1 p.m. with Director of Nursing (DON), Resident 2 ' s medical record (MR) was reviewed, and the following was noted: Resident 2 ' s Care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident (Resident 1) attending physician (AP) and resident ' s representative (RR) were notified of alleged abuse. This failure had the potential for Resident 1 ' s AP and RP not to be aware of the alleged abuse. Findings: During a review of the facility 5 day Investigation dated 1/29/24, indicated .He (Resident 1) stated they (staff) were throwing pillows at me last night. During a concurrent interview and record review on 2/5/24 at 3:26 p.m. with Director of Nursing (DON), DON stated notification should be made to the resident AP and RP as part of the Change of Condition the facility completes. DON reviewed Resident 1 ' s medical record and was unable to provide documentation Resident 1 ' s AP and RP were notified of the allegations of physical abuse. DON stated, I don ' t know what happen. During a review of the facility ' s policy and procedure (P&P) titled, Abuse Prevention and Prohibition Program, revised January 31, 2020, the P&P indicated, IX. Reporting/Response . D. The Facility 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 ensure two of three sampled residents (Resident 1 and Resident 2) received scheduled showers. This failure had the potential to result in unmet care needs. Findings: During a review of Resident 2' s Minimum Data Set, (MDS - an assessment tool) dated 10/17/23, the MDS indicated, Resident 2' s BIMS (Brief Interview for Mental Status) score was 11 (a score of 8 to 12 suggests the resident has moderately impaired cognition) During an interview on 12/12/23 at 11:49 a.m. with Resident 2, Resident 2 stated she has not been showered in 11 days. During an interview on 12/12/23 at 12:09 p.m. with Certified Nursing Assistant (CNA 1), CNA 1 stated there is a schedule for resident showers. CNA 1 stated showers are documented in the POC (point of care- part of the electronic medical record), and on shower sheet. CNA 1 stated the shower sheet must be signed off by the nurse. CNA 1 stated if the resident refuses, she offers at different time, she stated she tries to encourage and offer at least three time but if the resident refuse, she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 suspected abuse was reported timely for one of two sampled residents (Resident 1). This failure had the potential for Resident 1 ' s suspected abuse not to be investigated timely and for the suspected abuse to continue. Findings: During an interview on 12/5/23 at 11:7 a.m. with Accounts Payable (AP), AP stated License Vocational Nurse (LVN 1) made her aware Resident 1 used to have money, but recently LVN 1 was buying his cigarettes. AP stated LVN 1 asked her to investigate it. AP stated AP took Resident 1 to the bank. Resident 1 had his old debit card, the bank would not give him any information, due to not having an identification card (ID). AP stated Resident 1 was the only account holder for the bank account and he could not recall the last time he used his debit card. AP stated (AP) took Resident 1 to the department of motor vehicle to get an ID. AP stated on 11/2/23 the bank gave Resident 1 a print of the last 30 days and there were withdrawals for thousands of dollars. AP stated Resident 1 told her He has no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 titled, Privacy and Dignity and Catheter-Indwelling, Insertion of , when a urine collection bag [drains urine from the bladder through a tube] was not covered with a dignity bag [bag used to cover urine collection bag], for one of three sampled residents (Resident 3). This failure had the potential to cause Resident 3 embarrassment. Findings: During an observation on 10/31/23 at 2:44 p.m. in Resident 3's room, Resident 3 was lying in bed and had an uncovered urine collection bag on right side of Resident 3's bed. The urine collection bag was visible to the hallway where people were walking by and with opened privacy curtain. During a concurrent observation and interview on 10/31/23 at 2:57 p.m. with Licensed Vocational Nurse (LVN) 1, in Resident 3's room, LVN 1 verified Resident 3's urine collection bag remained uncovered. LVN 1 stated the urine collection bag should have been covered with dignity bag to provide privacy and dignity to Resident 3. 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, interview, and record review, the facility failed to follow its policy and procedure on change of condition (COC) notification for one of three sampled residents' (Resident 1) responsible party (RP). This failure had the potential for the responsible party (RP) to be unaware of Resident 1's COC. Findings: During a review of Resident 1's admission Record (AR), dated 8/1/23, the AR indicated, Resident 1 was initially admitted to the facility on [DATE], with diagnosis including altered mental status (AMS – a change in mental function that stems from illnesses, disorders, and injuries) and generalized muscle weakness. During a review of Resident 1's History and Physical (H&P), dated 2/14/23, the H&P indicated, Resident 1 was confused and disoriented, with difficulty in walking and was wheelchair bound. During a concurrent observation and interview on 8/1/23, at 12:05 p.m., with Resident 1, in Resident 1's room, Resident 1 was observed in bed alert and awake. Resident 1 slowly tried to speak one…

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

Based on interview and record review, the facility failed to notify the responsible party (RP) when one of three sampled residents (Resident 1) had a change of condition. This failure had the potential for Resident 1's RP to not be fully informed of Resident 1's health condition. Findings: During an interview on 7/13/23, at 1:51 p.m. with Registered Nurse (RN 1), RN 1 stated, when a resident had a change of condition, we notify the RP or family members (FM). During an interview on 7/13/23, at 2:01 p.m. with Licensed Vocational Nurse (LVN 1), LVN 1 stated, for a change of condition she would notify the FM or RP. During a concurrent interview and record review on 7/13/23, at 3:30 p.m. with Director of Nursing (DON), DON reviewed Resident 1's Nurses Note, (NN) dated 3/20/23, the NN indicated, Resident 1 had an altered level of consciousness, the physician was notified and ordered for Resident 1 to be transferred to the acute hospital. DON reviewed Resident 1's face sheet and confirmed Resident 1 had an RP. DON reviewed Resident 1's medical record and confirmed no notification was made…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe food handling and a sanitary kitchen environment when: 1. Dietary Aid (DA) 2 failed to perform hand washing after touching a soiled napkin on the floor, before returning to food preparation. 2. Bacon was removed from temperature control beyond facility policy of 30 minutes. 3. Effective contact time for sanitizing during three compartment cleaning method was not performed for water pitchers. These failures had the potential to result in foodborne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) to all of the facility's at-risk population. Findings: 1. During an observation on 4/3/23, at 9:58 AM, in the Kitchen, DA 2 picked up a soiled napkin from the floor and placed it in the trash can. DA 2 began food preparation without washing her hands. During an interview on 4/3/23, at 10 AM, with DA 2, DA 2 stated, I should have washed my hands before returning to food preparation after touching…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, Infection Prevention and Control Program, when the facility did not: 1. Have a water management program (identify hazardous conditions and control water-related healthcare associated infections) in place. 2. Have a system in place to identify unvaccinated staff. 3. Place one of one sampled resident (Resident 44), suspected to have a contagious infection, in isolation. 4. Promptly discard contaminated (used) intravenous (IV- into a vein) tubing. These failures had the potential for life threatening infections to develop and spread to all other residents, visitors, and staff in the facility. Findings: 1. During an interview on 4/5/23, at 1:23 PM, with Infection Preventionist (IP), IP stated, she was not sure if the facility had a water management program. During an interview on 4/5/23, at 1:29 PM, with Maintenance Supervisor (MS), MS stated, What's that [water management program]? MS stated, he had never heard of water management program before, and he would 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 provide a safe, homelike environment when: 1. Resident 41's remote control for her television did not work. This failure caused Resident 41 to be unable to watch television in her room. 2. Activity room's SMART television was broken. This failure caused residents' participating in activities to be unable to use special program applications they enjoyed. 3. Water was leaking in Resident 76's shared room, Resident 84's shared room, and room [ROOM NUMBER]. This failure had the potential to result in injury from residents or staff slipping on water. 4. Extension cords were wrapped around three of eight sampled residents' (Resident 76, Resident 39, and Resident 44) beds side rail and clutter was on the floor. This failure had the potential to result in resident injury. 5. There were no paper towels in the paper towel dispenser in Resident 15's room. This failure resulted in Resident 15 not having easy access to a method for hand drying.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 submit Quarterly Minimum Data Set (MDS- a standardized assessment tool) in a timely manner for four of 13 sampled residents (Resident 83, Resident 68, Resident 22, and Resident 40). This failure resulted in inaccurate assessments and had the potential to contribute to a lack of resident specific care plan interventions. Findings: During a concurrent interview and record review, on 4/6/23, at 2:20 PM, with the Minimum Data Set Coordinator (MDSC), Resident 83's Minimum Data Set Summary (MDSS), undated, was reviewed. The MDSS indicated, Resident 83's Quarterly MDS should have been completed by 2/26/23. MDSC stated, it was not completed or submitted yet. During a concurrent interview and record review, on 4/6/23, at 2:25 PM, with MDSC, Resident 68's MDSS, undated, was reviewed. The MDSS indicated, Resident 68's Quarterly MDS should have been completed by 3/9/23. MDSC stated, it was not completed or submitted yet. During a concurrent interview and record review, on 4/6/23, at 2:45 PM, with MDSC, Resident 22's MDSS, undated, 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 observation, interview, and record review, the facility failed to follow its Policy and Procedure (P&P) titled, Medication Storage and Labeling, for monitoring the receipt discontinued controlled medication (prescribed medication with a high risk for abuse/dependence). This failure had the potential for diversion of controlled medications (drugs which may be abused or cause addiction, such as opioids, stimulants, depressants, hallucinogens and steroids). Findings: During a concurrent observation, interview, and record review, on 4/4/23, at 3:24 PM, with Director of Nursing (DON), in DON's office, the locked office contained a locked cabinet where controlled medications were stored pending destruction. DON stated,When narcotic (pain medications) medications are discontinued, we will count the medications so there are no discrepancies (difference). DON stated, the pharmacist comes once a month for controlled medication to be destroyed. The Medication Log (ML-for discontinued controlled medications), dated 2/23, was reviewed. The ML did not indicate the DON and floor nurse…

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

Based on observation, interview, and record review, the facility failed to ensure the safe administration of medication when: 1. Medications were kept at Resident 117's bedside without a medication self-administration assessment or a physician order for one of 56 sampled residents (Resident 117). 2. Intravenous (IV- into or within a vein) antibiotic (medicine used to treat infection) bag and tubing were unlabeled for one of one sampled resident (Resident 417). These failures had the potential for medications to be administered incorrectly and unsafely. Findings: 1. During a concurrent observation and interview on 4/3/23, at 9:53 AM, with Licensed Vocational Nurse (LVN) 4, in Resident 117's room, Resident 117 had two inhalers (medications breathed into lungs that helps reduce inflammation, keeps airways open, and prevents/treats difficulty breathing) and Hydrocortisone (topical cream used to treat redness, swelling, itching and discomfort) on his bedside table. LVN 4 stated, It's not ok for [Resident 117] to have it [medications] here [Resident 117's bedside]. LVN 4 stated, 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 observation, interview, and record review, the facility failed to follow the menu as planned for therapeutic diets when: 1. The planned menu for a mechanical soft diet order was not followed for one of five sampled residents (Resident 29). 2. A fortified diet was not followed for two of five sampled residents (Resident 91 and Resident 18). 3. A large portion diet order was not followed for one of five sampled residents (Resident 49). 4. A no added salt diet order was not followed for one of five sampled residents (Resident 34). These failures resulted in residents' nutritional needs not being met. Findings: 1. During an observation on 4/4/23, at 11:47 AM, with Dietary Aide (DA) 1, in the kitchen, DA 1 placed Resident 29's lunch meal tray onto the meal delivery cart. During a concurrent observation, interview, and record review, on 4/4/23, at 11:48 AM, with Dietary Manager (DM), in the kitchen, Resident 29's lunch meal tray card was reviewed. Resident 29's lunch meal tray card indicated, Texture: Mech [mechanical] Soft. DM observed the whole (intact) piece of parsley garnish…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 follow their policy and procedure titled Catheter-Indwelling, Insertion of, when a urine collection bag (drains urine from the bladder through a tube) was not covered with a dignity bag, for one of two sampled resident (Resident 367). This failure had the potential to cause Resident 367 embarrassment. Findings: During an observation on 4/6/23, at 8:30 AM, in Resident 367's room, an uncovered urinary bag was hanging from the right side of Resident 367's bed frame. During an interview on 4/6/23, at 8:34 AM, with Licensed Vocational Nurse (LVN) 5, LVN 5 stated, Resident 367's urinary bag was not covered by a dignity bag; but Resident 367 should have a dignity bag. During a review of the facility's policy and procedure (P&P) titled, Catheter-Indwelling, Insertion of, dated 11/17, the P&P indicated, Cover the catheter with a dignity bag.

Based on interview and record review, the facility failed to follow their policy and procedure titled Change of Condition Notification [COC], when the physician was not notified of a COC for one of four sampled residents (Resident 85). This failure had the potential to result in further weight loss for Resident 85. Findings: During a review of Resident 85's Weight and Vitals Summary (WVS), dated 4/3/23, the WVS indicated, on 4/8/22, Resident 85 had an admission weight of 194 pounds (lbs). The WVS indicated, on 10/7/22, Resident 85 weighed 168 lbs, a 13.9% loss in a six month period. During a concurrent interview and record review, on 4/4/23, at 9:40 AM, with Licensed Vocational Nurse (LVN) 7, Resident 85's Progress Notes, dated 4/22, was reviewed. LVN 7 stated, she was unable to find documentation of the physician being notified of Resident 85's significant weight loss. LVN 7 stated, the physician should have been notified since the significant weight loss was a change of condition. During a review of the facility's policy and procedure (P&P) titled, 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 follow their policy and procedure (P&P) titled, Abuse Prevention and Prohibition Program, to report resident to resident abuse to the State Agency (SA) for one of five residents (Resident 20). This failure had the potential for abuse to continue and for Resident 20 and other facility residents to be a risk for abuse. Findings: During an interview on 4/4/23, at 8:42 AM, with Family Member (FM) 1, FM 1 stated, her sister told her Resident 20 had been hit in the face by another resident, but she was unsure of the date. During a concurrent interview and record review, on 4/5/23, at 9:35 AM, with Licensed Vocational Nurse (LVN) 1, Resident 20's medical record was reviewed. The IDT [Interdisciplinary Team] Note, dated 10/13/21, indicated, Resident 20 was hit in the face by another resident. LVN 1 stated, she did not find any documentation of the incident being reported to the SA. During a concurrent interview and record review, on 4/5/23, at 10:06 AM, with LVN 1, a folder brought from the Social Services office was reviewed. 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 ensure the risks, benefits, and alternatives (RBAs) of leaving the facility Against Medical Advice (AMA) were explained by the physician for one of three sampled residents (Resident 56). This failure resulted in Resident 56 not be fully informed of the RBAs of leaving AMA. Findings: During a concurrent interview and record review on 4/5/23, at 10:34 AM, with Licensed Vocational Nurse (LVN) 1, Resident 56's medical record was reviewed. LVN 1 stated, Resident 56 had been receiving antibiotics through a peripherally inserted central catheter (PICC- access to the large central veins near the heart used to give medications or liquid nutrition) line due to a staphylococcus (bacteria which can cause serious infections if it gets into the blood and can lead to sepsis or death) in her right prosthetic (artificial device used to replace a body part) hip. The Progress Notes (PN), dated 3/31/23, at 7:38AM, indicated, Resident 56 informed Social Services Assistant (SSA) that she was going to leave the facility on 4/2/23 for 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 follow their policy and procedure (P&P) titled, Transfer and Discharge, when the facility did not send a notice of transfer to the ombudsman (representatives who assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences) for one of five sampled residents (Resident 6). This failure had the potential to result in Resident 6 not having an advocate who could inform them of their admission, transfer, and discharge rights and options. Findings: During a review of Resident 6's medical record, dated 3/21, the medical record indicated, Resident 6 was transferred to the hospital. There was no indication in Resident 6's medical record the Ombudsman was notified. During an interview on 4/6/23, at 10:45 AM, with Social Services Assistant (SSA), SSA stated, Ombudsman was not notified of transfer of resident [Resident 6] to hospital. During a review of the facility's policy and procedure (P&P) titled, Transfer and Discharge, dated 6/1/21, the P&P indicated, Purpose: 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.

Based on interview and record review, the facility failed to complete and submit comprehensive Annual Minimum Data Set (MDS- standardized assessment tool) assessments in a timely manner for five of thirteen sampled residents (Resident 13, Resident 39, Resident 58, Resident 76, and Resident 60). This failure had the potential to result in inaccurate assessments and to contribute to a lack of resident specific care plan interventions. Findings: During a concurrent interview and record review, on 4/6/23, at 2:15 PM, with Minimum Data Set Coordinator (MDSC), Resident 13's Minimum Data Set Summary (MDSS), undated, was reviewed. The MDSS indicated, Resident 13's Annual MDS should have been completed by 3/2/23. MDSC stated, it was not done. During a concurrent interview and record review, on 4/6/23, at 2:35 PM, with MDSC, Resident 39's MDSS, undated, was reviewed. The MDSS indicated, Resident 39's Annual MDS should have been completed by 3/1/23. MDSC stated, Resident 39's Annual MDS assessment was not completed. During a concurrent interview and record review, on 4/6/23, at 2:40 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 interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS-a standardized assessment tool) for two of 5 sampled residents (Resident 85 and Resident 41). This failure had the potential for negative health outcomes for Resident 41 and Resident 85. Findings: During a review of Resident 85's Weight and Vitals Summary (WVS), dated 4/3/23, the WVS indicated, Resident 85 had an admission weight of 194 pounds (lbs) on 4/8/22. The WVS indicated, on 10/7/22, Resident 85 weighed 168 lbs, a 13.9% loss in a six month period. During a concurrent interview and record review, on 4/4/23, at 9 AM, with Minimum Data Set Coordinator (MDSC), Resident 85's MDS, dated 10/28/22, was reviewed. The MDS indicated, K0300 Weight Loss, Loss of 5% or more in the last month or loss of 10% or more in the last 6 months 0. NO or unknown. MDSC stated, this answer is incorrect and should have indicated YES, instead of NO. MDSC stated, Resident 85 had a 13.9% weight loss in the last six months. During a concurrent interview and record review, on 4/6/23, at 1:50 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Develop and implement a comprehensive care plan for one of six sampled residents (Resident 113). This failure had the potential to result in unrecognized care concerns, interventions, and outcome goals. 2. Implement a care plan for one of two sampled residents (Resident 57) who required supervision while smoking. This failure had the potential for Resident 57 to sustain burns and/or injury while being unmonitored Findings: 1. During a concurrent interview and record review, on 4/6/23, at 4:05 PM, with Licensed Vocational Nurse (LVN) 6, Resident 113's medical record was reviewed. Resident 113's medical record indicated the following: Resident 113's Diagnosis Report (DR), dated 4/6/23, indicated, Resident 113 had diagnoses of schizophrenia (mental health disorder) and major depressive disorder (mental health disorder) . Resident 113's Physicians Orders (PO), dated 4/23, and Medication Administration Record (MAR), dated 4/23, indicated, Resident 113…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 5 sampled residents (Resident 42) was placed on a bowel and bladder (B&B) training program to maintain or improve her urinary and bowel continence (the ability to control bladder and/or bowel). This failure had the potential to result in Resident 42 becoming permanently incontinent. Findings: During a review of Resident 42's medical record, the Bowel and Bladder Assessment, dated 7/1/22 (Resident 42's admission date), indicated, III. Bladder Evaluation Urinary Incontinence Type III. 3. Always incontinent. Bowel Evaluation. 3. Always incontinent. The MDS [Minimum Data Set, resident assessment tool] assessment Section H, dated 8/8/22, indicated, Resident 42 was Frequently incontinent of bowel and Frequently incontinent of urine and no urinary toileting program or bowel toileting program was used to manage or improve Resident 42's bowel or urinary continence. During a concurrent interview and record review, on 4/6/23, at 9:20 AM, with Licensed Vocational Nurse (LVN) 1 and Medical Records (MR) staff, Resident…

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

Based on observation, interview, and record review, the facility failed to ensure: 1. An order for a therapeutic (to cure or restore to health) nutritional supplement (used to increase calories and protein intake) was provided for one of four sampled residents (Resident 85). 2. Consumption of the supplement was accurately documented and monitored in one of four sampled residents (Resident 85). These failures had the potential to ineffectively evaluate and delay timely revision of interventions and impede accuracy of nutrition assessments needed to meet residents' nutritional needs. Findings: 1. During a concurrent observation and interview on 4/3/23, at 7:43 AM, with Resident 85, in Resident 85's room, Resident 85 was in her bed, with her breakfast tray on her bedside table feeding herself breakfast. An opened, four-ounce carton of vanilla health shake was observed on her breakfast meal tray. Resident 85 stated, I drink the shakes, I told them I like Ensure (therapeutic nutrition supplement) better. Resident 85 stated, she has been getting the small container of shakes this past…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, Behavior-Management, for completing a gradual dose reduction (GDR) for one of three sampled residents (Resident 22). This failure resulted in Resident 22 receiving unnecessary psychotropic medication (medications that affect a person's mental state). Findings: During a review of the monthly medication regimen review's Pharmacist's Recommendation for Resident 22, dated 12/12/22, the Pharmacist's Recommendation indicated, A dose reduction attempt is needed for the following psychotropic medication: Seroquel (antipsychotic, to reduce auditory hallucinations related to Post-Traumatic Stress Disorder) 25mg [milligram-unit of measurement] 0.5 tab [tablets] QHS [every night at bedtime]. Suggest a trial of D/Cing [discontinuing] the Seroquel. Resident 22's Physician signed that he agreed with the consultant pharmacist's recommendation. During a review of Resident 22's Physicians Orders, dated 4/4/23, Resident 22's Physicians Orders indicated, Resident 22 has an order for Seroquel…

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