The Orchards Post-Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure competency of their dietary aides of what consists of a full liquid diet for one of two sampled residents (Resident 39). This failure had the potential for Resident 39 to not meet his nutritional needs.Findings:During a concurrent observation and interview on 6/16/26 at 12:35 p.m. with Dietary Aide (DA) 1 in the kitchen during lunch trayline, DA 1 removed the pudding from the meal tray and placed apple juice in its place. DA 1 stated she checked the meal tray for accuracy to the meal tray ticket and it is full liquid diet, the meal tray had two bowls of soup and removed the pudding because it was not a liquid.During an interview on 6/16/26 at 12:40 p.m. with Registered Dietitian (RD), RD stated it is okay to place pudding on the tray per the full liquid diet.During a review of Resident 39's admission Record, (AR) dated 6/17/26, the AR indicated, Resident 39 was admitted on [DATE] with a diagnosis of Dysphagia [difficulty…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 planned menu for regular diet for one of six sampled residents (Resident 121). This failure had the potential to result in serving low-fat milk to residents on a regular diet which posed a risk for decreased milk consumption. During a concurrent observation and interview on 6/16/26 at 12:25 p.m. with Registered Dietitian (RD) in the kitchen during tray line, a dietary aide placed whole milk or 2% milk on regular diet trays. RD stated, it is regular diet, it can be either or, if no preference indicated.During a review of Resident 121's Meal Tray Ticket (MTT), dated 6/16/26, the MTT indicated, Puree Diet: Preferences Milk for breakfast, lunch and dinner.During a review of the facility's dietary menu titled, Winter Menus, (undated), the dietary menu indicated, The regular IDDSI [International Dysphagia Diet Standardization Initiative - a set of testing methods for texture-modified foods and thickened liquids to ensure safe consumption for individuals with swallowing difficulties] menu: 4oz Milk,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 honor the food preferences for two of 15 sampled residents (Resident 2 and Resident 137) when:1. Resident 2's request for sunny-side up eggs was not honored because the facility stopped purchasing the pasteurized shell eggs required to prepare them safely.2. Resident 137 did not receive margarine on vegetables as indicated on his meal tray card during lunch trayline.These failures had the potential to result in decrease nutritional intake and a decline in the quality of life for Resident 2 and Resident 137.Findings: 1. During an observation on 6/15/26 at 8:40 a.m. in the kitchen, inside the walk-in refrigerator was a box containing an open, unsealed bag of frozen fried eggs with hard egg yolk.During an interview on 06/15/26 at 10:38 a.m. with Director of Dietary Services (DDS), DDS stated they did not have pasteurized shell eggs. DDS stated they also did not have regular (non-pasteurized) shell eggs. DDS stated they purchased pre-cooked fried eggs that they just needed to heat up and/or pre-cooked hard…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 food in accordance with professional standards for food service safety when food items were not covered, were not dated as to when opened, and manufacturer's guidelines were not followed. These failures had the potential to place residents at an increased risk for foodborne illness.Findings:During a concurrent observation and interview on 6/15/26 at 8:31 a.m. with Director of Dietary Services (DDS) in the dry food storage room in the kitchen, there was a large, opened bag of dry pasta without an open date. DDS stated the bag of uncooked pasta should of been labeled with an open date.During a concurrent observation and interview on 6/15/26 at 8:36 a.m. with DDS in the dry food storage room in the kitchen, there was an opened bag of uncooked dry pasta that was not sealed or labeled. DDS stated, the bag of uncooked pasta should have been sealed and labeled with an open date.During a concurrent observation and interview on 6/15/26 at 8:39 a.m. with DDS in the dry food storage room in the kitchen, there 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 ensure an infection control program was implemented when: 1. Infection surveillance (the systematic, ongoing collection and analysis of data to prevent the spread of healthcare associated infections [HAI]) was not performed. This failure resulted in an increase in urinary tract infections. 2. One of one sampled resident (Resident 101) on Enhanced Barrier Precautions (EBP - gown and gloves are used during care of residents with indwelling medical devices and open wounds, to prevent infection) had foam material wrapped and secured with tape around both upper bed rails. This failure had the potential to result in Resident 101 developing an infection. 3. Two Certified Nurse Assistants (CNA 3 and CNA 4) did not follow EBP for one of one sampled resident (Resident 138) while providing direct care to Resident 138. This failure had the potential to result in Resident 138 developing an infection. Findings: 1. During a review of the facility's Monthly Infection Surveillance [observation, monitoring, or tracking] Report…

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

Based on observation, interview, and record review, the facility failed to ensure call lights were in reach of one of 71 sampled residents (Resident 127). This failure had the potential for Resident 127 not to be able to call for needed care and assistance.Findings:During a concurrent observation and interview, on 6/16/26 at 1:38 p.m. in Resident 127's room with Registered Nurse (RN) 1. Resident 127's call light was observed on the floor on the side of Resident 127's bed. RN 1 stated Resident 127 could not reach his call light.During a review of the facility's policy and procedure (P&P) titled, Call System, Residents, revised September 2022, the P&P indicated, Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station. Policy Interpretation and Implementation 1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor.

Based on interview and record review, the facility failed to ensure urine was collected as ordered by the physician after a change of condition for one of four sampled residents (Resident 1) when Resident 1 complained of painful urination. This failure had the potential to result in Resident 1 to receive delay of care.Findings:During a review of Resident 1's admission Record (AR), the AR indicated, Resident 1 had a history of Urinary Tract Infection (infection in any part of the urinary system [body system that filters waste from the blood and produces urine]).During a review of Resident 1's Order Summary (OS), the OS indicated, Order Date: 11/05/2025 06:53. Order Summary: UA C&S (Urinalysis with Culture and Sensitivity [urine test to confirm an infection]) one time only for painful urination.During a review of Resident 1's Nurses note (NN), dated 11/7/25, the NN indicated, resident refused to go to dialysis (medical treatment that filters waste and excess fluid from the blood) today related to painful urination, UA (urinalysis [urine test]) collected. Explained risk to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of five residents' restrooms (room [ROOM NUMBER]) linoleum floor covering was in good repair. This failure had the potential to place residents at risk for accidents and hazards. Findings: During a concurrent observation and interview on 4/29/25 at 1:22 p.m. with the Maintenance Director (MD) in room [ROOM NUMBER]. The restroom linoleum floor covering was torn and lifted causing an uneven surface. MD confirmed the observation and stated the uneven surface was a tripping hazard. During a review of the facility ' s policy and procedure (P&P) titled, Maintenance Service, revised December 2009, the P&P indicated, 1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include, [sic] but are not limited to: a. maintaining the building in compliance with current federal, state, and local laws, regulations, 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 follow their policy and procedure on Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating to immediately protect all the residents from potential abuse when an alleged (something is claimed or said to be true but hasn't been proven) perpetrator (someone who commits a harmful or illegal act) was allowed to enter the facility after the Administrator was informed of the allegation. This failure had the potential to expose all residents in the facility to harm and spread of infection. Findings: During a review of the California Department of Public Health (CDPH) Intake Form dated 3/20/25, the Intake Form indicated, Caller [complainant] stated a contractor named [Phlebotomist] from [agency which provides diagnostic services] is using needles on residents then cleaning them with alcohol wipes and taking those same needles to other facilities. Caller stated she knows the needles are being used at [another facility] as well as a hospital [Phlebotomist] works at. During an interview on 3/25/25 at 11:57 a.m.…

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

Based on observation, interview, and record review, the facility failed to: 1) Ensure three of three sampled clean linen carts were in good repair. 2) Follow the manufacturer's guidelines on how to disinfect the clean linen carts. 3) Ensure the laundry room was clean and sanitary. These failures had the potential for contaminating clean linens and spread of infections to all residents. Findings: 1) During a concurrent observation and interview on 3/12/25 at 7:42 a.m. in the hallway, with Laundry Aide (LA), LA was delivering clean linens to the clean linen closet. The clean linen cart edges were ripped, exposing the metal frames, and had a hole on the side. LA stated, I don't know how old they are, they must be too old. During a concurrent observation and interview on 3/12/25 at 7:55 a.m. in the laundry room, with Housekeeping and Laundry Supervisor (HLS). There were three clean linen carts with ripped edges exposing the metal frames. The clean linen carts had dark brownish discolorations. HLS stated, We need to buy new ones. 2) During a concurrent interview and record review on…

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

Based on interview and record review, the facility failed to follow their policy and procedure (P&P) on Surveillance for Infections when: 1) There were no documented signs/symptoms of the infections and antibiotic given in the antibiotic tracking log. 2) There were no tracking of locations of the infections. 3) There were no list of organism (germs) and/or review of indicators of infections on the antibiotic tracking log. These failures had the potential for ineffective infection control and tracking resulting in spread and increase in numbers of infections. Findings: 1) During a concurrent interview and record review on 3/12/25 at 3:18 p.m. with Infection Preventionist Nurse (IPN), the facility's Antibiotic Stewardship Log (ASL-list of residents taking antibiotics), dated 1/2025 was reviewed. The ASL indicated there were 64 recorded infections without documentation of signs and symptoms. IPN stated the 64 infections did not have documentation of signs and symptoms. 2) During a concurrent interview and record review on 3/12/25 at 3:19 p.m. with IPN, the Infection Control Committee…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff were communicating in a language three of three sampled residents (Resident 74, Resident 88, and Resident 110) were able to understand. This failure had the potential for making residents feel staff were being rude to them and feelings of lowered self-esteem. Findings: During an interview on 3/10/25 at 9:46 a.m. with Resident 74, Resident 74 stated, Staff were speaking Spanish in front of me when caring for me, they [staff] make me look bad. I did not like the two staff speaking Spanish in front of me, it's like they are talking about me. During a review of Resident 74's Minimum Data Set (MDS-comprehensive assessment tool), dated 1/17/25, the MDS indicated, Brief Interview for Mental Status [BIMS] summary score: 15 [score of 13-15 means cognitively intact]. During an interview on 3/11/25 at 9:08 a.m. with Resident 88, Resident 88 stated the morning shift staff speak their own language. During a review of Resident 88's MDS, dated 2/21/25, the MDS indicated Resident 88 had a BIMS summary score of…

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

Based on interview and record review, the facility failed to obtain and complete informed consents for psychotropic (drugs that affect a person's mental state) medication for three of 29 sampled residents (Resident 84, Resident 97, and Resident 77). This had the potential for Resident 84, Resident 97, and Resident 77 not being aware of the risks and benefits of taking psychotropic medication. Findings: During a concurrent interview and record review on 3/11/25 at 3:27 p.m. with Licensed Vocational Nurse (LVN) 2, Resident 84's Informed Consent Verification Form (ICFM), dated 10/9/24 was reviewed. The ICFM indicated, Resident 84 is on Divalproex (medication for seizures) 500 mg and on Olanzapine (used to treat schizophrenia [a chronic mental illness characterized by disruptions in thought, perception, emotion and behavior]) 10 mg. LVN 2 stated there are no medication dosage strength on the ICFM form. LVN 2 stated there should be dosage and frequency of medication information on the consent. During a concurrent interview and record review on 3/12/24 at 3:29 p.m. with Assistant Director…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Ombudsman (advocates for the rights and well-being of residents in long-term care facilities) of discharges for three of three sampled residents (Resident 9, Resident 97, and Resident 128). This failure had the potential for unsafe resident transfer and discharge. Findings: During a concurrent interview and record review on 3/11/25 at 11:43 a.m. with Assistant Director of Nursing (ADON), Resident 9's SBAR [Situation Background Assessment Recommendation] & Initial COC [change of condition]/Alert Charting & Skilled Documentation (SBAR), dated 8/19/24 and 1/18/25 were reviewed. The SBAR indicated Resident 9 was transferred to the hospital on 8/19/24 and 1/18/25. ADON stated and confirmed Resident 9 was transferred to the hospital. During a concurrent interview and record review on 3/12/25 at 11:03 a.m. with ADON, Resident 97's SBAR, dated 4/7/24 and 7/8/24 were reviewed. The SBAR indicated Resident 97 was transferred to the hospital on 4/7/24 and 7/8/24. ADON stated and confirmed Resident 97 was transferred to the…

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

Based on interview and record review, the facility failed to have daily completed Direct Care Service Hours Per Patient Day (DHPPD) for the month of January 2025 to February 21, 2025. This failure had the potential for all residents not receiving sufficient nursing care. Findings: During a review of the facility's DHPPD, dated January 2025 to March 2025, there was no DHPPD since 1/1/25 to 2/21/25. During a concurrent interview and record review on 3/13/25 at 3:43 p.m. with Administrator, the DHPPD dated 1/1/25-2/21/25 was reviewed. The Administrator stated there was no DHPPD completed since 1/1/25 to 2/21/25. During a review of the facility's policy and procedures (P&P) titled, Posting Direct Care Daily Staffing Numbers, dated July 2016, the P&P indicated, Our facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. Policy Interpretation and Implementation. 7. The previous shift's forms shall be maintained with the current shift form for a total of 24 hours of staffing information in a single location.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 annual performance evaluations for two of five sampled Certified Nurse Assistants (CNA 1 and CNA 2). This failure had the potential for CNA 1 and CNA 2 not being aware of their need for improvement in a certain area which could affect all residents' care. Findings: During a concurrent interview and record review on 3/13/25 at 3:10 p.m. with Director of Staff Development (DSD), CNA 1 and CNA 2 personal files were reviewed. CNA 1's personal file indicated her last annual performance review was 4/5/23. CNA 2's personal file indicated his last performance review was 11/15/11 and no recent annual performance review was on file. DSD stated there is no annual performance evaluations for CNA 1 and CNA 2 after those dates. During a review of the facility's policy and procedure (P&P) titled, Performance Evaluations, dated June 2010, the P&P indicated, The job performance of each employee shall be reviewed and evaluated at least annually. Policy Interpretation and Implementation 1. A performance evaluation will be completed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the monthly Medication Regimen Review (MRR- a review of all medications to identify any potential adverse effects and drug reactions) was reviewed and acted upon for the month of January 2025 for four of four sampled residents (Resident 84, Resident 51, Resident 15, and Resident 46). This failure has the potential to affect all residents' well being and result in adverse health outcomes. Findings: During a review of the facility's MRR dated 1/30/25, the MRR had 139 pharmacy recommendations. There was no documentation of the recommendations being acted upon. During a review of the Note to Attending Physician/Prescriber ([NAME]), dated 1/30/25, the [NAME] indicated there were no documentation of follow up and notification of the physician for the following: a) This patient [Resident 84] has continued Olanzapine [medication for mental illness] 10 mg [milligram] BID [twice a day] and Depakote [medication for metal illness] 500 mg BID. CMS [Centers…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. One of three sampled medication cart was free from expired medications. This failure had the potential for the medications to have decrease effectiveness. 2. Medications were stored properly in one of three sampled medication carts. This failure had the potential for the medications to be administered incorrectly and unsafely. 3. Controlled Drug Records (CDR) were signed by two licensed nurses. This failures had the potential for medication errors to occur and possible drug diversion. 4. Safe administration of medication for three of three sampled residents (Resident 8, Resident 9, and Resident 4) when medications were found at resident's bed side table. This failure had the potential for medications to be accessed by unauthorized staff and residents. Findings: 1) During a concurrent observation and interview on 3/10/25 at 9:21 a.m. with Licensed Vocational Nurse (LVN) 3 in the hallway, the medication cart had Latanoprost (Xalatan-used to treat glaucoma [increased pressure in the eye]) eye drops…

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

Based on observation and interview, the facility failed to ensure one of 24 sampled resident's bathrooms (Resident 72) was clean and sanitary. This failure had the potential to spread infections and/or affect their quality of life. Findings: During a concurrent observation and interview on 3/12/25 at 8:55 a.m. with Housekeeping and Laundry Supervisor (HLS), in Resident 72's bathroom, the toilet seat had splashes of dark brown colored stains, the toilet bowl had dark brown stains on the sides, the floor had multiple crumpled paper towels, and there was a large dark brown stain under the sink. HLS stated when the housekeepers are not around, the Certified Nursing Assistants (CNAs) should clean. During an interview on 3/12/25 at 11:33 a.m. with CNA 4, CNA 4 stated it is not her responsibility to clean the bathroom. CNA 4 stated she does not know where to get the disinfecting wipes. During a concurrent observation and interview on 3/13/25 at 10:40 a.m. with Resident 72, in Resident 72's bathroom, Resident 72 was sitting in his wheelchair, had a right leg amputation (loss or removal of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to have completed quarterly smoking assessments for two of two sampled residents (Resident 84 and Resident 70). This failure resulted in Resident 84 and Resident 70 not being assessed for safety while smoking and had a potential for residents to be burned while smoking. Findings: During a concurrent interview and record review on [DATE] at 11:35 a.m. with Assistant Director of Nursing (ADON), Resident 84's Smoking-Initial Assessment ([NAME]), dated [DATE] was reviewed. ADON stated Resident 84 was admitted on [DATE]. Smoking assessment should be completed upon admission and quarterly every 92 days. ADON stated the smoking assessment is completed to ensure resident is a safe smoker, and it was not completed for Resident 84. During a review of Resident 70's admission Record (AR), dated [DATE], the AR indicated, admission Date [DATE]. DIAGNOSIS INFORMATION. TOBACCO USE. During a review of Resident 70's Care Plan Report (CPR), dated [DATE], the CPR indicated,…

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

Based on observation, interview, and record review, the facility failed to implement the plan of care for one of eight sampled residents (Resident 91) fall precaution. This failure had the potential for Resident 91 to sustain serious injuries. Findings: During an observation on 3/13/25 at 12:08 p.m. in Resident 91's room, Resident 91 was lying in her bed. Resident 91's bed was in a high position. During a concurrent interview and record review on 3/13/25 at 12:09 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 reviewed Resident 91's Medication Administration Record (MAR). LVN 2 stated, The order indicated [Resident 91's] bed should be in low position. During a review of Resident 91's Care Plan (CP), dated 12/19/24, the CP indicated, [Resident 91] is at risk for fall related to history of falls, medications, poor safety awareness, unsteady gait. Interventions: bed in lowest position when in bed to lessen impact of fall. During a review of Resident 91's Morse Fall Assessment [fall risk assessment], dated 12/18/24, Resident 91's Morse Fall Assessment indicated, Score: 50 [score of…

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

Based on interview and record review the facility failed to check blood pressure prior to administration of blood pressure medication for one of one sampled resident (Resident 8). This failure had the potential for Resident 8 experiencing adverse health outcomes such as low blood pressure. Findings: During a review Resident 8's Physician Orders (PO), dated 3/4/25, the PO indicated, Losartan Potassium Tablet 25 MG [milligram] Give 1 tablet by mouth at bedtime related to ESSENTIAL (PRIMARY) HYPERTENSION [high blood pressure] Hold for SBP [Systolic blood pressure - pressure in the arteries when the heart contracts] < [less than] 110. During a concurrent interview and record review on 3/13/25 at 5:28 p.m. with Assistant Director of Nursing (ADON), Resident 8's MAR, dated March 2025, was reviewed. The MAR indicated there was no blood pressure documented from 3/3/25 to 3/12/25. ADON stated and confirmed there was no blood pressure documentation on 3/3/25 to 3/12/25. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated April 2019, the P&P…

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

Based on observation, interview, and record review, the facility failed to provide catheter (a thin, flexible tube inserted into the bladder to drain urine) care for one of two sampled residents (Resident 91) when the catheter tubing and collection bag was not changed in two months. This failure had the potential to result in Resident 91's repeated Urinary Tract Infections (UTI-bladder infection). Findings: During an observation on 3/11/25 at 9:46 a.m. in Resident 91's room, Treatment Nurse (TN) was performing wound dressing changes on Resident 91's back. Resident 91's catheter had thick whitish to grayish material and the urine collection bag had dark brownish discoloration. During a concurrent observation and interview on 3/12/25 at 4:26 p.m. with TN and Licensed Vocational Nurse (LVN) 5, in Resident 91's room. Resident 91's catheter had thick whitish to grayish material and the urine collection bag had dark brownish discoloration. TN did not change the tubing and the collection bag. TN stated, It [catheter tubing and urine collection bag] needs to be changed. I don't know when it…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their policy and procedures (P&P) titled, Oxygen Administration, for one of three sampled residents (Resident 99). This failure resulted in Resident 99 having low oxygen levels. Findings: During a review of Resident 99's Physician Order (PO), dated [DATE], the PO indicated, OXYGEN: Administer O2 [oxygen] @ [at] 3L/min [liter per minute] via NC [nasal cannula - supplemental oxygen] continuously. wean as tolerated to keep saturation above 92%. During a review of Resident 99's Care Plan Report (CPR), dated [DATE], the CPR indicated, Resident is at risk for impaired gas exchanged r/t [related to] History of aspiration [choking on inhaled fluids], Pneumonia [lung infection]. Interventions. Apply Oxygen per MD [medical doctor/physician] orders. During a review of Resident 99's Care Plan (CP) titled, [Resident 99] has Alteration in Musculoskeletal Status r/t [related to] Dx [diagnosis]: Quadriplegia [complete or partial loos of motor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Social Services Department documented and followed up on one of three sampled residents' (Resident 93) eyeglasses. This failure had the potential for Resident 93 suffering with poor vision. Findings: During an interview on 3/11/25 at 9:45 a.m. with Resident 93, Resident 93 stated she has been waiting for her eyeglasses for three months, and has been suffering with poor vision. During a review of Resident 93's Minimum Data Set (MDS-comprehensive assessment tool), dated 1/8/24, the MDS indicated, Cognitive Patterns: Brief Interview for Mental Status (BIMS) Summary Score: 15 [score of 13-15 indicates cognitively intact]. During a review of Resident 93's Eye Consult [EC-eye doctor consultation notes], dated 1/8/25, the EC indicated the eye consult was conducted on 1/8/25 (two months ago). Final Spectacle [eyeglasses] Rx [prescription]: BF [bifocal- lenses each with two parts with different focal lengths]. During an interview on 3/11/25 at 9:50 a.m. with Social Services Director (SSD), SSD stated she did not document…

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

Based on interview and record review, the facility failed to ensure medications were available to administer when Licensed Nurse did not reorder medications timely, notify physician of unavailable medication, and obtain alternative orders for two of two sampled residents (Resident 8 and Resident 1). This failure resulted in Resident 8 and Resident 1 not receiving physician ordered medications and had the potential to result in adverse health outcomes. Findings: During a review of Resident 8's Order Summary Report (OSR), dated 3/13/25, the OSR indicated the following orders: Losartan Potassium (to treat high blood pressure) Tablet 25 mg (milligram) give 1 tablet by mouth at bedtime related to Essential (primary) Hypertension (high blood pressure). Clobetasol Propionate External Ointment (to treat rash) 0.05%. Apply to hands, feet, torso topically two times a day for itching for 14 days daily. Ketorolac Tromethamine Opthalmic Solution [relieve itchy eye] 0.4% instill 1 dropt in right eye every 8 hours for status post Cataract Surgery. Omeprazole [to reduce stomach acid] Capsule 40 Mg…

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

Based on observation, interview, and record review, the facility failed to have a functional call light system for one of 52 sampled residents (Resident 99). This failure had the potential for Resident 99 unable to call for help. Findings: During a concurrent observation and interview on 3/10/25 at 12:06 p.m. with Licensed Vocational Nurse (LVN) 1 in Resident 99's room, Resident 99's call light did not light up when activated and his hands are contracted (unable to move). LVN 1 stated Resident 99's call light does not work. LVN 1 stated Resident 99 would benefit from a push call light since he is not able to use his hands very well due to contractures (unable to move). During an interview on 3/11/25 at 10:37 a.m. with Resident 99's Conservator, Conservator stated Resident 99 has limited ability of hands due to being very contracted. During an interview on 3/13/25 at 10:57 a.m. with Environmental Service Director (EVSD), EVSD stated he was not made aware the call light for Resident 99 was not functional. During a review of Resident 99's Care Plan (CP) titled, [Resident 99] has…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of 58 residents' rooms (room [ROOM NUMBER]) was in good repair. This failure had the potential to place residents at risk for accidents and hazards. Findings: During a concurrent observation and interview on 3/12/25 at 8:55 a.m. in room [ROOM NUMBER], with Housekeeper/Laundry Supervisor (HLS), the baseboard was ripped from the wall approximately 10 inches long and 1 inch open rip. During an interview on 3/12/25 at 8:55 a.m. with EVSD, EVSD stated they (maintenance department) have been inspecting each room daily, but have not seen the baseboard rip in room [ROOM NUMBER]. During a review of the facility's policy and procedure (P&P) titled, Maintenance Service, dated December 2009, the P&P indicated, Maintenance service shall be provided to all areas of the building, grounds, and equipment. 2. Functions of maintenance personnel include but are not limited to: . B. maintaining the building in good repair and free from hazards.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to readmit one of three sampled residents (Resident 1) after hospitalization. This failure resulted in violation of resident's rights to return to the facility and had the potential to negatively affect Resident 1's well-being. Findings: During a review of Resident 1's admission Record (AR), dated 1/16/25, the AR indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses including history of fracture (a break in the bone) of the right femur (hip) and respiratory disorders in diseases classified elsewhere. During an interview on 1/16/25 at 12:27 p.m. with the Facility Marketing Director (FMD), FMD stated Resident 1 was discharged from the facility to the acute hospital on 1/2/25. During an interview on 1/16/25 at 1:11 p.m. with acute hospital Case Manager (CM), CM stated Resident 1 was ready for discharge from the acute hospital to the facility on 1/13/25. CM stated she called and spoke with FMD on 1/13/25 at approximately 1:55 p.m.…

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

Based on interview and record review, the facility failed to ensure professional standards were followed when: 1. Medications were not administered according to physician's order for one of three sampled residents (Resident 2). This failure had the potential for Resident 2's infection (invasion and growth of germs in the body) to worsen. 2. Treatment orders were not administered according to physician's orders for one of three sampled residents (Resident 3). This failure had the potential for Resident 3's wounds to worsen. Findings: 1. During a concurrent interview and record review on 11/12/24 at 12:59 p.m. with Director of Nursing (DON). Resident 2's IV (Intravenous- administration of fluids, medications or nutrients directly into a vein) Medication Administration Record, (IVMAR) dated October 2024 was reviewed. The IVMAR indicated the following: Cefazolin (medication use to treat infection) .2 GM (gram - unit of measure) . Use 1 application intravenously every 8 hours for osteomyelitis (infection in the bone) to the foot for 6 Weeks -Start Date- 09/30/2024 2100 (9 p.m.) The IV…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff members (Licensed Vocational Nurse [LVN] 2 and Certified Nursing Assistant [CNA] 2) were competent in caring for residents with gastrostomy tubes (G- tube- the presence of a surgical opening into the stomach to provide fluids, nutrition, and medications). This failure had the potential to negatively affect the residents' well -being related to the lack of staff competence in providing the necessary care and services. Findings: During a concurrent interview and record review on 12/11/24 at 4:01 p.m. with Director of Staff Development (DSD) and Director of Nursing (DON), Licensed Vocational Nurse (LVN) 2 and Certified Nursing Assistant (CNA) 2's employee files were reviewed. DSD confirmed LVN 2 did not have competencies for caring residents with G- tubes (checking G-tube placement, checking gastric residual volume [the amount of fluid in the stomach after feeding] monitoring for signs and symptoms of respiratory distress [a condition where the body needs more oxygen], recognizing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Five-Day Investigation Report to implement a follow-up monitoring for one of seven sampled residents (Resident 1). This failure had the potential for Resident 1 having further altercations with other residents in the smoking area. Findings: During a review of facility ' s Five-Day Investigation Report dated 9/17/24, the Five-Day Investigation Report indicated, A verbal altercation occurred in the facility ' s smoking courtyard involving three residents. [Resident 1] smoking privileges will be closely monitored moving forward. During a concurrent interview and record review on 9/30/24 at 4:39 pm with Director of Nursing (DON), DON reviewed Resident 1 ' s clinical record and was unable to find documentation of closely monitoring Resident 1 on smoking privileges. DON stated, The one in charge [staff] is not documenting it [monitoring of smoking privileges]. During a review of the facility ' s policy and procedure (P&P) titled, Smoking Policy-Residents, dated August 2022, the P&P indicated Any resident 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 provide wound treatment as ordered by the physician for one of three sampled residents (Resident 1). This failure had the potential to result in delayed wound healing for Resident 1. Findings: During a review of Resident 1 ' s Skin Assessment (SA), dated 7/25/24, the SA indicated Resident 1 had glue stitches on her right groin and right upper thigh. During a review of Resident 1 ' s SBAR (Situation, Background, Assessment, Recommendation), dated 8/2/24, the SBAR indicated Resident 1 had wound dehiscence (complication where a cut made during a surgical procedure, opens) on her right groin and right thigh. During a review of Resident 1 ' s Order Summary Report (OSR), dated 8/2/24, the OSR indicated, Cleanse surgical site to the right groin with NS (normal saline [mixture of salt and water]), pat dry, apply santyl (medicated ointment used for treating wounds), if unavailable, apply hydrogel (medicated cream used for treating wounds), apply calcium alginate (medicated gel used for treating wounds) and cover with dry dressing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 foley catheter (a device that drains urine (pee) from the urinary bladder into a collection bag outside of your body when you can't pee on your own) care for one of three sampled residents (Resident 1) when Resident 1 ' s foley catheter was not assessed for approximately seven hours. This failure had the potential to result in Resident 1 suffering from abdominal pain, having to call 911, going to the emergency room, and having a UTI (urinary tract infection). Findings: During a concurrent observation and interview on 8/19/2024 at 1:42 p.m. with Resident 1 in Resident ' s 1 room, Resident 1 was laying in her bed with a foley catheter bag attached to the bed. Resident 1 had teary eyes. Resident 1 stated she was in a lot of abdominal pain for seven hours (approximately 1: 45 p.m. until 9:25 p.m. on August 9th, 2024, related to the foley catheter). During a review of Resident 1 ' s Minimum Data Set (MDS- assessment tool), dated July 31, 2024, the MDS indicated Resident 1 had a BIMS (Brief Interview for…

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

Based on observation, interview, and record review, the facility failed to follow their policy and procedure titled, Abuse, Neglect, Exploitation, or Misappropriation-Reporting Investigating for one of the six sampled residents (Resident 1), when the facility did not report an allegation of abuse to the California Department of Public Health (CDPH) and did not complete an investigation of the allegation of abuse. These failures had the potential to result in Resident 1 experiencing continued abuse, feeling unsafe, and having feelings of fear. Findings: During a concurrent observation and interview on 7/17/24 at 2:20p.m. with Resident 1, in Resident 1's room, Resident 1 was sitting in bed. Resident 1 stated Resident 2 threw a tray lid at her and bounced off the wall and few minutes later Resident 2 threw a glass plate from the food tray and shattered by Resident 1's foot. Resident 1 stated, I don't feel safe. During a review of Residents 1's Minimum Data Set (MDS-Assessment Tool), dated May 9, 2024. The MDS indicated Resident 1 had a Brief Interview for Mental Status BIMS score of 15…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure the kitchen was maintained clean and sanitary. This failure had the potential to result in the contamination of food, utensils, and surfaces where food is prepared, and the potential for spread of infectious diseases to residents, staff, and visitors. Findings: During an observation on 6/14/24 at 3:50 p.m. in the kitchen, the dry storage room ' s floor had black debris, scattered small containers of butter, and five lifeless flies on the floor. In the walk in freezer, the floor had debris and scattered unidentified particles. Under the sink area, the floor had black debris. During an interview on 6/14/24 at 3:50 p.m. with the Dietary Director (DD), DD stated she saw the black debris in the areas, containers of butter, and lifeless flies on the flood and would start cleaning right away. During an interview on 7/02/24 at 10:40 a.m. with Administrator, Administrator stated there is no contracted deep cleaning agency from an outside party for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement an effective pest control program for three of three sampled resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER]) and the kitchen. This failure had the potential to result in spread of infectious diseases to residents, staff, and visitors. Findings: During an interview on 06/14/24 at 3:00 p.m. with Resident 1, Resident 1 stated, I saw cockroaches crawling on the floor, when you turn on the bathroom light you see two to four of them on the floor. Last night, I saw two cockroaches coming from this window and door, then last night, I also saw one on my neighbor's face. The CNA (Certified Nursing Assistant 1) grabbed it and killed it. They [cockroaches] come in at night it starts when the sun goes down. One of the girls [staff] told me that in the kitchen it's all bad and there's little ones. Like come on, we eat their food. I have seen several CNA's stomping at the roaches. Last night, my CNA [1] helped me by…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review, the facility failed to provide nail care and hand hygiene for one of the five sampled residents (Resident 1). This failure had the potential for Resident 1 to result in skin breakdown and spread of infection. Findings: During an observation on 6/17/24 at 2:47 p.m. in Resident 1's room, Resident 1 was lying in bed covered with a bed sheet. Resident 1 was non-verbal. Resident 1's fingernails were long with black debris under fingernails. Resident 1 had brown stains spread on his right palm. During an interview on 6/17/24 at 2:53 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she did not trim Resident 1's fingernails and told Licensed Vocational Nurse (LVN) 1 because she was not aware if Resident 1 was diabetic [high blood sugar/diabetic patients have a potential for prolonged periods of wound healing]. CNA 1 stated Resident 1 has brown stains because he picks his buttocks. During an interview on 6/17/24 at 2:56 p.m. with LVN 1, LVN 1 stated, He's [Resident 1] not verbal and is not a diabetic. CNA [1] did not report to me…

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

Based on interview and record review, the facility failed to ensure the Physician was notified timely when one of three sampled residents (Resident 1) fell. This failure resulted in a delay of Physician notification. Findings: During a review of the Unusual Occurrence Investigation (UOI) dated 5/4/24, the UOI indicated, 5/3/24 approximately 2:20am resident was found ½ off the low bed on the left side legs dangling.CN (charge nurse) assisted resident to sit on the floor.On 5/3/24 @ (at) 6:30 pm charge nurse noted with RN (Registered Nurse) Supervisor resident right leg pain was not relieved by the ordered medication. MD (Doctor of Medicine) called and an order for transfer to the hospital for further evaluation of right leg pain was obtained. During an interview on 5/6/24 at 2:49 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was assigned to Resident 1 on 5/3/24 from 6 a.m. to 6:30 pm. LVN 1 stated Resident 1 began complaining of pain around 4 p.m. and at approximately 5 p.m. when the pain medication was not effective, Resident 1's roommate told her Resident 1 had…

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

Based on interview and record review, the facility failed to ensure medications were administered as ordered by the physician for one of three residents (Resident 2). This failure resulted in Resident 2 not receiving her medication. Findings: During a review of Resident 1's Medication Administration Record (MAR) dated 5/2024, the MAR indicated, Debrox solution (medication used to remove ear wax) .instill 2 drops in both ears every 12 hours for impacted cerumen (ear wax) to left ear for 4 days. There was a 9 documented on the MAR for 5/3, 5/4 and 5/5, indicating the medication was not given and a progress note should have been documented. During a concurrent interview and record review on 5/6/24 at 3:58 p.m. with Assistant Director of Nursing (ADON), ADON stated Debrox was an over-the-counter medication and central supply should have been notified to provide the medication. During a concurrent interview and record review on 5/14/24 at 2:51 p.m. with Registered Nurse Supervisor (RNS), RNS reviewed Resident 2's Progress Notes (PN) dated 5/3/24 at 9:39 p.m., the PN indicated, Instill 2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide showers to one of three sampled residents (Resident 1). This failure had the potential for Resident 1 to have a negative self-image and had the potential for increased risk of infection. Findings: During a review of Resident 1's admission RECORD (AR), dated 3/6/24, the AR indicated, Resident 1 was a [AGE] year-old with diagnoses including Myocardial Infarction (known as a heart attack, it occurs when not enough oxygen get to an area of the heart), muscle weakness, difficulty walking and Chronic Obstructive Pulmonary Disease (a disease of the lungs that causes restricted airflow and breathing problems). During a review of Resident 1's Care Plan (CP), dated 9/30/23, the CP indicated, Resident 1 required partial to moderate staff assistance with showering and bathing. The CP indicated Resident 1 required one staff member to help with showering/bathing. During a review of Resident 1's MDS (Minimum Data Set – an assessment tool) under section BIMS…

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

Based on observation, interview, and record review, the facility failed to implement infection control practices when: 1. Hand hygiene was not provided to residents prior to eating in the dining room. 2. A Physical Therapy Assistant (PTA) did not perform hand hygiene in between glove changes and in between resident's care. 3. Clean linen were not stored in a sanitary manner. 4. A Certified Nursing Assistant (CNA) 8 did not perform hand hygiene in between delivering meal trays. These failures had a potential to spread germs and infections to residents, staff, and visitors. Findings: 1. During a concurrent observation and interview on 2/12/24 at 11:55 a.m. with Resident 19 in the dining room, Resident 19 stated staff do not offer hand hygiene before meals. Multiple residents were sitting in the dining room being served with meal trays without hand hygiene provided. During an interview on 2/12/24 at 12:07 p.m. with CNA 9, CNA 9 stated the activity staff usually provides hand hygiene. During an interview on 2/12/24 at 12:11 p.m. with Activities Director (AD), AD stated hand washing…

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

Based on observation, interview, and record review, the facility failed to ensure call lights were within reach for three of 78 sampled residents (Resident 37, Resident 15, and Resident 64). This failure had the potential to affect resident's psychosocial and physical needs. Findings: During a concurrent observation and interview on 2/12/24 at 9:12 a.m. with Certified Nursing Assistant (CNA) 3 in Resident 37's room, Resident 37 was lying in bed and her call light was hanging outward to the right side rail of the bed, out of Resident 37's reach. CNA 3 stated Resident 37 was unable to reach her call light. During a review of Resident 37's MDS (Minimum Data Set - assessment tool), dated September 6, 2023, the MDS indicated, Functional limitation on range of motion: upper extremities: impairment on both sides, and needed two plus persons physical assist with bed mobility. During a review of Resident's 37 Care Plan, dated October 22, 2023, the Care Plan indicated, Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance. 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.

During an observation, interview, and record review, the facility failed to maintain a clean and sanitary environment for six of six sampled residents (Resident 42, Resident 52 Resident 88, Resident 92, Resident 95, and Resident 353). This failure had the potential to affect residents' quality of life and potential for the transmission and development of communicable diseases. Findings: During an observation on 2/12/24 at 10:22 a.m. in the shared bathroom of Resident 42, Resident 52 Resident 88, Resident 92, Resident 95, and Resident 353, there were brown stains under the toilet paper and above the handlebar by the toilet bowl. During an observation on 2/13/24 at 9:34 a.m. (the next day) in the shared bathroom Resident 42, Resident 52 Resident 88, Resident 92, Resident 95, and Resident 353, there was the same brown stain as yesterday on the left side of the toilet under the toilet paper and above the handlebar by the toilet bowl. During an interview on 2/13/24 at 9:38 a.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated, It [brown stain] looks like BM [bowel movement] on the…

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

Based on interview and record review, the facility failed to complete and submit comprehensive Annual Minimum Data Set (MDS- standardized assessment tool) assessments annually for six of six sampled residents (Resident 41, Resident 75, Resident 66, Resident 71, Resident 23 and Resident 1). 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 2/14/24 at 2:28 p.m. with Minimum Data Set Coordinator (MDSC) 2, Resident 41's clinical record (CR) was reviewed. MDSC 2 stated Resident 41's Annual MDS should have been completed by 12/22/23. MDSC 2 stated Resident 41's Annual MDS was not completed and is out of compliance. During a concurrent interview and record review on 2/14/24 at 2:36 p.m. with MDSC 2, Resident 75's CR was reviewed. MDSC 2 stated Resident 75's Annual MDS had not been completed, and should have been completed on 12/29/23 and was out of compliance. During a concurrent interview and record review on 2/14/24 at 2:43 p.m. with MDSC…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 MDS (Minimum Data Set - assessment tool) quarterly (every three months) assessments were completed for four of four sampled residents (Resident 15, Resident 13, Resident 64, and Resident 37). This failure had the potential for the delay in development and implementation of residents' individualized care plan. Findings: During a concurrent interview and record review on 2/14/24 at 3:31 p.m. with Minimum Data Set Coordinator (MDSC) 1, MDSC 1 stated MDS assessments need to be completed within 14 days of the Assessment Reference Date (ARD-the specific end point of look-back periods in the MDS assessment process). The following residents' MDS assessments were reviewed: a) Resident 15's quarterly MDS assessments dated December 28, 2023 (35 days overdue), indicated the MDS assessment was not completed. b) Resident 13's quarterly MDS assessments dated November 24, 2023 (69 days overdue), indicated the MDS assessment was not completed. c) Resident 37's quarterly MDS assessments dated November 30, 2023 (63 days overdue),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, Care Plans, Comprehensive Person-Centered for five of 78 sampled residents (Resident 64, Resident 15, Resident 7, Resident 93 and Resident 29) when the facility failed to: 1. Complete Interdisciplinary Team (IDT-brings together knowledge from different healthcare disciplines to help residents receive the care they need) meetings for Resident 64 and Resident 15. 2. Develop a care plan for Resident 7 regarding the pulling and dislodgement (detachment) of the gastrostomy tube (G-tube - a tube inserted through the belly that brings nutrition directly to the stomach). 3. Develop a comprehensive person-centered care plan to address Resident 93's psychosocial needs. 4. Incorporate personalized interventions for trauma informed care and document the refusal of mental health services in the care plan for Resident 29. These failures had the potential to impact residents' physical, mental, and psychosocial well…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 four sampled residents (Resident 58) dialysis (procedure to mechanically remove waste products and excess fluid from the blood when the kidneys stop working properly) assessments were completed. This failure had the potential for dialysis related complications to occur. Findings: During a review of Resident 58's Order Listing Report (OLR), printed date 2/15/24, the OLR indicated, Check dry weight taken after dialysis treatment by Dialysis Center in the Communication Binder. Check for any precautions noted by dialysis center if any.active 12/13/22.Check Vital Signs after Dialysis.every Mon [Monday], Wed [Wednesday], Fri [Friday].active 12/14/22.Check Vital Signs before dialysis.every Mon, Wed, Fri. active 12/14/22. During an interview on 2/15/24 at 8:59 a.m. with Licensed Vocational Nurse (LVN) 5, LVN 5 stated assessments and vitals are completed before and after dialysis treatments. LVN 5 stated the nurse documents this information in the residents' chart and on a dialysis form that is sent 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 observation, interview, and record review, the facility failed to ensure an effective Quality Assessment and Assurance program was in place, when deficient practices still occurred after being identified. This had the potential for identified issues to go unresolved, potentially affecting residents who receive dialysis (procedure to mechanically remove waste products and excess fluid from the blood when the kidneys stop working properly) treatments. Findings: During a concurrent interview and record review on 2/15/24 at 9:05 a.m. with Licensed Vocational Nurse (LVN) 5, Resident 58's Dialysis Communications form (DCF), dated 2/12/24 was reviewed. LVN 5 stated Resident 58 had dialysis on 2/12/24. LVN 5 stated Resident 58's assessment and vitals were not completed after dialysis. LVN 5 stated dialysis residents should be assessed immediately upon returning to the facility. During a concurrent observation and interview on 2/15/24 at 9:15 a.m. with LVN 5 at the nurses' station, Resident 58 came to the nurses' station with a DCF dated 2/14/24 and set the paperwork on the nurses'…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain a hazard-free environment when: 1. The overhead light switch was not accessible for four of four sampled residents (Resident 37, Resident 22, Resident 453, and Resident 402) to reach. 2. The vinyl board was peeling off the wall in six of 78 sampled residents' (Resident 458, Resident 203, Resident 85, Resident 15, Resident 65, and Resident 13) rooms. 3. Residents' rooms were not maintained in good repair for four of 78 sampled residents (Resident 1, Resident 88, Resident 92, and Resident 353). These failures had the potential to affect residents' quality of life and place residents at risk for injury. Findings: 1. During a concurrent observation and interview on 2/14/24 at 9:25 a.m. with Maintenance Director (MD) in room [ROOM NUMBER], the overhead light string switch of Resident 37, Resident 22, and Resident 453 were approximately two inches and were not within reach. There were three residents lying in bed with the lights off.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, Behavioral Assessment, Interventions and Monitoring for two of eight sampled residents (Resident 605 and Resident 25) when: 1. Facility did not refer Resident 605 for a 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) Level II after he was diagnosed with a serious mental illness. 2. Facility did not follow up after Resident 25's PASRR Level II was not completed. These failures had the potential for residents to be placed in an inappropriate setting and not receive the necessary services to meet their needs. Findings: 1. During a concurrent interview and record review on 2/14/24 at 7:34 a.m. with Director of Nursing (DON), Resident 605's Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 2/13/24 was reviewed. The PASRR indicated, Result of Level I Screening: Level I- Positive. DON stated the original…

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

Based on interview and record review, the facility failed to ensure a neurological assessment (checking motor and sensory function following possible head trauma) was not completed after an unwitnessed fall for one of one sampled resident (Resident 29). This failure had the potential to result in a serious head injury going undiagnosed. Findings: During a concurrent interview and record review on 2/14/24 at 8:27 a.m. with Director of Nursing (DON), Resident 29's SBAR [Situation Background Assessment Recommendation] -FALLS (WGC)-V2 (SBAR), dated 1/12/24 was reviewed. The SBAR indicated, 8. Neurochecks as indicated (unwitnessed & if resident hit head) c. N/A . Resident noted sitting on the floor next to her bed. Per resident, she slid from the edge of the bed to the floor. DON stated she could not find a neurological assessment that was completed after Resident 29's unwitnessed fall on 1/12/24. DON stated neurological assessments should have been completed. During a review of the facility's policy and procedure (P&P) titled, Neurological Assessment, dated October 2010, the P&P…

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

Based on observation, interview, and record review, the facility failed to ensure nail care was provided for one of 30 sampled residents (Resident 61). This failure had the potential to result in skin injuries, infections, and pain. Findings: During a concurrent observation and interview on 2/13/24 at 9:16 a.m. Resident 61 was in bed, his fingernails were long and dirty. Resident 61's fingernails were estimated to be about 1 centimeter (cm-unit of length) past the nail bed. Resident 61 stated he would like some help getting his nails trimmed. During an interview on 2/13/24 at 9:19 a.m. with Registered Nurse (RN) 1, RN 1 stated she thinks Resident 61's fingernails were too long. RN 1 stated Resident 61 is diabetic (trouble controlling blood sugar and using it for energy) if he gets scratched, it can cause infections that are hard to heal. During a review of Resident 61's admission Record (AR), printed date 2/14/24, the AR indicated, Hemiplegia [paralysis affecting one side of the body] and Hemiparesis [partial weakness affecting one side of the body] as a current diagnosis affecting…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 recommendations made by the Registered Dietician (RD) to promote weight gain were carried out within 72 hours for two of three sampled residents (Resident 72 and Resident 88). This failure had the potential to result in further weight loss and malnutrition. Findings: 1. During a concurrent interview and record review on 2/14/24 at 7:54 a.m. with Director of Nursing (DON), Resident 72's clinical record (CR) was reviewed. The Nutritional Services Progress Note, dated 1/22/24 indicated, RD Wt [weight] Change Review.Weight change(s):-9.0% [percent] -12 x1wk [week].start Resource [nutritional drink used to add calories] 90ml [milliliters- unit of volume] TID [three times a day] w/ [with] med [medication] pass liquids for wt gain. DON stated she could not find an order or any evidence the RD recommendation was carried out. DON stated the recommendation should have been carried out sooner. During a concurrent interview and record review on 2/14/24 at 10:06 a.m. with RD, Resident 72's CR was reviewed. The CR indicated, the…

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

Based on interview and record review, the facility failed to ensure behavior monitoring was accurately completed according to physicians' orders for one of three sampled residents (Resident 605). This failure had the potential to inaccurately reflect changes in the resident's behavioral health, and lead to unmet behavioral health needs. Findings: During an interview on 2/12/24 at 1:31 p.m. outside of Resident 605's room, with Certified Nursing Assistant (CNA) 1, CNA1 stated Resident 605 shouldn't be here. CNA 1 stated Resident 605 is violent and has thrown water pitchers and cups of coffee at staff. CNA 1 stated he needs male staff, refuses to be changed, and staff go in two at a time. CNA 1 stated staff can't do anything for him. During an interview on 2/12/24 at 1:45 p.m. with Director of Nursing (DON), DON stated staff provide care 2 or 3 at a time if needed. DON stated Resident 605 had been here a while, the facility had tried different roommates for compatibility, but he is very difficult to place anyone with, so he has his own room. DON stated Resident 605 refuses 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 communicate to social services when the resident lost his ability to make medical decisions and did not have effective family representation for one of one sampled resident (Resident 605). This failure had the potential to result in a resident who lacked decision-making capacity to not be appropriately represented. Findings: During a concurrent interview and record review on 2/14/24 at 7:34 a.m. with Director of Nursing (DON), Resident 605's History and Physical (H&P), dated 9/5/23 and admission Record (AR), printed date 2/14/24 were reviewed. The H&P indicated, PT [patient] Does Not Have Capacity. The AR indicated, Responsible Party [RP]-Self. DON stated Resident 605 started to have aggressive behaviors after he was admitted , and a new diagnosis of schizophrenia (mental illness affecting ones ability to think, feel, and behave clearly) was added after he was seen by the psychologist. DON stated Resident has a sister involved who is elderly herself. DON stated she likes to be updated about Residents care, but does not…

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

Based on interview and record review, the facility failed to follow their policy and procedure (P&P) titled Adverse Consequences and Medication Errors for one of one sampled resident (Resident 604). This failure had the potential to result in an allergic or adverse reaction. Findings: During a concurrent interview and record review on 2/14/24 at 8:07 a.m. with Director of Nursing (DON), Resident 604's Medication Administration Record (MAR), dated January 2024 and MD Note, dated 2/4/24 were reviewed. The MAR indicated, Allergies Ketoconazole [medication used to treat fungal infections]. Fluconazole [medication used to treat fungal infections] Oral Tablet given 1/22/24 through 1/27/24. MD Note indicated, The system has identified a possible drug allergy for the following order: Fluconazole Oral Tablet. DON stated the nurse who updated the order for Fluconazole did not clarify the order with the physician and should have clarified the order before continuing to give the medication. During a review of the facility's P&P titled Adverse Consequences and Medication Errors, dated April…

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

Based on observation, interview, and record review, the facility failed to ensure: 1. Multi dose medication was labeled after being opened. 2. An unlabeled medication was properly discarded. These failures had the potential for medication errors to occur. Findings: 1. During a concurrent observation and interview on 2/14/24 at 8:02 a.m. with Registered Nurse (RN) 2, in hallway 100 at the medication cart, RN 2 prepared two tablets of Acetaminophen (medication for treating mild to moderate pain and fever) for a resident. Acetaminophen bottle had no open date written on the bottle. RN 2 stated she was not sure when the bottle was opened. 2. During a concurrent observation and interview on 2/14/24 at 2:11 p.m. with RN 2 in the medication storeroom, one opened unlabeled ampule (a small vessel holding solution) of Albuterol sulfate (medication used to prevent and treat wheezing, difficulty breathing) was in a box of Albuterol. RN 2 stated the loose, opened unlabeled ampule should not have been in the full box of Albuterol. RN 2 stated the ampule needed to be discarded. During an interview…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dishware was stored safely, and food was stored and prepared safely when: 1. The clean plate holder area was observed to have pieces of brown debris inside the compartment. 2. Food was stored on shelves three inches from the floor. 3. Dietary staff was not wearing a beard protector correctly. These failures had the potential to spread foodborne illnesses to residents, and the potential to lead to pest infestation. Findings: 1. During a concurrent observation and interview on 2/12/24 at 9:35 a.m. with Assistant Kitchen Manager (AKM) in the kitchen, small brown pieces of debris were inside the clean plate warmer/plate holder area. AKM stated that area was not clean. During a review of the facility's policy and procedure (P&P) titled, SANITATION AND INFECTION CONTROL, dated 2023, the P&P indicated, CLEANING FREQUENCY. All kitchen equipment and surfaces which come in contact with food will be cleaned and sanitized after each use . Plate Holder.DAILY. 2. During a concurrent observation and interview on…

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

Based on interview and record review, the facility failed to ensure the medical record accurately reflected the behavioral health concerns for two of two sampled residents (Resident 29 and Resident 605). This failure had the potential for Resident 29 and Resident 605 to not have their behavioral and psychosocial needs met. Findings: 1. During a concurrent interview and record review on 2/13/24 at 11:27 a.m. with Social Services Director (SSD), Resident 29's Trauma Screening Tool (WGC) (TST) dated 2/3/23, 3/30/23, 4/27/23, 7/25/23, 10/24/23, 11/13/23, and 12/14/23 were reviewed. The TST indicated, Sometimes things happen to people that are unusually or especially frightening, horrible, traumatic. For example: -a serious accident or fire -a physical or sexual assault or abuse -an earthquake or flood -a war -seeing someone be killed or seriously injured -having a loved one die through homicide or suicide Have you experienced this kind of event? NO. SSD stated Resident 29 had a history of sexual abuse from when she was young and does not like to be touched or woken up because of it. SSD…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assess, evaluate, and provide a call system appropriate for one of three sampled residents (Resident 37). These failures had the potential for Resident 37's inability to call for assistance when needed. Findings: During a concurrent observation and interview on 2/13/24 at 4:11 p.m. with Resident 37 in Resident 37's room, there was a corded red button-top call light grasped in her right palm. Resident 37's elbows were bent, curled fingers, and she was unable to press the call button. Resident 37 was asked how she would call for help, and Resident 37 did not respond. When asked if she can press or use her call light, Resident 37 stated, No. During a concurrent observation and interview on 2/13/24 at 4:12 p.m. with Certified Nursing Assistant (CNA) 4 and CNA 5 in Resident 37's room, CNA 4 was removing the call light from Resident 37's right hand and hung it (call light) on the right side rail. CNA 4 stated, Even though she [Resident 37] 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 observation, interview, and record review the facility failed to provide warm water for showers/bathing and adequate water pressure for four of four sampled residents (Resident 1, Resident 2, Resident 3, Resident 4). This failure had the potential for residents experiencing discomfort, pain, spread of infection, and feeling of worthlessness during showering/bathing. Findings: During a review of Resident 1 ' s Brief Interview for Mental Status (BIMS – an assessment tool for cognition), dated 12/13/23, the BIMS indicated, Resident 1 had a score of 15 out of 15 (0 to 7 points suggests severe cognitive impairment. 8 to 12 points suggests moderate cognitive impairment. 13 to 15 points suggests that cognition is intact). During a concurrent observation and interview on 11/28/23 at 12:14 p.m. with Resident 1, in Resident 1 ' s room, Resident 1 ' s sink was noted to trickle water although it was opened fully. Resident 1 stated when she is bathed, the staff need to get hot water from the kitchen because the water is cold in the resident rooms and facility shower rooms. Resident 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 ensure one of three sampled residents (Resident 2) had a completely covered window blinds for privacy. This failure had the potential for Resident 2 to be seen from the outside when she changes her clothes. Findings: During a concurrent observation and interview on 12/20/23 at 11:26 a.m. with Resident 2 in her room, a part of the window blinds was covered with paper towels. Resident 2 stated she placed it there because she was not comfortable to change her clothes as she might be seen outside. During a concurrent observation and interview on 12/20/23 at 12:36 p.m. with Environmental Services Manager (ESM) in Resident 2 ' s room, a part of the window blinds was covered with paper towels. ESM stated the blinds for the window did not cover the whole window and needs to be replaced. ESM stated he was not aware of the situation. During a review of Resident 2 ' s Minimum Data Set (MDS - comprehensive assessment tool) , dated September 28, 2023, MDS indicated, BIMS (Brief Interview for Mental Status) score was 15…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure three of four sampled residents (Resident 1, Resident 2, and Resident 3) were treated with respect and dignity. This failure had the potential for Resident 1, Resident 2, and Resident 3, self-esteem and self-worth to be negatively affected. Findings: During a review of Resident 1's Minimum Data Set, (MDS - an assessment tool) dated 7/3/23, the MDS indicated, Resident 1's BIMS (Brief Interview for Mental Status) score was 15 (a score of 13 to 15 suggests the resident is cognitively intact). During an interview on 10/4/23 at 3:29 p.m. with Resident 1, Resident 1 stated, her roommate is not all there and CNAs [certified nursing assistants] will come in and start texting and talking on their phone because [roommate] is not all there, but I am here, that is disrespectful. During a review of Resident 2's MDS dated 6/28/23, the MDS indicated, Resident 2's BIMS score was 15. During a review of Resident 3's MDS dated 7/11/23, the MDS indicated, Resident…

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

Based on interview and record review, the facility failed to implement its policy and procedure (P&P) titled Administering Medications for one of three sampled residents (Resident 1). This failure had the potential to result in medication error. Findings: During a review of the facility's GRIEVANCE INVESTIGATION, INTERVENTION/S & RESOLUTION [GIIR] form, dated 9/13/23, the GIIR indicated, Resident 1's daughter made a complaint to the facility, Registered Nurse (RN) 1 entered Resident 1's room (9/11/23) and attempted to give medications by mouth (PO). Resident 1's daughter stated she had to remind RN 1, Resident 1 had a G-tube (a tube inserted through the stomach to provide nutrition, hydration, and medication) and was NPO (nothing by mouth). During an interview on 9/19/23 at 1:15 p.m. with RN 1, RN 1 stated he was assigned to Resident 1 on 9/11/23. RN 1 stated he had entered Resident 1's room with his medications and was going to give them PO. RN 1 stated Resident 1's family was in the room and had reminded him Resident 1 was NPO. RN 1 stated he did not follow the facility P&P (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 administer pain medication according to physician's order for one of three sampled residents (Resident 1) for two days. This failure resulted in Resident 1's pain not being managed effectively. Findings: During an interview on 8/29/23 at 1:15 p.m. with Resident 1, Resident 1 stated the nurse (Licensed Vocational Nurse/LVN) stated the pharmacy ran out of Norco (narcotic medication for severe pain). Resident 1 stated she did not receive Norco for two days (8/12/23 and 8/13/23). During a review of Resident 1's Medication Administration Record (MAR), dated August 2023, the MAR indicated, Norco Oral Tablet 10-325 MG [milligram-unit of measurement] Hydrocodone-Acetaminophen Give 1 tablet by mouth one time a day for Pain; Prior [before] therapy services NTE [not to exceed] 3 gm [gram-unit of measurement] in 24 hours. During a review of the facility's Narcotics Investigation (NI), undated, the NI indicated, Resident's [1] medication was ordered and delivered on 8/10/23 from pharmacy. Resident's [1] medication was not placed in its…

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

Based on interview and record review, the facility failed to provide adequate needed supplies for two of three sampled residents (Resident 1 and Resident 2). This failure had the potential to result in inability to meet residents needs during care. Findings: During an interview on 9/7/23, at 11:40 a.m. with Resident 1, Resident 1 stated the facility runs out of supplies. Resident 1 stated last month (August) the facility did not have adult briefs and the certified nursing assistants (CNA) were going room to room looking for adult briefs. Resident 1 stated a CNA came and got three adult briefs from her. During an interview on 9/7/23, at 12:01 p.m. with Resident 2, Resident 2 stated the facility seems to run out of wipes and adult briefs. Resident 2 stated A few weeks ago I had to have my friend go buy me the size I wear because they did not have them. Resident 2 stated the facility had to use towels under her bottom because the facility ran out of chux pads (flat absorbent pads used to protect sheets). Resident 2 stated Then the facility runs out of towels. During an interview on…

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

Based interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) received medications as ordered by the attending physician (AP). This failure resulted in Resident 2 not receiving three doses of needed medications. Findings: During an interview on 9/7/23, at 12:01 p.m. with Resident 2, Resident 2 stated the nurse informed her she was out of insulin (medication used to control blood sugar) on Tuesday (9/5/23). Resident 2 stated she was getting insulin every 12 hours to help regulate her blood sugar. Resident 2 stated the nurse told her today (9/7/23 two days later) the insulin was still not available. During a review of Resident 2's Order Summary Report, (OSR) the OSR indicated, Novolin [insulin medication used to control blood sugar over many hours throughout the day]. Inject 30 unit subcutaneously [placing of medication beneath the skin by injection] every 12 hours for DM [diabetes mellitus- disease characterized by high levels of sugar in the blood] hold for bs [blood sugar] < [less than]100 . Start Date 07/07/2023. 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 observation, interview, and record review, the facility failed to provide sufficient staffing to accommodate residents needs by not answering call lights timely for two of three sampled residents (Resident 1 and Resident 2). This failure had the potential for Resident 1 to not receive timely care and unmet care needs. Findings: During a concurrent observation and interview on 9/7/23, at 11:40 a.m. with Resident 1, in Resident 1's room. Resident 1 stated call lights on the worst day can take up to one hour or more. Resident 1 stated she had sat in a soiled brief waiting to be changed. Resident 1 stated I have sensitive skin on my bottom. Resident 1 stated the wait make me feel upset, angry, and anxious. Resident 1 stated she was using the clock on the wall in front of her bed, to calculate the wait time. A clock was noted on the wall with correct time. During a review of Resident 1's Minimum Data Set, (MDS – an assessment tool) dated 6/6/23, the MDS indicated, Resident 1's BIMS (Brief Interview for Mental Status with a range of 0-15) score was 15 (a score of 13 to 15…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accommodate two of three sampled residents (Resident 1 and Resident 2) food allergies and preferences. This failure had the potential to result in unplanned weight loss. Findings: During an interview on 9/7/23, at 11:40 a.m. with Resident 1, Resident 1 stated she requests [soda] for lunch and the kitchen will send me other beverages or no drink at all. During an interview on 9/7/23, at 12:01 p.m. with Resident 2, Resident 2 stated she had a lot of food allergies (dairy and gluten [is a protein naturally found in some grains including wheat, barley, and rye]). Resident 1 stated sometimes dairy products were on her meal tray. During an interview on 9/7/23, at 12:23 p.m. with Certified Nursing Assistant (CNA 1), CNA 1 stated the kitchen gets the resident meal trays wrong a lot, the kitchen is not paying attention to what is on the dislike and substitution paper, so the CNAs must go back to the kitchen all the time. CNA 1 stated the kitchen stopped putting juice on the beverage cart because they (kitchen staff)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 titled Abuse Investigation and Reporting for one of three sampled residents (Resident 1). This failure had the potential for Resident 1 ' s allegation of financial abuse to not be investigated thoroughly and be at risk for continued abuse. Findings: During an interview on 7/5/23 at 10:45 a.m. with Resident 1, Resident 1 stated, a few weeks ago, approximately the end of June 2023, Maintenance Staff (MS) 1 borrowed 200 dollars from him. Resident 1 stated, (MS) never gave him his money back. Resident 1 stated, he informed Maintenance Director (MD) his money was missing, a week after it was borrowed and not returned by MS 1. During a review of Resident 1 ' s Brief Interview for Mental Status (BIMS: assessment used to determine mental status), dated 5/31/23, the BIMS indicated, a score of 14 (a score above 13 indicates the resident is cognitively intact). During an interview on 7/5/23 at 11:50 a.m. with MD, MD stated, around two weeks ago, approximately the last week of June 2023, Resident 1 informed him, MS 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 interview and record review, the facility failed to provide adequate supervision for two of three sampled residents (Resident 1 and Resident 2) to prevent a resident to resident altercation. This failure resulted in a fracture (break in bone) of Resident 2's left shoulder. Findings: During an interview on 8/8/23 at 12:10 p.m. with Director of Nursing (DON), DON stated on 8/6/23, Resident 1 wandered into Resident 2 and Resident 3's room and Resident 1 told Resident 3 her (Resident 3) lunch was his (Resident 1). Resident 3's Family Member (FM) was present when the incident happened, and FM told Resident 1, It was not his [Resident 1] lunch. FM stated Resident 1 began to exit the room and on his way out hit Resident 2 in the left shoulder. DON stated Resident 1 has a diagnosis of Dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change) and is under conservatorship (a guardian appointed by a judge to manage the personal or financial affairs of…

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

Based on interview and record review, the facility failed to follow its policy and procedure on Administering Medications for one of three sampled residents (Resident 1) when a cup of medication was not administered and was left on Resident 1's table. This failure had the potential for medication error and result in Resident 1 experiencing adverse health outcomes. Findings: During an interview on 8/7/23 at 3:13 p.m. with Resident 1, Resident 1 stated, The [nurses] generally drop it [medications] off and I take it [medications], they [nurses] don't watch me taking it [medications]. During an interview on 8/7/23 at 4:00 p.m. with the Director of Nursing (DON), DON stated it (medication administration) was the Licensed Vocational Nurse's (LVN) responsibility to stay until the resident (1) takes the medication. During an interview on 8/8/23 at 3:54 p.m. with LVN, LVN stated she was passing her morning medications when (Resident 1) asked her to leave the medication. LVN stated she takes full responsibility she did not make sure Resident 1 had swallowed the medication. LVN 1 stated, I…

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

Based on observation, interview, and record review, the facility failed to implement their planned intervention to provide one of three sampled residents (Resident 1) a call bell to minimize the chance of fall incident. This failure had the potential for Resident 1 to have fall with injury. Findings: During a concurrent observation and interview on 8/8/23 at 12:45 p.m. with Resident 1 in Resident 1's room, Resident 1 was observed sitting up in her wheelchair speaking with a member of her church. Resident 1 stated she had fallen twice in the last two months (unsure of the dates). Resident 1 stated she had attempted to get herself out of bed without asking for assistance the two times she fell. Resident 1 stated she was not offered a call bell for use in her room. Resident 1's room was observed, and a call bell was not seen. During an interview on 8/8/23 at 2:44 p.m. with Resident 1, Resident 1 stated she was brought a call bell for her use approximately 15 minutes ago by a staff member (unable to identify). During an interview on 8/8/23 at 2:45 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.