Valley Healthcare Center

Based on observation, interview, and record review, the facility failed to provide the individualized activities services for one of 22 sampled residents (Resident 97). This failure had the potential for Resident 97 to have diminished functional needs to promote maximum participation in activities. Findings:During an observation on 1/26/26 at 9:15 a.m. in Resident 97's room, Resident 97 was lying in bed staring at the walls. During an interview on 1/26/26 at 2:39 p.m. with Family Member (FM) 1, FM 1 stated, Resident 97 is in bed all the time. FM 1 stated he had requested activities to be provided to Resident 97 in the room because FM 1 feels that Resident 97 is depressed. During a review of Resident's 97's admission RECORD (AR), dated 11/15/25, the AR indicated, Resident 97 had muscle weakness, lack of coordination, and assistance with personal care.During a review of Resident 97's Care Plan (CP) Activities, [undated], the CP indicated, Resident 97 goal is, express satisfaction with type of activities and level of activity involvement when asked.During a concurrent interview and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to give one of 22 sampled residents (Resident 35) oxygen per the physicians' orders. This failure had the potential for hypoxia (insufficient oxygen reaching body tissues to maintain normal function causing shortness of breath, confusion, rapid heart rate, bluish skin, and other negative outcomes up to and including death).Findings:During a review of Resident 1's admission RECORD (AR), dated 1/29/26, the AR indicated, Resident 35 was admitted to the facility on [DATE] with diagnosis of muscle weakness, need for assistance with personal care, hypertensive heart disease (damage to the heart muscle, valves, or blood vessels caused by long-term high blood pressure [measures the pressure your blood is pushing when the heart beats] with heart failure (the heart can't pump enough oxygen-rich blood to meet the body's needs), acute (severe, sudden) on chronic (persistent long lasting condition) combined systolic (blood pressure when the heart is at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure three of 22 sampled residents (Resident 98, Resident 97, and Resident 35) had staff with skills (specific abilities to perform their job) and competency (knowledge, skills, abilities, and behaviors) to provide care and services when: 1.Registered Nurses (RN 1, RN 2, RN 3, RN 4, RN 5, and Director of Nursing [DON]) were not competent to provide TPN (total parenteral nutrition - is a method of delivering all essential nutrients-such as protein, carbohydrates, fats, vitamins, and minerals-directly into the bloodstream through an PICC ( a long, this, flexible tube inserted into a vein in the upper arm and threaded into a large vein near the heart) line for two of two sampled residents (Resident 98 and Resident 97). This failure had the potential for TPN associated negative outcomes up to and including death. 2. Certified Nursing Assistants (CNA 1, CNA 2, and CNA 3) were not competent to provide direct care to residents that included: hand hygiene,…

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

Based on observation, interview, and record review, the facility failed to ensure medications were stored at proper temperature. This failure had the potential for medication to be ineffective or harmful to residents and staff.Findings:During a concurrent observation and interview on 1/27/26 at 2:01 p.m. with Infection Prevention Nurse (IP) in the facility medication room, three boxes of Prevnar 20-valent Conjugate Vaccine (pneumococcal (flu) vaccine) was stored in the facility freezer temperature at 20 degrees. IP stated the pharmacist stated to store the extra boxes in the freezer. IP stated the box of Prevnar indicated Do not freeze, and the medication should be discarded and not stored in the freezer.During a review of Prevnar's Instructions for Use (IFU) [undated], the IFU's indicated, After shipping, Prevnar 20 may arrive at temperatures between 36 degrees F (Fahrenheit) to 77 degrees F. Upon receipt, store refrigerated at 36 degrees F to 46 degrees F. Do not freeze, Discard if the vaccine has been frozen.During a review of the facility's policy and procedure (P&P) titled ,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the correct amount of ingredients to a meal per the facility recipe for three of 22 residents (Resident 21, Resident 51, Resident 80). This failure had the potential for Resident 21, Resident 51, and Resident 80's nutritional and caloric intake to be inaccurate and result in unwanted weight loss or gain. Findings:During a concurrent observation and interview on 1/28/26 at 11:32 a.m. with Facility [NAME] (FC) 1 in the facility kitchen, FC was observed making five quesadillas as a substitute meal for Resident 21, Resident 51, and Resident 80. FC 1 was observed using his hands to grab cheese and dispense unmeasured amounts onto a tortilla. FC 1 stated he had not measured how much cheese was used for the quesadillas and did not know what the facility recipe required as far as amount. During a review of the facility document titled RECIPE: CHEESE QUESADILLA (RCQ), dated 2025, the RCQ indicated, Add 1/2 cup cheese per tortilla.

Based on observation, interview, and record review the facility failed to:Label and date opened food items. Maintain a clean refrigerator per policy and procedure (P&P) REFRIGERATOR AND FREEZER. Accurately document the temperature of the facility dry food storage area. These failures had the potential to cause food to spoil and cause foodborne illness.Findings:1.During a concurrent observation and interview on 1/26/26 at 8:02 a.m. with Certified Dietary Manager (CDM) in the facility kitchen, the following food items were observed to have no open date or label:One pound (lb.) container of paprika, One lb. container of ground thyme, One lb. container of ground rosemary, One lb. container of sesame seeds, One lb. container of ground cumin, One lb. container of lemon pepper seasoning, One lb. container of dill weed, One lb. container of bay leaves, and Three pink 32-ounce containers with whitish thick liquid substance found in the walk-in refrigerator. There was no indication of what the liquid was.CDM stated per the facility, process food items should have an 'open and used by' date,…

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

Based on interview and record review facility failed to follow its policy and procedure (P&P) titled, Infection Prevention and Control Program, when there was no surveillance conducted on nursing staff. This failure had the potential for unsanitary conditions.Findings:During a concurrent interview and record review on 1/28/26 at 9:27 a.m. with Infection Prevention Nurse (IP), surveillance records (form that audit staff for infection control practices) were reviewed. IP stated there was no surveillance conducted for certified nursing assistants and Licensed and Registered nurses for any infection control practices. IP stated it should have been done. During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, dated 12/1/2021, the P&P indicated, V. Gathering Surveillance Data.E. At least on a monthly basis, the IP. will conduct an infection control audit.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure 23 of 34 resident rooms measured at least 80 square feet per resident. This failure had the potential for residents to experience negative outcomes due to having insufficient personal space in their rooms.Findings:During a review of facility documented titled Client Accommodation Analysis (CAA), (a facility document indicating the size of resident rooms), [undated], the CAA indicated the following room measurements:room [ROOM NUMBER]: 153 square feetroom [ROOM NUMBER]: 154 square feetroom [ROOM NUMBER]: 132 square feetroom [ROOM NUMBER]: 210 square feetroom [ROOM NUMBER]: 210 square feetroom [ROOM NUMBER]: 210 square feetroom [ROOM NUMBER]: 225 square feetroom [ROOM NUMBER]: 210 square feetroom [ROOM NUMBER]: 156 square feetroom [ROOM NUMBER]: 220 square feetroom [ROOM NUMBER]: 220 square feetroom [ROOM NUMBER]: 220 square feetroom [ROOM NUMBER]: 220 square feetroom [ROOM NUMBER]: 220 square feetroom [ROOM NUMBER]: 220 square feetroom [ROOM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 report results of investigation of the allegation of abuse to the California Department of Public Health (CDPH) within five days of the incident for two of two sampled residents (Resident 1 and Resident 2). This failure had the potential to delay the investigation of the abuse allegation incident.Findings:During a review of facility document titled SOC 341 - Report of Suspected Dependent Adult/Elder Abuse (SOC 341-a state form used in California for mandated reporters to report suspected elder and dependent adult abuse or neglect. The SOC stands for Social Services, and 341 is the specific document number for this report), dated 9/1/25, the SOC 341 indicated an allegation of resident-to-resident abuse involving Resident 1 and Resident 2 on 9/1/25.During an interview on 9/11/25 at 12:25 p.m. with the Director of Nursing (DON), DON stated the facility became aware of an allegation of abuse involving Resident 1 and Resident 2 on 9/1/25 and reported it to the CDPH on 9/2/25 using the SOC 341. DON stated the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, sanitary, and comfortable environment for five of five sampled residents (Resident 1, Resident 2, Resident 3, Resident 4,and Resident 5). This failure had the potential to cause resident harm, decrease resident comfort, and affect resident dignity. During an observation on 7/2/25 at 1:31 p.m. in Resident 1's room, the following was observed in the shared resident restroom/shower room (Resident 1's restroom is also used by the facility to provide showers for the other residents): a. On the ceiling directly over the sink was an oval shaped approximately 12-inch (a unit of measurement) area of multiple orange and black shaped dots scattered around. b. On the ceiling toward the shower stall entry was approximately 24-inch in length by 24-inch in width area of exposed wood with three exposed screws.c. The tile ramp leading into the shower stall was a triangular shaped approximately two-inch piece of missing tile. d. The shower…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 address the hydration (the process of replenishing the water content in the body) needs of one of three sampled residents (Resident 1) who was dependent on hydration and nutrition via gastrostomy tube (G-Tube is a tube inserted through the belly that brings nutrition and hydration directly to the stomach), and who had an order for nothing by mouth (NPO) when there was no physician's order for hydration/water flushes, the physician was not notified of the Registered Dietician's (RD) recommendations for hydration, RD did not follow up timely to ensure the recommendations for hydration was carried out, and the facility did not follow their policy and procedure (P&P) on Intake and Output Recording to monitor and record intake and output of residents with feeding tube. These failures had the potential to result in insufficient fluids to maintain proper hydration for Resident 1. Findings: During a review of Resident 1's History and Physical Examination…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 revise the care plan (a detailed document outlining how the facility staff will provide care to meet the resident's specific needs) interventions as recommended by the Interdisciplinary Team (IDT - a group of healthcare professionals who collaborate to provide comprehensive care to a patient) for one of three sampled residents (Resident 1). This failure resulted in Resident 1 falling on 5/28/25 and sustaining an acute fracture (clean and immediate break in the bone) of her pelvis (bowl-shaped bony structure in the lower part of your body located between your lower back and your legs) S3 and S4 region (third and fourth sacral [triangular bone at the base of the spine] vertebrae [backbone]) and subluxation (when bones are moved out of place resulting in pressure and irritation) of S2 and S3 (second and third sacral bone -area of the pelvis) requiring the resident to be transferred to the acute hospital (from 5/28/25 to 6/1/25).Findings: During a review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Quality Assurance and Performance Improvement (QAPI-systematic process for ensuring that products and services ensure quality care) committee failed to maintain, identify, and correct a physical environment deficient practice identified by the survey team (reference tag F-919). This failure resulted in a non-functional resident restroom call light system and an unsafe physical environment of care for all 85 facility residents. Findings: During a concurrent interview and record review on 3/27/25 at 2:03 p.m. with Medical Director (MD), the facility document titled, Facility Assessment Tool, dated 11/25/24 was reviewed. MD stated he reviewed the completed facility assessment as part of the QA committee. MD stated the facility assessment tool included the facility's call light system. MD stated there was no resident restroom call light deficits the QA committee was aware of. MD stated the residents' nonfunctional restroom call lights were a safety concern and needed to alarm staff of an emergency. During a concurrent interview and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 18 of 18 resident bathrooms and three of three resident shower rooms had operational call lights within reach of residents. This failure had the potential for all 85 residents not to be able to call for help if they required assistance while using the bathrooms and shower rooms. Findings: During a concurrent observation and interview on 3/27/25 at 9:10 a.m., with the Maintenance Supervisor (MS), the call light systems located in resident bathrooms and shower rooms were checked for proper functioning and placement. The MS stated resident bathrooms and shower rooms were equipped with a call light system that when activated alerted staff at the nurse's station. The call light in the bathroom shared by residents in Rooms #1 and #3 was activated but there was no corresponding visual or auditory alarm outside the rooms or in the nurse's station. The call light in the bathroom used by residents in room [ROOM NUMBER] was activated but…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, Med Pass for two of three sampled medication carts (Medication Cart 1 and Medication Cart 2). This failure had the potential for residents, staff, and visitors to unsafely access medications. Findings: During a concurrent observation and interview on 3/26/25 at 6:02 a.m. with Director of Nursing (DON) in the South Main Hallway, Medication Cart 2 was unaccompanied in the corner of the hallway in front of the nurse's station. All of Medication Cart 2's drawers, except for the controlled medication (drug or substance regulated by the government due to its potential for abuse and addiction) drawer, were unlocked and able to be opened. There was no nurse in the proximity of Medication Cart 2. DON was in the hallway; she was able to open the unlocked drawers. DON attempted to lock the cart but was unable to secure the locking mechanism. DON stated the unlocked medication cart had the potential 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: 1. Failed to ensure three of three dietary staff (DS 1, DS 2 and DS 3) washed their hands according to the Centers for Disease Control and Prevention (CDC) guidelines on hand washing and failed to ensure its policy and procedure (P&P) on Hand Hygiene conformed to the CDC guidelines on hand washing. This failure had the potential for the spread of infectious diseases in the facility. 2. Failed to ensure it kept an inventory of Personal Protective Equipment (PPE - gowns, gloves, masks, goggles and faceshields). This failure had the potential for the facility to run out of PPE and placing residents at risk of infectious diseases. Findings: 1. During an observation on 3/26/25 at 6:10 a.m., in the kitchen, with DS 1, DS 1 washed her hands in the handwashing sink as follows: DS 1 first applied soap to her hands and rubbed them together, wet her hands under running water, rubbed her hands, rinsed and dried them. During an observation on 3/26/25 at 6:12 a.m., in the kitchen, with DS 2, DS 2 washed her hands in the handwashing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 23 of 34 resident rooms measured at least 80 square feet per resident in multiple resident rooms. This failure had the potential for residents to experience negative outcomes due to having insufficient personal space in their rooms. Findings: During a review of facility document titled Client Accommodations Analysis (CAA) (a facility document indicating the size of resident rooms), dated 3/12/18, the CAA indicated the following room measurements: room [ROOM NUMBER]: 153 square feet room [ROOM NUMBER]: 154 square feet room [ROOM NUMBER]: 132 square feet room [ROOM NUMBER]: 210 square feet room [ROOM NUMBER]: 210 square feet room [ROOM NUMBER]: 210 square feet room [ROOM NUMBER]: 225 square feet room [ROOM NUMBER]: 210 square feet room [ROOM NUMBER]: 156 square feet room [ROOM NUMBER]: 220 square feet room [ROOM NUMBER]: 220 square feet room [ROOM NUMBER]: 220 square feet room [ROOM NUMBER]: 220 square feet room [ROOM NUMBER]: 220 square feet room…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Responsible Party (RP) 1 was notified when a change in diet texture was ordered for one of four sampled residents (Resident 35). This failure resulted in RP 1 not being aware of changes in Resident 35's status. Findings: During an interview on 3/24/25 at 3:01 p.m. with RP 1, RP 1 stated Resident 35 was placed on a pureed (pudding-like consistency) diet and the facility did not inform her. RP 1 stated she was speaking on the phone with Resident 35 and Resident 35 told her the facility was feeding her baby food. RP 1 stated Resident 35 can eat a regular diet if she is sitting up. During a concurrent interview and record review on 3/25/25 at 3:03 p.m. with Director of Nursing (DON), DON stated Resident 35 saw another resident in the dining room eating a pureed diet and requested one. DON stated nurses can change a resident's diet order, without informing the physician, if the diet consistency is being downgraded. The Physician Order dated 7/15/24 indicated Resident 35's diet order was Regular with a thin consistency…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident assessments were completed for two of two sampled dialysis (medical procedure that filters waste products and excess fluids from the blood when the kidneys no longer function adequately) residents (Resident 8 and Resident 59). This failure resulted in an incomplete assessment of Resident 8 after dialysis, and an incomplete assessment of Resident 59 before and after dialysis. Findings: During a concurrent interview and record review on 3/26/25 at 7:40 a.m. with Registered Nurse (RN) 1, Resident 8's Nursing Dialysis Communication Record (NDCR), dated 3/5/25 was reviewed. The NDCR indicated no pain assessment was done after dialysis for Resident 8. RN 1 stated Resident 8's pain should have been assessed. RN 1 stated a nursing assessment of Resident 8 was very important after dialysis for the early identification of complications. During a concurrent interview and record review on 3/26/25 at 7:50 a.m. with RN 2, Resident 59's NDCR, dated 2/12/25 was reviewed. The NDCR indicated Resident 59 did not have her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that facility failed to ensure one of five sampled residents (Resident 13) psychotropic medication (medication that alters mood, behavior, and mentation), Oxcarbazepine (medication prescribed for bipolar-mood disorder) was reviewed quarterly (every 3 months) by the interdisciplinary team (IDT- healthcare professionals including physician, pharmacist, social services, activities, and nursing). This failure resulted in Resident 13 not having an IDT medication review for Oxcarbazepine and had the potential for unnecessary medications. Findings: During a concurrent interview and record review on 3/26/25 at 11:29 a.m. with Social Service Director (SSD), Resident 13's Physician Order (PO) dated 2/21/25 was reviewed. The PO indicated Resident 13 was prescribed Oxcarbazepine 600 mg by mouth once daily for bipolar disorder. SSD stated Resident 13 had been taking Oxcarbazepine as prescribed daily. During a concurrent interview and record review on 3/26/25 at 11:57 a.m. with SSD, Resident 13's Gradual Dose Reduction Binder (GDRB- attempts made to lower…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 its food preparation sink in the kitchen had an air gap (a backflow prevention device consisting of vertical space between the water outlet and flood level of a sink designed to ensure contaminated water does not flow back into the clean water supply). This failure had the potential to contaminate residents' food supply and exposure to infectious diseases. Findings: During an observation on 3/26/25 at 6:33 a.m., in the kitchen, there was no air gap in the two compartment sink. During an interview on 3/26/25 at 6:50 a.m., in the kitchen, with the Consultant Dietary Services Manager (CDSM), the CDSM stated the two compartment sink in the kitchen was used to wash produce and food for residents. The CDSM stated the two compartment sink in the kitchen had no air gap. During an observation on 3/26/25 at 7:25 a.m., in the kitchen, dietary staff washed fresh strawberries in the two compartment sink. During a concurrent observation and…

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

Based on interview and record review, the facility failed to ensure care plans were developed and implemented for two of three sampled residents (Resident 1 and Resident 2). This failure had the potential for Resident 1 and Resident 2 to experience accidents and injuries. Findings: During a review of Resident 1's Fall Risk Assessment, (FRA) dated 11/28/24, the FRA indicated Resident 1 scored a 45 (High risk 45 and higher, moderated risk 25-44 and low risk 0-24) Resident 1 was at high risk for falls. During a concurrent interview and record review, on 12/10/24 at 4:24 p.m. with Director of Nursing (DON), Resident 1's FRA, dated 11/28/24 was reviewed. There was no fall risk care plan noted in the clinical record. DON confirmed there was no fall risk care plan developed for Resident 1. During a review of Resident 2's FRA, dated 4/3/24, the FRA indicated Resident 2 scored a 60, Resident 2 was at high risk for falls. During a review of Resident ' 2 s SBAR (situation, background, assessment, recommendation- form used to communicate information) Summary for Providers, (SBAR) dated 6/21/24,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement their policy and procedure (P&P) titled, Abuse Prevention and Prohibition Program, when two of three sampled residents (Resident 1 and Resident 3) medical doctor (MD) was not notified regarding the allegation of abuse and one of three sampled residents (Resident 1) responsible party (RP) was not notified of the allegation of abuse. These failures had the potential for Resident 1 and Resident 3 ' s MD and Resident 1 ' s RP not to be aware of Resident 1 and Resident 3 ' s allegation of abuse. Findings: During an interview on 10/15/24 at 11:50 p.m. with the Director of Nursing (DON), the DON stated they (management) received an email from a former employee alleging abuse against Resident 1, Resident 2, and Resident 3. During a review of Resident 1's admission Record, (AR) the AR indicated, Resident 1 was admitted on [DATE], the AR indicated Resident 1 had a responsible party. During a review of Resident 3's AR, the AR indicated, Resident 3 was…

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

Based on interview and record review, the facility failed to consistently implement care plans for two of three sampled residents (Resident 1 and Resident 3).This failure had the potential for Resident 1 and Resident 3 to have unmet psychosocial and physical needs. Findings: During an interview on 10/15/24 at 11:50 p.m. with the Director of Nursing (DON), the DON stated they (management) received an email from a former employee alleging abuse against Resident 1, Resident 2, and Resident 3. During an interview on 10/15/24 at 2:11p.m. with Registered Nurse (RN) 1, RN 1 stated for allegations of abuse he would create a care plan for delayed injury and psychosocial outcome and monitor for 72 hours. During a review of Resident 1 ' s care plan with the focus on Alleged incident of physical abuse, initiated 10/9/24. The care plan indicated one of the intervention was to Monitor For Pyschosoical [sic] Well Being X (times) 72 Hours. During a review of Resident 3 ' s care plan with the focus on Alleged incident of neglect on unspecified date, initiated 10/9/24. The care plan indicated one 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 provide reasonable access to a telephone that provided privacy for three of three sampled residents (Resident 1, Resident 2, and Resident 3). This failure resulted in a violation of residents' rights to a private conversation. Findings: During an interview on 5/28/24 at 11:29 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated residents wanting to use the phone need to be able to get up out of bed and use the phone in the Administrator's office and/or use the facility main office phone. During an interview on 5/28/24 at 11:44 a.m. with LVN 2, LVN 2 stated residents want to use the phone were taken to the nursing station to make phone calls. LVN 2 stated if the call needed to be private it is difficult as there are no cordless phones for the residents to use to allow privacy. During a review of Resident 1's MDS (Minimum Data Set – an assessment tool) under the section Brief interview for Mental Status (BIMS – an assessment tool for cognition [mental processes including perception, memory, and thought], dated 5/5/24,…

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

Based on interview and record review, the facility failed to ensure one of three sampled resident (Resident 1) medical records were accurate. This failure resulted in inaccurate information in Resident 1's medical record. Findings: During a concurrent interview and record review on 5/15/24 at 11:25 a.m. with Director of Nursing (DON), DON reviewed Resident 1's Wound Weekly Observation Tool, (WWOT) dated 4/4/24. DON confirmed Resident 1 had an SDTI (suspected deep tissue injury-intact or non-intact skin with localized area of persistent non-blanchable [the skin does not turn white when touched with a finger] deep red, maroon, purple discoloration or epidermal [outer layer of skin] separation revealing a dark wound bed or blood-filled blister [small bubble on the skin filled with serum]) to the left heel and skin intact. DON reviewed Resident 1's care plan with the focus on stage 3 (Full-thickness loss of skin, in which adipose [fat] is visible) pressure injury (is localized damage to the skin and underlying soft tissue usually over a bony prominence) to left heel initiated on 4/4/24…

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

Based on interview and record review, the facility failed to follow their policy and procedure (P&P) titled Discharge Against Medical Advice, on contacting Adult Protective Services (APS - a program that promotes the safety, independence, and quality-of-life for vulnerable adults) when one of three sampled residents (Resident 1) left the facility against medical advice (AMA - leaving a facility prior to a doctor recommends discharge). This had the potential for adverse health outcomes. Findings: During a review of Residents 1's AMA Form [AMAF], dated 5/1/24, the AMAF indicated Resident 1 signed himself out of the facility AMA on 5/1/24. During an interview on 5/6/24 at 2:18 p.m. with Administrator, Administrator stated Resident 1 is his own responsible party (RP - the person responsible for making decisions). Administrator stated Resident 1 signed himself out AMA from the facility on 5/1/24. During a review of Resident 1's admission RECORD (AR), dated 5/6/24, the AR indicated, Resident 1 was not his own RP. The AR indicated Resident 1 Family Member (FM) 1 is his responsible party…

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

Based on observation, interview, and record review, the facility failed to ensure the air mattress (a pressure-relief device that is constantly being inflated with air to prevent skin breakdown, wounds and/or assist with the healing of wounds) for three of three sampled residents (Resident 1, Resident 2 and Resident 3) was in safe operating condition. This failure had the potential to impact the safety of the residents. Findings: During a concurrent observation and interview on 4/22/24 at 2:07 p.m. with Licensed Vocational Nurse (LVN) 1 in Resident 1's room, Resident 1 was observed laying on an air mattress in bed. LVN 1 observed the air mattress setting and stated it was set at 290 pounds (lbs.). During a review of Resident 1's Weights and Vitals Summary (WAVS), dated 3/3/24, the WAVS indicated, Resident 1 weighed 110 lbs. During an interview on 4/22/24 at 2:17 p.m. with Treatment Nurse (TN), TN stated the facility maintenance sets up the air mattresses for the residents. TN stated she has not been educated nor does she know how to set up an air mattress or its settings 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.

Based on observation, interview, and record review, the facility failed to provide oxygen per physician's orders for one of three sampled residents (Resident 1). This failure had the potential for negative outcomes. Findings: During a concurrent observation and interview on 4/22/24 at 2:07 p.m. with Licensed Vocational Nurse (LVN) 1 in Resident 1's room, Resident 1 was observed with oxygen being given via nasal canula (a flexible tube with two protruding tips that sit inside the nostrils to deliver oxygen) at six liters (a unit of measurement). LVN 1 stated Resident 1 had the oxygen set at six liters, but it was supposed to be set at two liters. During a review of Resident 1's Order Summary Report (OSR), dated 4/22/24, the OSR indicated, Resident 1 diagnosis including Chronic Obstructive Pulmonary Disease (COPD – a common lung disease causing restricted airflow and breathing problems), Pneumonia (infection of the lung) and Respiratory failure (a serious condition that makes it difficult to breathe on your own). The OSR indicated Resident 1 had a physician's order to receive oxygen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 activity assessments were completed for 16 of 16 sampled residents (Resident 6, Resident 9, Resident 12, Resident 27, Resident 60, Resident 82, Resident 135, Resident 185, Resident 200, Resident 201, Resident 202, Resident 203, Resident 204, Resident 205, Resident 206, Resident 207). This failure had the potential for residents to not meet their physical, mental, and psychosocial well-being. Findings: During a concurrent interview and record review on 3/26/24 at 2:41 p.m. with Activity Director (AD), Resident 60's admission Record (AR), dated 3/18/24, was reviewed. The AR indicated, Resident 60 was admitted on [DATE]. AD stated, Resident 60 did not have activity assessment completed. During a concurrent interview and record review on 3/26/24 at 2:46 p.m. with AD, Resident 200's AR, dated 3/13/24 was reviewed. The AR indicated, Resident 200 was admitted on [DATE]. AD stated, Resident 200 did not have activity assessment completed. During a…

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

Based on interview and record review, the facility failed to ensure staff competencies for five of five sampled Licensed Nursing Staff (Registered Nurse [RN] 1, RN 2, RN 3, Licensed Vocational Nurse [LVN] 4, and LVN 6) were evaluated and completed. This failure had the potential to result in harm to residents. Findings: During an interview on 3/27/24 at 3:43 p.m. with TN 1, TN 1 stated she took a three-day class and then a test to become a Certified Wound Nurse. TN 1 stated she did not receive on-the-job training, even for the computerized medical record, and had to figure it out for herself. During an interview on 3/28/24 at 9:24 a.m. with Director of Nursing (DON), DON stated there used to be a competency checklist for staff, but he was updating the form and the competency checklist was not available for use. DON stated he reviewed nurses' resumes for level of experience, but no competency assessments were currently being done. During a concurrent interview and record review on 3/28/24 at 1:43 p.m. with Director of Staff Development (DSD), Employee Educational Records (EER) were…

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

Based on observation, interview, and record review, the facility failed to: 1. Ensure the kitchen was maintained in a sanitary manner for 71 of 71 sampled residents. 2. Ensure food was properly stored and labeled for 71 and 71 sampled residents. 3. Ensure employees followed dress code policy for two of two sampled staff (Dietary Supervisor (DS) and [NAME] 2 (CK) 2). 4. Ensure food was served in a sanitary manner for one of one sampled resident (Resident 61). These failures had the potential for the spread of foodborne illnesses throughout the facility. Findings: 1. During a concurrent observation and interview on 3/25/24 at 6:10 a.m. with CK 1 in the kitchen, a tall dirty ladder was leaning against a rack of clean plastic pitchers and storage bins on the right wall near the entrance, paint spatters were on the floor, and scaffolding containing paint supplies were at the end of the kitchen spanning over two freezers. CK 1 stated they were repairing and painting the ceiling in the kitchen over the past weekend. During an interview on 3/25/23 at 6:45 a.m. with Certified Dietary Manager…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 infection control practices were implemented for 4 of 4 sampled residents (Resident 27, Resident 5, Resident 48, and Resident 15) in accordance with nationally recognized infection control and prevention guidelines. This failure had the potential to transmit infectious diseases. 2. Ensure staff implemented infection control practices for handling trash, transmission-based precautions, and laundry services for 71 of 71 residents residing in the facility. This failure had the potential to transmit infectious diseases or parasite infestations throughout the facility. 3. Conduct infection prevention surveillance activities (collection and analysis of data) on hand hygiene effectively. This failure resulted in the facility's inability to have measurable data to improve resident health outcomes, and to identify, address, and correct departures from nationally recognized infection control practices. 4. Ensure the facility has an effective Infection Control Program for 71 of 71 residents in the facility.…

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

Based on interview and record review, the facility failed to ensure the Infection Control Preventionist (IP-health professional responsible for preventing and controlling the spread of infections) maintained Influenza (a contagious respiratory illness caused by influenza viruses that infect the nose, throat, and sometimes the lungs) and Pneumonia (an infection of one or both of the lungs caused by bacteria, viruses, or fungi) vaccinations for all current residents in the facility. This failure had the potential for the residents to not have the immunity for certain infectious diseases, which could be detrimental to their health and well-being. Findings: During a concurrent interview and record review on 3/28/24 at 11:38 a.m. with IP, the Immunization Report, dated 8/7/23 - 3/31/24, was reviewed. Eleven of 71 current residents were not included on the immunization report. IP was not able to provide influenza vaccination for 11 residents currently residing in the facility. IP was not able to verify receipt or refusal of pneumonia vaccination for 40 of 71 residents. IP confirmed the…

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Based on interview and record review, the facility failed to ensure the Infection Preventionist (IP-health professional responsible for preventing and controlling the spread of infections) maintained an accurate record of the Employee COVID-19 (a highly contagious respiratory illness caused by coronavirus) Vaccination for 110 of 159 employees. This failure resulted in incomplete employee COVID-19 vaccination record and unaccounted number of employees with or without immunity to the type of infection. Findings: During a concurrent interview and record review on 3/28/24 at 11:53 a.m. with IP, Employee COVID-19 Vaccination Records were reviewed. IP stated she did not have a log of the employee COVID-19 vaccinations, not manually or electronically. IP stated she has a binder where she keeps the employee COVID-19 vaccination cards. IP stated, Not everyone has proof of COVID-19 vaccination. I have some of the vaccination cards. There's a lot of employee movement, coming and going. During a review of the active Employee Roster on 3/28/24 at 12 PM with IP, the Active Employee Roster (AER)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 five of five Licensed Nurses (Registered Nurse [RN] 1, RN 2, RN 3, Licensed Vocational Nurse [LVN] 4, and LVN 6) were trained to meet the behavioral health requirements of 29 of 29 sampled residents (Resident 1, Resident 11, Resident 12, Resident 13, Resident 14, Resident 15, Resident 17, Resident 21, Resident 27, Resident 28, Resident 30, Resident 31, Resident 36, Resident 37, Resident 43, Resident 44, Resident 46, Resident 48, Resident 53, Resident 55, Resident 56, Resident 60, Resident 61, Resident 71, Resident 76, Resident 135, Resident 185, Resident 202, and Resident 204). This failure had the potential to result in staff being unable to provide appropriate assessments and interventions for residents with behavioral health needs. Findings: During an interview on 3/28/24 at 9:24 a.m. with the Director of Nursing (DON), DON stated no competency assessments were currently being done for any staff on anything. During a concurrent interview and record review on 3/28/24 at 1:43 p.m. with Director of Staff Development…

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

Based on interview and record review, the facility failed to ensure three of five sampled residents (Resident 43, Resident 52, and Resident 3) had Minimum Data Set (MDS- resident assessment tool) assessments completed timely. This failure had the potential to result in unidentified health problems. Findings: During a concurrent interview and record review on 3/28/24 at 10:21 a.m. with MDS Coordinator (MDSC) 1, Resident 43's Quarterly MDS assessment, dated 12/31/23, was reviewed. Resident 43's Quarterly MDS Assessment indicated a status titled, Export Ready. MDSC 1stated the Quarterly MDS assessment was completed on 3/20/24 but had not been transmitted. MDSC 1 stated, Yes, it is late. During a concurrent interview and record review on 3/28/24 at 10:28 a.m. with MDSC 1, Resident 52's Quarterly MDS assessment, dated 12/29/23, was reviewed. Resident 52's Quarterly MDS Assessment indicated a status titled, Export ready. MDSC 1 stated Resident 52's Quarterly MDS assessment had not been sent and was late. During a concurrent interview and record review on 3/28/24 at 10:29 a.m. with MDSC 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: 1. Ensure Pharmacy Consultant conducted Medication Regimen Review (MRR- a thorough evaluation of the residents' medications and minimizing adverse consequences) for two of two sampled residents (Resident 15 and Resident 55) on psychotropic (refer to antidepressants, anti-anxiety, stimulants, antipsychotic, and mood stabilizers) medications. 2. Ensure Pharmacy Consultant conducted monthly medication review for all 71 residents in the facility . These failures had the potential for adverse consequences when there is no pharmacy oversight and monitoring of medications. Findings: 1. During a concurrent interview and record review on 3/27/24 at 8:31 a.m. with Minimum Data Set (resident assessment tool) Coordinator (MDSC) 1, Resident 15's Medication Administration Record (MAR), dated 3/1/24/ to 3/26/24, was reviewed. The MAR indicated Abilify 30 mg (milligram), give one tablet one time a day for bipolar disorder (mental illness causing extreme mood swings that include emotional highs and lows) manifested by (m/b) sexual…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a language-assistance service for one of one sampled resident (Resident 64). This failure had the potential for unmet care needs. Findings: During a concurrent observation and interview on 3/25/24 at 7:05 a.m. in Resident 64's room, Resident 64 was seated at the edge of the bed trying to say something in [NAME] (language native to the Punjab region of Pakistan and [NAME]). Certified nursing assistants (CNA) 2 and CNA 3 entered Resident 64's room. CNA 3 spoke in one syllable words and made gestures to communicate with Resident 64. Resident 64 and CNA 3 could not clearly communicate and understand each other. Resident 64 put both her elbows on the overbed table, held her hair and put her head down. During an interview on 3/25/24 at 7:10 a.m. with CNA 3, CNA 3 stated she (CNA 3) communicated with Resident 64 using body language and action. CNA 3 stated Resident 64 understood bathroom. CNA 3 stated there are two staff members who…

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

Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 15 and Resident 26) had access to a call light. This failure had the potential for unmet care needs. Findings: During a concurrent observation and interview on 3/25/24 at 10:37 a.m. with Resident 26, in Resident 26's room, Resident 26 was sitting on her bed with no call light visible. Resident 26 stated she knew how to call for help and pointed to the bed's remote control attached to the side rail. During a concurrent observation and interview on 3/25/24 at 10:40 a.m. with Certified Nursing Assistant (CNA) 4, CNA 4 retrieved Resident 26's call light from the floor at the end of her roommate's bed and attached it to Resident 26's side rail. CNA 4 stated the call light should have been where Resident 26 could reach it. During a concurrent observation and interview on 3/25/24 at 8:51 a.m. with Resident 15, in Resident 15's room, the call light was hanging on the wall located in the back of Resident 15's headboard. Resident 15 was unable to find his call light in his…

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

Based on interview and record review, the facility failed to follow their policy and procedure (P&P) titled Notification of Responsible Party, when the responsible party was not notified of a change of condition for one of four sampled residents (Resident 17). This failure had the potential to result in family not being involved in Resident 17's care. Findings: During a concurrent interview and record review on 3/26/24 at 2:33 p.m. with Treatment Nurse (TN), Resident 17's eInteract Change in Condition Evaluation-V 5.1 (COC), dated 2/25/2024, was reviewed. The COC indicated, Resident 17 had a skin tear on toe and under Resident Representative notification had self. TN stated, Resident 17 doesn't have capacity to make her own decisions. TN stated Resident 17 had the COC on 2/25/24. TN stated Resident 17's representative was never notified about Resident 17's COC. During a record review of Resident 17's History and Physical Examination (H&P), dated February 2024, the H&P indicated, [Resident 17] does not have the capacity to understand and make health care decisions. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide accurate transfer/discharge documents signed by the Responsible Party for one of one sampled resident (Resident 55) with dementia (group of symptoms affecting memory, thinking and social abilities). This failure had the potential to result in an unsafe and unorderly transfer for Resident 55 without the family being aware. Findings: During a review of Resident 55's admission Record (AR), the AR indicated, Resident 55 is an [AGE] year-old-female admitted on [DATE] with diagnosis including, Unspecified Dementia, Anxiety Disorder (intense, excessive, and persistent worry and fear about everyday situations), and Adult Failure to Thrive (group of symptoms including weight loss, decreased appetite and poor nutrition, and inactivity accompanied by dehydration and depression). During a review of Resident 55's Minimum Data Set (MDS-resident assessment tool), the MDS Section C-Cognitive [thinking, reasoning, remembering ability] Patterns, dated 11/17/23,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure four of four sampled residents (Resident 15, Resident 19, Resident 56, and Resident 209) received a summary of the Baseline Care Plan (BCP-the minimum healthcare information necessary to properly care for each resident immediately upon their admission) within 48 hours of admission. This failure had the potential for unmet care needs for Resident 15, Resident 19, Resident 56, and Resident 209. Findings: During a review of Resident 15's admission Record (AR), the AR indicated, Resident 15 was readmitted on [DATE] after a recent hospitalization. Resident 15 had a diagnosis including Type 2 Diabetes Mellitus (DM-high levels of blood sugar) with Polyneuropathy (a complication of diabetes mellitus characterized by progressive death of nerve fibers, which leads to loss of nerves, increased sensitivity, and development of foot ulcers), and Hemiplegia (one-sided paralysis)/hemiparesis (loss of strength in the arm, leg, and face on one side of the body)…

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

Based on interview and record review, the facility failed to develop and implement a care plan for two of two sampled residents (Resident 208 and Resident 55). This failure had the potential for negative outcomes. Findings: 1. During a review of Resident 208's Progress Notes (PN), dated 1/24/24, at 7:46 p.m., the PN indicated Resident 208 refused to go to the hospital for an unidentified change of condition. During a review of Resident 208's PN dated 1/29/24 at 7:10 a.m. the PN indicated Resident 208 refused to have his blood sugar checked. During a review of Resident 208's PN dated 2/16/24 at 8:10 p.m. the PN indicated Resident 208 had a blood pressure (the pressure of blood pushing against the walls of your arteries [blood vessel]) of greater than 240/110 (extremely high, normal range is 120/80) despite being given two medications to control it. Resident 208 refused to be sent out for higher level of care. During a review of Resident 208's PN dated 3/2/24 at 11:01 a.m. the PN indicated Resident 208 refused to take his medications, refused his blood sugar checked and refused to go…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medication according to the physician's order for one of three sampled residents (Resident 209). This failure had the potential for adverse outcomes for Resident 209. Findings: During a concurrent interview and record review on 3/26/24 at 10:12 a.m. with Director of Nursing (DON). DON reviewed Resident SC's Medication Administration Record, (MAR) dated 2/2024. DON confirmed the following: Percocet [combination of medication used to relieve severe pain] Oral Tablet 10-325 MG [milligram- unit of measure] .Give 1 tablet by mouth every 4 hours as needed for severe pain (7-10) . -Order Date- 2/19/2024 1543 [3:43 p.m.] 2/18/24 at 12:30 a.m., Percocet was administered for a pain level of 5. 2/18/24 at 4:47 a.m., Percocet was administered for a pain level of 6. 2/19/24 at 4:53 a.m., Percocet was administered for a pain level of 5. 2/20/24 at 6:30 a.m., Percocet was administered for a pain level of 6. 2/22/24 at 6:17 a.m., Percocet was administered for a pain level of 5. DON stated Percocet was given outside of physician…

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

Based on interview and record review, the facility failed to: 1. Notify a Medical Doctor (MD) of a change in one of three sampled residents (Resident 208) condition. 2. Conduct an Interdisciplinary team (IDT - a group of various professionals that coordinate assessment and treatment for residents, so that problems can be dealt with consistently and comprehensively) for one of three sampled residents' (Resident 208) change in condition. These failures had the potential for Resident 208 to not obtain the proper treatment, not have consistent care given, not identify the best course of action for Resident 208's concerns, and potentially lead to harm up to and including death. 1. During a review of Resident 208's Progress Notes (PN), dated 2/16/24 at 8:10 p.m, the PN indicated Resident 208 had a blood pressure (the pressure of blood pushing against the walls of your arteries [blood vessel]) of 240/110 (extremely high, normal range is 120/80) despite being given two medications to control it. Resident 208 refused to be sent out for higher level of care. During a concurrent interview and…

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

Based on observation, interview, and record review the facility failed to: 1. Provide preventive measures for pressure injuries (break down of the skin and underlying tissue) for one of two sampled residents (Resident 5). 2. Ensure weekly wound assessments for two of two sampled residents (Resident 5 and Resident 21). These failures had the potential to result in the development of additional pressure injuries and the inability to determine the healing progress of current wounds. Findings: 1. During a review of Resident 5's admission Record (AR), dated 3/27/24, the AR indicated Resident 5 diagnoses included quadriplegia (paralysis of all four limbs), cellulitis (skin infection) of buttocks, muscle wasting and atrophy (decrease in size) of both shoulders, generalized muscle weakness, reduced mobility, and a history of Stage 2 pressure injury (partial thickness loss of skin cause by pressure or shearing forces presenting as a shallow ulcer or fluid filled blister) to right buttocks. During a review of Resident 5's Minimum Data Set (MDS-resident assessment tool)- Section M- Skin…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a fall risk for assessment two of three sampled residents (Resident 209 and Resident 55). These failures had the potential for Resident 209 and Resident 55 to have unmet care needs and potential for injury. Findings: During a review of Resident 209's admission Record, (AR), the AR indicated, Resident 209 was admitted on [DATE], with diagnoses including lack of coordination, muscle wasting, reduced mobility, and need for assistance with personal care. During a concurrent interview and record review on 3/19/24 at 3:41 p.m. with the Director of Nursing (DON), Resident 209 and Resident 55's medical records were reviewed. DON stated a fall risk assessment should be completed on admission, quarterly, and after a fall. DON reviewed Resident 209's medical record. DON confirmed Resident 209 did not have a fall risk assessment on admission. DON stated a fall risk assessment should have been completed for Resident 209. DON reviewed Resident 55's medical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 five of five sampled residents (Resident 15, Resident 19, Resident 41, Resident 55, and Resident 56) were assessed to determine the level of risk for bed entrapment (an event in which an individual is caught, trapped, or entangled in the spaces in or about the bed rail, mattress, or bed frame) prior to the application of bedrails. This failure places residents at risk for harm when bed entrapment risk assessment has not been completed. Findings: During a concurrent observation and interview on 3/27/24 at 11 a.m. with Maintenance Supervisor (MS), in Resident 15, Resident 19, Resident 41, Resident 55, and Resident 56's room, all five residents's beds had quarter siderails up on each side of their beds. MS stated we just discussed bed entrapment two weeks ago with the Administrator-in training (AIT). MS stated, I do not have a log specific for the siderails and I do not have a record of bed rail measurements. I am aware of the bed entrapment requirements from previous employment, but we do not have that implemented…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Registered Nurse (RN) was scheduled and on duty eight hours a day, seven days a week. This failure had the potential for resident care to be negatively impacted. Findings: During a concurrent interview and record review on 3/28/24 at 10:26 a.m. with Director of Nursing (DON), the nursing staffing schedule dated October 2023, November 2023, December 2023 were reviewed. The nursing staffing scheduled indicated, In October 10/1/23, 10/2/23, 10/7/23, 10/8/23, 10/13/23, 10/14/23, 10/19/23, 10/20/23, 10/25/23, 10/26/23, 10/31/23, 11/1/23, 11/6/23, 11/12/23, 11/18/23, 11/19/23, 11/24/23, 11/25/23, 11/30/23, 12/1/23, 12/6/23, 12/7/23, 12/12/23, 12/13/23, 12/18/23, 12/19/23, 12/24/23, 12/25/23, 12/30/23, 12/31/23 there was no Registered Nurse (RN) on duty on above dates. DON stated there was no RN working on the floor 8 hours a day on above dates. During a review of the facility's policy and procedure (P&P) titled, Nursing Department-Staffing, Scheduling & Postings, dated 2006, the P&P indicated, To ensure an adequate…

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

Based on observation, interview, and record review, the facility failed to ensure two of four sampled residents (Resident 135 and Resident 44) were free from medication error rate of greater than five percent (%) when two medication errors occurred within 29 opportunities resulting in a 6.9 % error rate. This failure had the potential for Resident 135 and Resident 44 not receiving the full therapeutic effects of the medication and potential for adverse health outcomes. Findings: During an observation and interview on 3/27/24 at 8:20 a.m. in Resident 135's room, Registered Nurse (RN) 1 administered Resident 135's medication. At 8:27 a.m. RN 1 stated she did not administer Resident 135's Eliquis (medication used to thin the blood) 5 milligram as she did not have any in her medication cart to administer. During a concurrent observation and interview on 3/27/24 at 8:56 a.m. in Resident 44's room, Licensed Vocational Nurse (LVN) 5 administered Resident 44's medications. LVN 5 stated she did not have Resident 44's inhaler (Trelegy Ellipta Aerosol Powder Breath Activated Inhaler -…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe administration of medication for one of 66 sampled residents (Resident 8) when medications were found at Resident 8's bedside table. These failures had the potential for medications to be administered incorrectly and unsafely. Findings: During a review of Resident 8's Order Summary Report (OSR), dated 3/26/24, the OSR indicated, ProAir HFA inhalation Aerosol Solution 108 (90 microgram per actuation (MCG/ACT) (Albuterol Sulfate--Medication used to prevent and treat breathing and shortness of breath) 2 puffs inhale orally every 6 hours for Chronic Obstructive Pulmonary Disease (COPD-lung disease caused by airflow blockage that can cause difficulty breathing). During an observation on 3/25/24 at 6:30 a.m. in Resident 8's room, an albuterol inhaler was on the bedside table. During a concurrent observation and interview on 3/25/24 at 6:34 a.m. with Licensed Vocational Nurse (LVN) 7 in Resident 8's room, Resident 8 had an albuterol inhaler on the bedside table. LVN 7 stated, That should not be 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure dietary staff was assigned to conduct assessment of food preferences for one of one sampled resident (Resident 56). This failure had the potential to result in unplanned weight loss. Findings: During an interview on 3/26/24 at 9:05 a.m. with Resident 56, Resident 56 stated he did not like the food served at the facility. Resident 56 stated no one has come to talk to him about his food preferences. During a concurrent interview and record review on 3/27/24 at 9:54 a.m. with Dietary Supervisor (DS) and Certified Dietary Manager (CDM), Resident 56's dietary food card was reviewed. The dietary food card indicated, Resident 56 disliked fish. DS stated he was responsible for asking residents their food likes and dislikes, but he had not seen Resident 56 since he talked to the resident during his admission to the facility on [DATE]. CDM stated, Resident 56's food preference needs to be updated. During a review of the facility's policy and procedure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a pureed diet (a texture-modified diet useful for people who have difficulty chewing and swallowing foods and liquids) was served according to the physician's order for one of 66 sampled residents (Resident 8). This failure had the potential to adversely affect the resident's health. Findings: During a review of Resident 8's admission Record (AR) dated 3/28/24, the AR indicated, Resident 8 is a [AGE] year-old female, admitted on [DATE], with diagnosis of cerebral infarction (lack of adequate blood flow to brain), hemiplegia (paralysis on one side of the body) and hemiparesis (partial weakness), and dysphagia (difficulty in swallowing). During a review of Resident 8's Diet Card (DC) [undated], the DC indicated, Resident 8 is on a Regular, Puree, Nectar Thick Liquids. During a review of Resident 8's Order Summary Report (OSR) dated 3/25/24, The OSR indicated, Regular Diet: Pureed texture, Nectar consistency, large portion. During a…

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

Based on interview and record review, the facility failed to ensure treatment orders were administered per physician orders for one of three sampled residents (Resident 1). This failure had the potential for worsening of Resident 1's wounds. Findings: During a concurrent interview and record review on 1/10/24 at 4:51 p.m. with Director of Nursing (DON), DON reviewed Resident 1 ' s Treatment Administration Record, (TAR) for 11/23 and 12/23, and confirmed the following: Right Inner Thigh MASD [Moisture-associated skin damage is the general term for inflammation or skin erosion caused by prolonged exposure to a source of moisture]: Clean with wound spray, pat dry, apply xeroform gauze [occlusive dressing for use on wounds] and cover with bordered gauze [dressing with adhesive border] everyday shift -Order Date- 11/24/23 0909 [9:09 a.m.] -D/C Date- 12/8/23 1557 [3:57 p.m.] 11/30/23, there was no documentation the Right Inner Thigh MASD treatment was administered (blank). 12/1/23, there was no documentation the Right Inner Thigh MASD treatment was administered (blank). 12/2/23, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an effective pest control program for 71 of 71 sampled residents residing at the facility when: 1a. Two of 35 rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) were observed with multiple (approximately 15 pieces) rodent- (small gnawing mammals) like shiny black granular-size droppings 1/2 - ¼ inch (in - unit of measurement). 1b. A live mouse (small rodents with pointed snout) observed by Certified Nursing Assistant (CNA) 1 in room [ROOM NUMBER] (occupied by Resident 3, Resident 4, and Resident 5), room [ROOM NUMBER] (occupied by Resident 1 and Resident 2), and room [ROOM NUMBER] (occupied by Resident 6, Resident 7, and Resident 8) on 11/7/23, 11/8/23, and 11/9/23. 1c. A live mouse observed by one of 17 sampled residents (Resident 14) on 11/9/23. 2. room [ROOM NUMBER] (empty) had a hole on the floor measured 36 inches by 32 inches (36 X 32 in). 3. room [ROOM NUMBER] (occupied by Resident 9, Resident 10, and Resident 11) had hole…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop a baseline care plan for one of three sampled residents (Resident 1) Percutaneous indwelling central catheter (PICC) line (long tube that is inserted through a vein). This failure had the potential for infection. Findings: During a review of Resident 1's Nurses Note (NN), dated 10/7/23 at 8:54 p.m. Resident 1 was readmitted back to the facility (10/7/23), with a PICC line on left upper arm related to IV (intravenous) therapy until 10/10/23. The baseline care plans were reviewed and noted no care plan developed for Resident 1's PICC line. During an interview on 10/20/23 at 12:25 p.m. with Director of Nurses (DON), DON stated Resident 1 was re-admitted on [DATE], with a PICC line to left upper arm. DON reviewed Resident 1's baseline care plans and confirmed no care plan was developed for Resident 1's PICC line. DON stated, There should have been one. During a review of the facility's policy and procedure (P&P) titled, Care Plans-Baseline, dated…

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

Based on interview and record review, the facility failed to implement discharge planning for one of three sampled residents (Resident 1) when Resident 1 was discharged home with no medications. This failure resulted in Resident 1 missing to take her medications for two days after being discharged and had the potential to place Resident 1 at risk for adverse health outcomes. Findings: During an interview on 9/27/23 at 1:11 p.m. with Resident 1, Resident 1 stated she was discharged home without the following medications: a) Fluconazole (medication for fungal infections) b) Gabapentin (medication to treat seizures -involuntary movements and nerve pain) c) Low dose aspirin (medication to reduce the risk of heart attack) d) Metoprolol (medication to treat high blood pressure) Resident 1 stated she was discharged home without medication and was told by the Licensed Vocational Nurse (LVN) 1 to call the pharmacy (a store where medication is dispensed and sold) to get her medications but the pharmacy stated it (medications) will take about three to four days to have the medications…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assist one of three sampled resident's (Resident 1) with personal hygiene when Resident 1 had dark debris under her long fingernails. This failure had the potential for Resident 1 to have skin breakdown and spread of infection. Findings: During a concurrent observation and interview on 8/30/23 at 3:15 p.m., in Resident 1's room, with Director of Staff Developer (DSD), Resident 1 had dark debris under her long fingernails. DSD stated Resident 1's nails should be trimmed and cleaned which was not done. During an interview on 8/30/23 at 3:15 p.m. with Resident 1, Resident 1 stated, I didn't know they [fingernails] were long and dirty. During a review of Resident 1's Care Plan (CP), dated August 2023, the CP indicated, Resident 1 requires extensive assist by one staff for personal hygiene. During a review of Resident 1's Minimum Data Set (MDS – comprehensive assessment tool), dated August 2023, MDS indicated, BIMS (Brief Interview for Mental Status) score was 13 (score 13-15 means cognitively intact). During a…

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

Based on observation, interview and record review, the facility failed to follow infection control practices when: 1. The Activity Assistant (AA) in the dining room area did not performed hand hygiene and changed his gloves for one of 13 sampled residents (Resident 1) after touching the aloe vera wipe used to clean Resident 1's hand and threw the aloe vera wipe in the trash can. 2. All visitors were not screened prior to entering the facility when there was a known Covid-19 outbreak in the facility per recommendation from the local public health department. These failures had the potential to spread infection to residents, staff, and visitors. Findings: 1. During a concurrent observation and interview on 8/16/23, at 11:15 a.m. with AA in the dining room, AA was assisting the residents in the dining area to clean their hands before lunch with aloe vera wipes followed by the hand sanitizer. The following residents were in the dining room before lunch: 1. Resident 1 2. Resident 2 3. Resident 3 4. Resident 4 5. Resident 5 6. Resident 6 7. Resident 7 8. Resident 8 9. Resident 9 10.…

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

Based on interview and record review, the facility failed to follow its policy and procedure titled Care Plans, Comprehensive Person-Centered for one of two sampled residents (Resident 1). This failure had the potential for Resident 1 ' s pain to not be managed appropriately, following a change in condition. Findings: During a review of Resident 1 ' s Change in Condition Report (CIC), dated 7/4/23, the CIC indicated, [Certified Nursing Assistant] CNA [1] was in [Resident 1 ' s] room when she witnessed resident jump out of bed and threw himself to the floor face first.resident has open wound approximately 4 inches long on his chin. During an interview on 7/17/23, at 9 a.m., with Director of Nursing (DON), DON stated, he was informed Resident 1 had a fall on 7/4/23, and a later X-ray finding on 7/4/23, indicated, Resident 1 had fractured his mandible (jaw bone). During a review of Resident 1 ' s Care Plan, dated 7/6/23, there was no care plan noted for pain management following the change in condition after Resident 1 had fractured his mandible on 7/4/23. During an interview on…

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

Based on interview and record review, the facility failed to protect the residents' rights for eight of 50 sampled residents (Resident 2, Resident 3, Resident 8, Resident 20, Resident 21, Resident 23, Resident 25, and Resident 33). These failures resulted in Resident 2, Resident 3, Resident 8, Resident 20, Resident 21, Resident 23, Resident 25, and Resident 33 not to be fully informed of change in physician, the rights to choose a physician and participate in decisions and care planning. Findings: During an interview on 7/18/23, at 11:31 a.m., with Resident 2, Resident 2 stated, the facility offered her choice of two physicians, and she picked one. During an interview on 7/18/23, at 11:45 a.m., with Resident 8, Resident 8 stated, she changed physicians recently. Resident 8 stated, the reason for the change was new owners. During an interview on 7/18/23, at 11:57 p.m., with Resident 33, Resident 33 stated, the facility changed her physician. Resident 33 stated, she liked her prior physician. During an interview on 7/18/23, at 12:10 p.m., with Resident 25, Resident 25 stated, no one…

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

Based on interview and record review, the facility failed to ensure physicians' orders were carried out timely for four of ten sampled residents (Resident 4, Resident 9, Resident 11, and Resident 14). These failures had the potential for Resident 4, Resident 9, Resident 11, and Resident 14 to have a delay in care. Findings: During a concurrent interview on 7/27/23, at 2:15 p.m., with Social Services Director and Registered Nurse (RN 2), SSD stated, on 6/13/23, she was informed by Director of Business Development (DBD) that Physician 1 and Physician 2's resident would need to transfer to other physicians' care. SSD stated, she called and notified the family and responsible party (RP) and spoke to the residents prior to implementing the order. RN 2 stated, once the notification was made, the order was taken to the nurse and the nurse carried out the order, then the order was taken to the front office for billing purposes, and medical record was notified to place the sticker on hard chart. During an interview on 7/27/23, at 2:29 p.m., with DBD, DBD stated, around 6/13/23, she 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.