Sunrise Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure, an assessment was conducted by Licensed Vocational Nurse (LVN) 1, prior to obtaining a pain medication order to treat migraine ( severe headache) for one of eight residents reviewed (Resident 35). This failure has the potential to result to inadequate pain management for Resident 35. Findings:On September 9, 2025, at 11:41 a.m., an observation with a concurrent interview was conducted with Resident 35. Resident 35 was in bed, alert, and interviewable. Resident 35 stated she had been requesting to see her physician because she needed to talk to him about her pain medications.On September 9, 2025, Resident 35's record was reviewed. Resident was admitted to the facility on [DATE] with diagnoses including fibromyalgia (condition that causes pain in muscles and soft tissues all over the body).The Physician's Order' dated August 21, 2025, indicated to give Nurtec Oral Disintegrating (brand name medication used to treat migraine) Tablet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and effective pharmaceutical services when: 1. For two of two residents (Resident 34 and Resident 35), inhalers were not appropriately administered. This failure had the potential for the residents to experience preventable breathing problems and/or other adverse clinical outcomes. 2. One of one opened blood glucose (sugar) test strip vial stored in the medication cart was undated in accordance with the manufacturer's instructions. This failure had the potential for unusable test strips to be used to measure residents' fingerstick blood glucose levels to determine the dose of insulin to be administered. Findings:1a. During a review of Resident 34's HISTORY AND PHYSICAL EXAMINATION [H&P - comprehensive patient assessment], dated March 19, 2025, the H&P indicated a past medical history of COPD [chronic obstructive pulmonary disease - ongoing lung condition]. During a review of Resident 34's medical record, the medical record indicated a physician's orders dated August 27, 2025, for…

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

Based on observation, interview, and record review, the facility failed to ensure safe and effective medication labeling and controlled (narcotics) drug storage when: 1. Three of three artificial tears (drug to lubricate dry eyes) medication bottles were not properly labeled with sufficient information to identify the specific resident. This failure had to potential to cause preventable infections from cross-contamination from eye drops were inadvertently mixed up with other residents. 2. The keys to the discontinued controlled substances were stored in an unlocked drawer in the half-opened Director of Nursing (DON) office. This failure had the potential for drug diversion (theft or preventable loss) and impaired (under the influence) staff providing care for a universe of 62 residents. Findings:1. During a concurrent observation and interview on September 8, 2025, at 3:33 p.m., an inspection of a medication cart was conducted with Registered Nurse 1 (RN 1). When the medication cart was opened, three opened carton boxes of artificial tears eye drops (National Drug Code 57896-181-05)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 nutrition services were provided for two of three residents (Resident 22 and Resident 26) reviewed, when:1.Resident 22, dietary preferences were not met; and2.Resident 26 annual (yearly) nutritional assessment had not been conducted.These failures had the potential for Resident 22 and Resident 26 to have inadequate dietary intake because reasonable efforts were not made to accommodate Resident 22's food preferences and Resident 26's annual nutritional assessment were not performed.Findings:1.On September 8, 2025, at 9:34 a.m., Resident 26 was observed sitting up in bed alert and oriented. During a concurrent interview with Resident 26, she stated the facility food is a mushy mess and did not receive what is on the menu. Resident 26 further stated if she did not like what is on the menu she ordered her own food. One box of Cheerios cereal and a case of cup of noodles soup was observed stored on Resident 26's closet.On September 8,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 expired food items were not stored in the refrigerator, readily available for use. This failure had the potential to result in foodborne illness to a vulnerable facility population.Findings:On September 8, 2025, at 8:50 a.m., during the initial tour of the kitchen, an observation and concurrent interview was conducted with the Dietary Supervisor (DS) and the Dietary Aide (DA). One prune juice carton labeled with a use-by- date of August 30, 2025, was observed in the refrigerator, readily available for use. The DA stated the August 30, 2025 date was the date when the juice carton was opened, and it should have been discarded five days after the open date. In a concurrent interview, the DS stated the date of August 30, 2025 was the date when the prune juice was opened and once opened, it was good for five days. The DS stated the prune juice should have been discarded and not stored in the refrigerator passed the use-by-date.The facility policy and procedure, titled, Dry Goods Storage Guidelines, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure infection control measures were followed and implemented when two employees from a consulting doctor's office did not follow an Enhanced Barrier Precautions (EBP - infection control intervention designed to reduce transmission of resistant organisms that required use of gown and glove during high contact resident care activities) for one of five residents reviewed (Resident 59).This failure had the potential to increase the spread of pathogens (germs) and infections by staff to the residents. Findings:On September 9, 2025, at 10:49 a.m. an observation was conducted on Resident 59's room. Observed outside Resident 59's room was a sign indicating Resident 59 and his room mate were both on EBP. PPE (Protective Personal Equipment - items of protective clothing or equipment designed to guard against health and safety hazards, e.g. mask, gown, gloves) supplies, including gown, mask, and gloves were observed stored by the door. The EBP…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a report with sufficient information to describe the alleged physical abuse that occurred between two residents (Residents 1 and 2) was provided to the State Agency (SA) and Long Term Care (LTC) Ombudsman (a resident advocate) on May 8, 2025. This failure had the potential for the SA and other officials to receive misleading informations which could negatively affect the investigation compromising the safety of the residents at the facility. Findings: On May 9, 2025, Resident 2 ' s admission record was reviewed. Resident 2 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss), impulse disorder (a mental health condition) and hospice care services (specialized end-of-life care). A review of Resident 2's History and Physical, dated April 9, 2023, indicated Resident 2 does not have the capacity to understand and make decisions. A review of Resident 2's IDT (Interdisciplinary Team) Note, dated May 8, 2025,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed, for one of three residents (Resident 1), to ensure an Advance Directive Acknowledgement (AD- written instruction such as living will or durable power of attorney for health care about the provision of care and services the resident preferred when he is no longer able to decide for himself), Consent to Treat, POLST (Physician Orders for Life Sustaining Treatment - a physician's order that outlines a plan for end of life care reflecting both a resident's preference and a physician's judgement based on medical evaluation), and Bed Hold Notification Policy were initiated and/or discussed with the resident, family member, and/or legal representative upon admission to the facility. This failure had the potential for the residents to receive unnecessary care/treatment and services. Findings: On January 2, 2025, at 10:55 a.m., an interview with a concurrent record review was conducted with the Social Service Director (SSD) regarding Resident 1.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure, for two of three residents (Residents 1 and 2) a discharge plan was developed upon admission to meet the individual discharge planning needs. This failure had the potential for the residents to not receive necessary care and services to address resident's discharge needs and goals. Findings: On January 2, 2025, at 10:55 a.m., an interview with a concurrent record review was conducted Social Service Director (SSD). Resident 1 was admitted to the facility on [DATE], with diagnoses that included dementia (a progressive disease that affects memory and other important mental functions). The document titled, Social History Assessment, printed on January 2, 2024, did not indicate a discharge plan was conducted for Resident 1. The discharge assessment section of the document was blank. Resident 1's Social History Assessment was 13 days past due. In a concurrent interview, the SSD stated a family member of Resident 1 called a few days after…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the appropriate medical transfer to an acute hospital emergency department was provided to one of two residents reviewed (Resident 3). This failure had the potential to result in actual or potential harm to Resident 3's physical, mental, and/or psychosocial well-being. Findings: On [DATE], at 9:19 a.m., an interview with a concurrent record review was conducted with Registered Nurse (RN) 1. Resident 1 was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD- type of lung disease that block airflow making it difficult to breathe). The History and Physical dated [DATE], indicated Resident 3 had the capacity to understand and make decisions. The Physician's Orders for Life sustaining Treatment (POLST- a physician's order that outlines a plan for end of life care reflecting both a resident's preference and a physician's judgement based on medical evaluation), dated [DATE], indicated Resident 1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to hold a bed, during the 7-day bed hold period, for one out of four residents (Resident 1). The failure resulted in a prolonged stay at the General Acute Care Hospital (GACH) when Resident 1 was ready for discharge back to the facility. Findings A review of Resident 1's medical records, titled, Resident information, dated, November 19, 2024, indicated, Resident 1 was admitted to the facility on , June 27, 2024, with a diagnosis of subarachnoid hemorrhage (brain bleed). Further review of Resident 1's record indicated, Resident 1 had a Brief Interview for Mental Status ({BIMS}-memory assessment), score of 00 (severe memory impairment). Resident 1 had a legal Representative authorized to make medical decisions for resident. On December 4, 2024, at 9:58 a.m., an interview was conducted with the Medical Record (MR), who stated, when a resident is admitted to the facility, the admissions nurse reviews the 7-day Bed Hold Notification Policy, with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents' mail was protected for privacy and confidentiality for one of three sampled residents (Resident 1), when the mailbox was not locked. This deficient practice had the potential for confidential information's, personnel letters, sensitive documents to be accessed by unauthorized individual. Findings: On October 7, 2024, at 10:00 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding resident rights. A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included orthopedic (dealing with bones or muscles) aftercare and wasting and atrophy (decrease in size of an organ or tissue). On October 7, 2024, at 10:40 a.m., during a concurrent observation and interview, the Director of Staff Development (DSD) stated that there were two mailboxes located outside the gate. The DSD stated both mailboxes were noted to be easily…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, for three of five residents reviewed for unnecessary medication (Residents 5, 53, and 56), to ensure: a. An assessment was conducted for the continued use of antipsychotic medications (medication to treat mental disorders) for Residents 5, 53 and 56; and b. Monitoring for the use of hypnotic medication (medication use to help people fall asleep) for Resident 56. These failures had the potential for Residents 5, 53 and 56 to not be properly monitored and to receive unnecessary medications that could cause harm and or death. Findings: 1. On August 7, 2024, Resident 5's admission RECORD, was reviewed. Resident 5 was admitted to the facility on [DATE], with diagnoses which included bipolar disorder (mental disorder that causes extreme mood swings). A review of Resident 5's History and Physical dated July 11, 2024, indicated Resident 5 can make decisions. A review of Resident 5's Order Summary Report, dated July 1- 31, 2024, indicated, .Aripiprazole (an…

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

Based on interviews and record reviews, the facility failed to ensure dietary staff were able to carry out the functions of food and nutrition services safely and effectively when [NAME] (CK) 1 and Dietary Aide (DA) 1 were unable to accurately verbalize the cool down process for hot food and ambient food temperatures. This failure had the potential to place residents at risk for food borne diseases (illness resulting from ingestion of contaminated food) that can cause sickness and or death. Findings: On August 6, 2024, at 12:50 p.m., during an interview with DA 1 regarding the cool-down process for hot food and ambient food temperatures inside the kitchen, DA 1 stated she does not know the cool-down process for hot food. DA 1 further stated I will put ice on it. DA 1 stated for cooling down ambient food temperatures, such as tuna salad, she would place the tuna on ice after the food is made. DA 1 further stated she does not know the process for cooling down ambient food like tuna. On August 6, 2024, at 1 p.m., during an interview with CK 1 regarding the cool-down process for ambient…

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

Based on observation, interview, and record review, the facility failed to ensure a sanitary environment, prepare, and served food in accordance with professional standards for food service safety, when multiple sheet pans were found with brown-black discoloration. This failure had the potential to place residents at risk for food borne diseases (illness that result from ingestion of contaminated food) that can cause sickness and or death. Findings: On August 5, 2024, at 8:15 a.m., during a concurrent walk-through observation and interview inside the kitchen with the Director of Food and Nutrition Services (DFS), one piece half-sheet pan and six full-sheet pans were found to have brown-black grime build up. The DFS stated the the pans are very old and needs to be replaced, and the brown- black discoloration was food residue. The DFS further stated the pans should not be in that condition, as the grime can cross-contaminate food and cause food borne illness to the residents. On August 8, 2024, at 8:16 a.m., during an interview with the RD, she stated that her expectation is the…

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

Based on interview and record review, the facility failed to ensure the Quality Assessment and Performance Improvement (QAPI) committee monitored and re-evaluated identified concern regarding hot temperature levels in resident rooms (rooms 22, 23, 24 and 25). This failure resulted in unsafe and uncomfortable temperature levels (above 81 degrees Fahrenheit) in resident rooms, affecting the quality of care, quality of life, and resident safety (cross-reference F584). Findings: On August 8, 2024, at 12:58 p.m., a concurrent interview and record review of the facility QAPI meeting was conducted with the Administrator (ADM). The ADM stated during the QAPI meeting on July 24, 2024, it was identified that resident rooms 22, 23, 24 and 25 had hot temperatures due to the facility central air conditioning (AC) units 4 and 5 breaking down on July 9, 2024. The ADM stated fans were placed inside the affected rooms and large coolers were placed in the hallway to help cool down the residents room temperatures. The ADM further stated the facility did not monitor or re-evaluate the effectiveness of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure education and resources regarding Advance Directive (AD - written statement of a person's wishes regarding medical treatment) were provided to the residents and/or resident reresentatives, for three of eight residents reviewed for Advance Directives (Residents 40, 46, and 54). This failure had the potential for Residents 40, 46, and 54 and the resident representatives uninformed about AD which could result in the facility being unable to know and honor the residents' wishes regarding their medical treatment. Findings: On August 6, 2024, Residents 40, 46, and 54's medical records were reviewed and indicated the following: 1. A review of Resident 40's admission RECORD, indicated Resident 40 was admitted to the facility on [DATE], with diagnoses which included bipolar disease (a disorder associated with mood swings), anxiety (worry about future concerns) and schizoaffective (mental health condition). A review of Resident 40's Minimum Data Set (MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure for one of six residents reviewed (Resident 32), the resident was able to voice a grievance without feeling uncomfortable. This failure had the potential for Resident 32's concerns to go unaddressed, leading to ongoing dissatisfaction and affecting the resident's quality of life. Findings: A review of Resident 32's admission RECORD, indicated, Resident 32 was admitted to the facility on [DATE], with diagnoses which included bilateral osteoarthritis of the knee (bone disease of both knees), fibromyalgia (chronic disorder that causes widespread pain in the body), dementia (disease characterized by loss of memory and language) and depression (feelings of hopelessness). A review of Resident 32's Minimum Data Set (an assessment tool) dated July 3, 2024, indicated Resident 32's Brief Interview for Mental Status (tool to assess cognitive function in residents) score was 15 (cognitively intact). On August 7, 2024, at 9:57 a.m., during the Resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the medication Carvedilol (medication used to treat high blood pressure) was administered as directed by the licensed nurse, for one of nine residents observed for medication administration (Resident 47). This failure has the potential for the resident to experience adverse effects of the medication if not taken as directed. Findings: On August 7, 2024, at 8:37 a.m., a medication administration observation was conducted with Licensed Vocational Nurse (LVN) 3. LVN 3 prepared Resident 47's medication that included Carvedilol 3.125 milligrams (mg- unit of measurement). The instructions on the medication bubble pack indicated to give one tablet of Carvedilol 3.125 mg by mouth. The medication label included an instruction to give the medication with food. On August 7, 2024, at 8:50 a.m., LVN 3 administered Resident 47's medication including the one tablet of Carvedilol 3.125 mg. LVN 3 was observed to not have given food to Resident 47…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facilty failed to ensure Licensed Vocational Nurse (LVN) 1 was provided adequate training in the documentation of a narcotic pain medication administration for two of three residents reviewed (Residents 6 and 14). This failure has the potential to result in inaccurate assessment of the resident's pain and documentation of pain medication administration. Findings: On August 8, 2024, at 10:29 a.m., an observation, interview, with a concurrent record review was conducted with Registered Nurse (RN) 1. A narcotic medication reconciliation was conducted and the following were observed: a. Resident 14 had a medication bubble pack for the medication Oxycodone-Acetaminophen (narcotic pain medication that is controlled due to it's high potential for addiction) 10-325 milligrams (mg - unit of measurement) with a stock dose of 13 tablets. The medication count sheet for the Oxycodone-Acetaminophen 10-325 mg indicated one tablet was signed out on July 23, 2024 at 12:53 p.m., by LVN 1 and LVN 3. In a concurrent interview, RN 1 stated, 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 the licensed nurse documented the medication Hydrocodone-Acetaminophen (controlled drug pain medication) as administered for one of three residents reviewed (Resident 34). This failure resulted to the delay in the identification of drug discrepancies and possible medication diversion of controlled medications. Findings: On August 8, 2024, at 10:55 a.m., an observation, interview, and record review was conducted narcotic medication reconciliation was conducted with Registered Nurse (RN) 1. Resident 34 was admitted to the facility on [DATE], with diagnoses that included osteoarthritis (type of degenerative joint disease that can affect joint tissues, usually manifested by pain). The Physician's Order dated March 12, 2024, indicated to give Norco Oral (brand name of narcotic pain medication) 5-325 milligrams (mg) one tablet by mouth every six hours as needed for moderate to severe pain. The Medication Count Sheet indicated Licensed Vocational…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 timely dental services for one of nine residents, (Resident 21). This failure had the potential to lead to mouth pain, infection, and/or complications related to dental and nutritional needs for Resident 21 if left untreated. Findings: On August 5, 2024, Resident 21's admission RECORD, was reviewed. Resident 21 was admitted to the facility on [DATE], with diagnoses which included multiple sclerosis (a central nervous system autoimmune disease, and anxiety disorder (a chronic condition characterized by an excessive and persistent sense of apprehension). A review of Resident 21's Care Plan, dated January 12, 2024, indicated, .Has oral/dental health problems r/t (related to) obvious or likely cavity or broken natural teeth . Coordinate arrangements for dental care, transportation as needed/as ordered, report to MD (physician) s/sx (signs and symptoms) of oral/dental problems needing attention . A review of Resident 21's Minimum Data…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure for one of one resident (Resident 54) a pest free environment when one fly was observed on resident 54's lunch meal. This failure had the potential to place Resident 54 at risk for food borne illness (illness caused by food contaminated with bacteria) that can cause sickness and or death. Finding: On August 6, 2024, Resident 54's admission RECORD, was reviewed. Resident 54 was admitted on [DATE], with diagnoses which included hemiplegia (partial or total paralysis on one side of the body), hemiparesis (partial paralysis or weakness), and cognitive communication deficit (difficulty communicating due to disruption in cognition). A review of Resident 54's History and Physical indicated, Resident 54 does not have the capacity to understand and make decisions. A review of Resident 54's Minimum Data Set (an assessment tool), dated May 23, 2024, indicated, Resident 54 had a Brief Interview for Mental Status (a tool to assess cognitive function in…

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

Based on interview and record review, the facility failed to address a doctor's concern regarding ongoing weekly telephone appointment for one of four sampled residents (Resident 1). This failure resulted for Resident 1 not receiving necessary care that he needed to achieve his highest level of physical well-being. Findings: During an interview on April 12, 2024, at 10:39 a.m., Resident 1 stated he had weekly phone appointments with a doctor, his therapist. Resident 1 stated it had been some time since his last session. Resident 1 stated the facility was aware of these appointments. During an interview on April 12, 2024, at 1:38 p.m., with the SS, the SS stated, she had spoken to Resident 1's doctor a few times. The SSD stated, she received an email from Resident 1's therapist on March 22, 2024, expressing concern about the lack of communication with the resident. During an interview on April 12, 2024, at 2:09 p.m., with the Licensed Vocational Nurse (LVN), the LVN stated, the doctor was required to provide an order for appointments. The LVN stated, the SS was responsible 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident's rights were respected, for one of four residents reviewed (Resident 1), when the facility cordless phone was not accessible for private conversations. This failure increased the potential to negatively affect Resident 1's psychosocial well-being. Findings: On March 26, 2024, at 11:36 a.m., an unannounced visit was conducted at the facility for two complaint investigations. On March 26, 2024, at 12:04 p.m., Resident 1 was observed lying in bed on his cell phone. During a concurrent interview, Resident 1 stated his cell phone no longer worked to receive phone calls, but he continued to use it for internet access. Resident 1 stated he needed to use the facility phone to make and receive phone calls. Resident 1 stated the facility had a cordless phone, but it was not available for use. Resident 1 stated he had weekly phone calls with his doctor, and he was not able to receive the calls because staff stated the cordless…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interveiw and record review, the facility failed to: 1) Administer medications as prescribed to 3 out of 3 Residents (Resident 1,2 and 3). 2) Order controled drug Xanax (An anti-anxiety medication) and failed to assure the medication was made available to Resident 1 as per Physician orders. This failure had the potential to: 1) Subject Resident ' s 1, 2 & 3 to negative health effects, due to not receiving their medications, as prescribed by the physician. 2) Subject Resident 1 to untreated feelings of anxiety, and withdrawl side effects from anti-anxiety medication Xanax. Findings: On December 6th, 2023, an unannounced visit was made to the facility for the investigation of a quality-of-care issue. 1) A review of Resident 1 ' s facility admission records, indicated, Resident 1 was admitted to the facility on [DATE], with a diagnosis of Generalized Anxiety Disorder (A mental health condition in which an individual experiences signs and symptoms of anxiety, such as fear, worry, sweating and pounding…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an allegation of physical abuse within 2 hours to California Department of Public Health (CDPH) after the allegation was made, for one of five residents (Resident 1). This failure had the potential to result in further abuse for Resident 1, affecting the resident's physical, emotional, and psychosocial well-being. Findings: On October 18, 2023, at 12:00 p.m., an unannounced visit to the facility was conducted to investigate a complaint allegation of abuse. A review of Resident 1's record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses which included hemiplegia, affecting left limb dominant side (inability to move one side of the body). During a review of Resident 1's Minimum data Set (MDS- an assessment tool) dated October 26, 2023, the MDS indicated a BIMS (Brief Interview for Mental Status) score of 5 (moderately impaired cognition). A review of Resident 1's Change of Condition, dated October 13, 2023, at 5:58 p.m.,…

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

Based on interview and record review, for one (Resident 1) of four residents, the facility failed to ensure Resident 1's care plans were reviewed and updated to meet the resident needs, and is made readily accessible for the staff to implement a consistent approach in keeping the resident free from fall and accident. The facility failure had resulted for Resident 1 to experience a fall when intervention in place was not meeting the resident's need to keep herself supervised, safe, and free from accident on July 27, 2023, at 2:22 a.m. Furthermore, the facility had failed to make Resident 1's care plan readily accessible to staff to provide a consistent approach in keeping Resident 1 safe and free from accident/injury. Findings: On October 18, 2023, at 1:15 p.m., an unannounced facility visit was conducted to investigated quality of care issue for allegation staff takes their break at the same time, causing the residents to be unattended and at risk for fall and accident. On October 18, 2023, a concurrent interview and care plan review were conducted with Director of Nursing (DON) and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, for one (Resident 1) of four residents, the facility failed to ensure services that meet standards of care for resident supervision was met when Certified Nursing Assistant 1 (CNA) went on a break and had not properly endorsed Resident 1 was confused and disoriented. The facility failure had resulted for Resident 1 to fall on July 27, 2023, at 2:22 a.m. while CNA 1 was on her break. Findings: On October 3, 2023, at 9:30 a.m., an unannounced facility visit was conducted to investigated quality of care issue for allegation staff takes their break at the same time, causing the residents to be unattended. On October 3, 2023, Resident 1's record was reviewed. Resident 1's record indicated an entry made by Licensed Vocational Nurse 1 (LVN), on July 27, 2023, at 2:22 a.m., Resident's roommate (Resident 4) made staff aware that she (Resident 1) was on the floor. This writer checked on resident and found her laying on her left side on the floor next to the bottom of her bed. Upon…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, for one (Resident 1) of four residents, the facility failed to ensure Resident 1's psycho-active medications were reviewed to be kept at a minimum to prevent excessive doses and to minimize adverse consequences. The facility failure had the potential for Resident 1 to experience potential risks (i.e., sedation) associated with over medication and duplication. Findings: On October 18, 2023, at 1:15 p.m., an unannounced facility visit was conducted to investigated quality of care issue for allegation Resident 1 was overly tired and ' dopey and had experience a fall and injury on July 27, 2023, at 2:22 a.m. On October 18, 2023, Resident 1's record was reviewed. The record indicated medications that included: * Ativan Oral Tablet (Lorazepam-a controlled substance, a sedative that can be used to relieve anxiety) Give 1 tablet by mouth every 6 hours as needed for Anxiety, order dated June 27, 2023, to July 7, 2023; * Dilaudid Oral Tablet MG (Hydromorphone HCl-controlled substance, it can treat moderate to severe pain) Give 1 tablet by mouth every 4…

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

Based on interview and record review the facility failed to follow their policy and procedure for one of three sampled residents (Resident 2) when the facility failed to obtain the signatures for disposition of resident's belongings at discharge. This failure had the potential for Resident 2 to lose personal property. Findings: A review of Resident 2's admission record indicated the resident was admitted to the facility with diagnoses which included left femur (thigh bone) fracture, dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities, and Alzheimer's disease (a type of dementia that affects memory, thinking and behavior). The record further indicated the resident's daughter as Power of Attorney (PoA). A review of Resident 2's Resident Inventory of Personal Effects indicated the resident's personal effects were inventoried on admission. The form further indicated a signature of the resident at admission. The form indicated a signature of the resident or responsible party at discharge. The form did not indicate a signature of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to follow physician orders for one of three sampled residents (Resident 1) when the facility did not record input for Resident 1. This failure had the potential to cause fluid imbalance for Resident 1. Findings: A review of Resident 1's admission record indicated the resident was admitted to the facility on [DATE], with diagnoses which included urinary tract infection, dysphagia (difficulty swallowing), moderate protein-calorie malnutrition, and gastrostomy (opening into the stomach). The record indicated Resident 1's sister, as the responsible party. A review of Resident 1's Brief Interview for Mental Status (BIMS) dated August 2, 2023, indicated a score of 5 (severe cognitive impairment). A review of Resident 1's Swallowing/Nutrition Status assessment dated [DATE], indicated the resident is receiving 51% or more of her nutrition via feeding tube. The assessment indicated the resident's average fluid intake was 501 cc/day or more. On September 11, 2023,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an allegation of physical abuse within 2 hours to California Department of Public Health (CDPH) after the allegation was made, for one of four residents (Resident 1). This failure had the potential to result in further abuse for Resident 1, affecting the resident's physical, emotional, and psychosocial well-being. Findings: On September 26, 2023, at 8:50 a.m., an unannounced visit to the facility was conducted to investigate an allegation of abuse. A review of Resident 1's record indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included Diabetes Mellitus (high blood sugar levels). During a review of Resident 1's Minimum data Set (MDS- an assessment tool) dated September 26, 2023, the MDS indicated a BIMS (Brief Interview for Mental Status) score of 9 (moderately impaired cognition). A review of Resident 1's Behavior Note, dated September 21, 2023, at 5:04 p.m., indicated, .RN notified that resident verbalized to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and interview, the facility failed to ensure the resident's room temperatures were maintained at a comfortable level (between 71-81 degrees) for 15 out of 32 rooms, when the rooms were found with temperatures above 81 degrees. This failure had the potential for the residents to feel uncomfortable and had the potential to increase the risk of dehydration and heat exhaustion in an already vulnerable population. Findings: On July 28, 2023, at 2:23 p.m., an unannounced visit was conducted at the facility for a complaint the facility temperature was 100 degrees inside. On July 28, 2023, Resident 2 was observed sitting in her wheelchair in her room, lights were observed off and a fan was on. During a concurrent interview, Resident 2 stated it was hot, too hot and had been for a couple of days. Resident 2 stated staff have been offering fluids and ice. On July 28, 2023, at 2:41 p.m., all 32 facility rooms were temped with the maintenance supervisor (MS). 15 out of the 32 rooms temperatures 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to follow their policy and procedure on personal belongings when: 1. Personal inventory forms were not completed for three of three sampled residents (Resident 1, Resident 2 & Resident 3); and 2. Resident's personal clothing items were not labeled. These failures resulted in the sample residents losing personal items and had the potential for the facility residents receiving laundry service to lose personal clothing. Findings: 1. A review of Resident 1's admission record indicated the resident was admitted to the facility on [DATE], with diagnoses which included Covid-19, muscle weakness, and cerebral infarction. The record indicated the resident was discharged to an assisted living on July 7, 2023. A review of Resident 1 ' s Resident Inventory of Personal Effects form did not indicate the inventory was signed by the resident nor the resident representative on July 7, 2023. The form indicated, I received on discharge the appropriate personal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 menus were followed when: 1. Six of six residents on a puree (smooth consistency foods) diet, received 1/3 cup of the meat but should have received 1/2 cup. 2. 11 of 11 residents on mechanical soft (a texture-modified diet that restricts foods that are difficult to chew or swallow) diet, received three ounces of meat and 1/3 cup of vegetable but should have received four ounces of meat and a 1/2 cup of vegetables. 3. Ten of ten residents on regular (not include any dietary restrictions) diet, received 1/3 cup of the vegetables but should have received 1/2 cup. 4. 24 of 24 residents with diabetes (chronic health condition that affects how your body turns food into energy) on CCHO (consistent carbohydrates for residents with diabetes) diet, received a dessert with sherbet instead of vanilla ice cream as specified on the approved recipe. These failures led to residents not getting enough food per the planned and approved menu which had the potential to lead to weight loss and further compromise the…

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

Based on observation, interview and record review, the facility failed to ensure that residents were able to receive and consume food brought by family and visitors. This failure limited residents from enjoying favorite foods and reduced resident food options and choices that could lead to weight loss for a medically compromised population of 53 residents. Findings: On November 1, 2021 at 10:03 a.m., during an interview, the RD stated the facility did not allow outside food to be brought into the facility due to COVID-19 ( illness caused by a virus). She stated she was not aware of the federal regulation regarding food brought from home, and that she would coordinate with the Food and Nutrition Supervisor (FNS) to see how they could best meet the needs of the residents according to the regulation. On November 1, 2021 at 4:16 p.m., an interview was conducted with the Food and Nutrition Supervisor (FNS). The FNS stated the facility had not allowed food to be brought by visitors since March of 2020, because of COVID-19. On November 2, 2021 at 3:33 p.m., a concurrent observation and…

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

Based on observation, interview, and record review, the facility failed to implement infection prevention and control program to prevent transmission of communicable disease and infection, when: 1. One licensed nurse was observed entering the PUI (person under investigation due to unknown COVID-19 [Corona Virus Disease 2019- an infectious disease caused by the SARS-CoV-2 virus, that can be transmitted from person to person]) room without appropriate personal protective equipment (PPE-gown, mask, shield/goggles, gloves and N95 mask, used in combination or alone). ; 2. The Treatment Nurse (TN) was observed donning and doffing gloves multiple times without performing hand hygiene in-between, while performing wound care to Resident 32's wound on the right heel. ; 3. One Certified Nursing Assistant (CNA) did not perform hand hygiene before touching the medical device (nasal cannula) attached to the resident. In addition, the staff resumed assisting resident (Resident 154) with his meal, after touching the nasal cannula without conducting hand hygiene. These failures had the potential to…

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