Villa Del Rio

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure privacy curtains were installed and privacy was maintained for one out of six sampled residents (Resident 14) when Resident 14's colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall to allow waste to leave the body) bag, which was filled with stool (bodily waste), was assessed by the licensed nursing staff.This deficient practice had the potential to result in Resident 14 experiencing a diminished sense of dignity and self-worth.Findings:During a review of Resident 14's admission Record, the admission Record indicated Resident 14 was initially admitted to the facility on [DATE] and readmitted [DATE]. Resident 14's diagnoses included Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), aphasia (a disorder that makes it difficult to speak) following cerebral infarction (stroke, loss of blood flow to a part of the brain), and colostomy status…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 determine the responsible party (RP- an individual appointed to make decisions for an individual without decision-making capabilities) for one of two sampled residents' (Resident 9).This deficient practice resulted in Resident 9 not having an RP who could make medical decisions for her.Findings:During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 9's diagnoses included metabolic encephalopathy (a broad term for brain dysfunction caused by chemical imbalances, systemic illnesses, or organ failure), schizophrenia (a mental illness that is characterized by disturbances in thought) and heart failure (when the heart does not pump blood to the body as well). The Face Sheet listed two family members as Resident 9's emergency contacts. During a review of Resident 9's Minimum Data Set (MDS, a resident assessment tool), dated 5/29/2026, 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 notify two of two sampled residents' (Residents 135 and 9) physician and responsible party (RP- appointed individual to make medical decisions) of changes in condition by failing to: 1. Ensure Resident 9 had hypotensive (blood pressure below 90 over 60 [90/60] millimeters of mercury [mmHg, a unit of measuring blood pressure]) blood pressure readings taken on 7/5/2026 and 7/14/2026.2. Notify the physician when Resident 135 had bleeding scabs on his forehead on 7/10/2025. This deficient practice had the potential to result in Resident 9 experiencing adverse side effects of hypotension, including dizziness, nausea, and fainting. This deficient practice had the potential to result in Resident 135's wound to go unmonitored, worsen and become infected. Findings: 1. During a review of Resident 9's admission Record (Face Sheet, front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to verify the Notice of Medicare Non-Coverage Coverage (NOMNC, a form that notifies Medicare residents that their covered services are going to end) and Advance Beneficiary Notice (ABN, a notice notifying that Medicare may deny payment for specific treatments, and provides residents the opportunity to accept or refuse services if Medicare denies payment) forms were signed by someone with decision making capabilities when the Medicare Part A (insurance that primarily covers inpatient skilled nursing facility stays) coverage ended for two of three sampled residents (Resident 24 and Resident 157).This deficient practice resulted in Residents 24 and 157 being unable to make an informed decision about their care.Findings:a. During a review of Resident 24's admission Record, the admission Record indicated Resident 24 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 24's diagnoses included anemia (a condition where the body does not have…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the quarterly Minimum Data Set (MDS, a resident assessment tool) assessments were completed and submitted within the required federal timeframe for four of 24 sampled residents (Residents 44, 46, 47, and 75).The deficient practice had the potential to affect the accuracy and timeliness of resident assessments, care planning decisions, and the facility's compliance with federal Medicare and Medicaid requirements.Findings: During a review of Resident 44's admission Record, the admission Record indicated Resident 7 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 44's diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought), dementia (a progressive state of decline in mental abilities), chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 fall care plan was revised after a fall for one out of two sampled residents (Resident 135).This deficient practice placed Resident 135 at risk for bodily injury from another fall. Findings:During a review of Resident 135's admission Record, the admission Record indicated Resident 135 was initially admitted to the facility on [DATE] and readmitted [DATE]. Resident 135's diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), epilepsy (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) muscle weakness, muscle wasting (weakening, shrinking, and loss of muscle), and lack of coordination. During a review of Resident 135's Minimum Data Set (MDS, a resident assessment tool), dated 5/4/2026, the MDS indicated Resident 1's cognition (ability to think and process) was moderately impaired. During a review 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 conduct the assessments for one of three sampled residents (Resident 38) in accordance with the physician's orders on 6/13/2026.This deficient practice had the potential to result in Resident 38 experiencing undetected adverse reactions of medications, changes of conditions, and abnormal vital signs requiring intervention.Findings:During a review of Resident 38's admission Record, the admission Record indicated Resident 38 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 38's diagnoses included hypertension (high blood pressure), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (a mental health condition characterized by excessive, persistent fear or worry), schizophrenia (a mental illness that is characterized by disturbances in thought), and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review 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 observation, interview, and record review, the facility failed to ensure three of four sampled residents (Residents 135, 12, and 9) were free of accidents and hazards by failing to:1. Ensure adequate supervision and visual checks were rendered and documented for Resident 135.2. Ensure orthostatic blood pressure (a measurement of the change in blood pressure between lying down and sitting up) orders were followed for Resident 12 for May 2026, June 2026, and July 2026. 3. Ensure Resident 9's orthostatic blood pressure was monitored on 6/13/2026.These deficient practices resulted in Resident 135 falling and sustaining a bruise under his left eye and scattered scabs across his forehead with the potential for Resident 135 to sustain more falls and had the potential to result in Residents 12 and 9 experiencing adverse effects of hypotension (low blood pressure), including dizziness, lightheadedness, fatigue, nausea, blurred vision, and fainting. Cross reference F657Findings: 1. During a review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to inform the responsible party for one of seven sampled residents (Resident 30) when Resident 30's initial podiatry appointment (a specialized medical visit to diagnose and treat conditions affecting the feet, ankles) was canceled due to lack of transportation.This deficient practice had the potential to place Resident 30 at risk for delayed diagnosis, treatment and delivery of care. Findings:During a review of Resident 30's admission Record, the admission Record indicated Resident 30 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 30's diagnoses included chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in beathing), Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia (a progressive state of decline in mental abilities).During a review of Resident 30's History and Physical (H&P), dated 9/29/2025, the H&P…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to follow the physician-ordered medication parameters for two of two residents (Resident 12 and 9) by failing to: 1. Ensure Lisinopril and metoprolol were not administered outside of the physician-ordered heart rate parameter for Resident 12.2. Ensure Lantus and losartan were not administered outside of the physician-ordered parameters for insulin and blood pressure for Resident 9These deficient practice had the potential to result in adverse outcomes, including hypotension, bradycardia, and hypoglycemia.Findings: 1). During a review of Resident 12's admission Record, the admission Record indicated Resident 12 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 12's diagnoses included atrial fibrillation (an irregular and often very rapid heart rhythm), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), dysphagia (difficulty swallowing) and schizoaffective…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical records were accurate for three of twelve sampled residents (Resident 3, 34, and 135) by failing to: Ensure Licensed vocational nursing staff documented an assessment, monitoring, and treatment for Resident 135's bleeding scab on his forehead.Ensure Resident 34's admission Sheet (Face Sheet, front page of the chart that contains a summary of basic information about the resident) was kept accurate and indicated Resident 34 was self-responsible (able to make his or her own independent medical and lifestyle decisions).Ensure Resident 3 was assigned to the correct room in the electronic health record and physical chart. These deficiencies had the potential to result in unmonitored and unassessed injuries for Resident 135, inaccurate informed consent for Resident 34, and possible medical errors related to misidentification for Resident 3. Cross Reference F552 and F580. Findings: 1. During a review of Resident 135's admission…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that the Arbitration Agreement (is a contract where parties agree to resolve disputes out of a court room) document was executed through an appropriate and informed decision-making process by obtaining the signature of a resident with impaired cognitive status without involving or consulting the resident's daughter, who was identified by the facility as the emergency point of contact, for one of three residents sample residents (Resident 32).This deficient practice had the potential to result in the resident signing a legally significant document without fully understanding its contents, purpose, or implications, thereby compromising the resident's ability to make an informed decision and placing the resident's rights and interests at risk. Findings:During a review of Resident 32's admission Record, the admission Record indicated Resident 32 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 32's diagnoses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Infection Prevention and Control measures for one of three sampled residents (Resident 7) by failing to identify, clean, and disinfect urine contamination in Resident 7's room.This deficient practice had the potential to create unsanitary living conditions, attract pests, increase the risk of infection, produce offensive odors, and negatively affect the resident's comfort, dignity, and quality of life. Findings: Findings: During a review of Resident 7's admission Record, the admission Record indicated Resident 7 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 7's diagnoses included end stage renal disease (ESRD, irreversible kidney failure) schizophrenia (a mental illness that is characterized by disturbances in thought), overactive bladder (causes a sudden, uncontrollable urge to urinate), dementia (a progressive state of decline in mental abilities), and nodular prostate (enlarged…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one out of three sampled residents' (Resident 1) belongings were listed in the residents belonging inventory (a process which of all the resident's items were listed) on readmission.This failure had the potential for the resident's belongings to be lost or stolen and the potential to violate the resident's right to a safe environment . Findings:During a review of Resident 1s admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included polyosteoarthritis (breakdown of joint cartilage [tough, flexible tissue throughout the body]) and unspecified (unknown) psychosis (a mental state where a person loses touch with reality) not due to a substance or known physiological condition.During a review of Resident 1's History and Physical (H&P), the H&P indicated Resident 1 was able to understand and make decisions.During a review of 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: 1). Follow its policy and procedure (P&P) titled, Bed Hold (reserving resident's bed for 7 days while temporarily away from the facility, such as during hospitalization or therapeutic visits) Notice, which indicated to provide written information to the resident and/or the resident representative (RP) regarding bed hold practices both well in advance, and at the time of transfer, hospitalization or therapeutic leave.2). Offer the facility's first available bed to one of three sampled residents (Resident 1), who was hospitalized and ready to return to the facility after the seven (7)-day bed hold period. These failures resulted in violating the resident's right to be permitted to return in the facility's first available bed on 6/17/2026. Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included…

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

Based on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Facility Assessment, which indicated, the facility assessment should be reviewed and updated as necessary whenever there is any change that would require a substantial modification to any part of the assessment, when the facility did not have a contracted Respiratory Therapy ([RT], a specialized healthcare where practitioners are trained in pulmonary [relating to the lungs] medicine to work with people suffering from pulmonary disease) in the building. This failure had the potential for the facility not to provide adequate care and services to residents requiring RT services.Findings: During a review of facility's Facility Assessment (a facility-wide assessment used to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies), dated 1/27/2026, the Facility Assessment indicated Respiratory Therapy ([RT], a specialized healthcare field where practitioners are trained in pulmonary (relating to the lungs)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow its policy and procedure (P&P) for discharge against medical advice (AMA) for one of one sampled resident (Resident 1) when Resident 1 left the faciity on 5/22/2026. This deficient practice had the potential to place Resident 1 at risk for unmet care needs, continuum of care, and adverse health outcomes. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought), anxiety (a feeling of fear and dread), and epilepsy (a neurological \disorder characterized by recurrent, unprovoked seizure). During a review of Resident 1's record titled Social Services History and Initial Assessment, dated 5/19/2026, the record indicated Resident 1 had the ability to understand and be understood by others. The record indicated Resident 1's cognition (the ability to think…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Licensed Vocational Nurse (LVN) 1 accurately and timely documented a resident's aggressive behavior for one of three sampled Residents (Resident 1). This deficient practice had the potential to result in incomplete communication among staff regarding Resident 1's behavior status, delayed assessment, and the provision of care and/or interventions for the resident.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought), anxiety (a feeling of fear and dread), and epilepsy (a neurological disorder characterized by recurrent, unprovoked seizure). During a review of Resident 1's record titled Social Services History and Initial Assessment, dated 5/19/2026, the record indicated Resident 1 had the ability to understand and be understood by others. 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 two of three sampled residents (Residents 2 and 3) received treatment and care in accordance with professional standards of practice by failing to:Ensure Licensed Nurses administered treatment for Resident 2's Candidiasis (common fungal skin infection characterized by a bright red, itchy rash) as ordered by the physician.Ensure the physician was notified and treatment orders were obtained when Resident 3 reported an itchy rash to the groin area on 1/31/2026.These failures placed Residents 2 and 3 at risk for discomfort, worsening skin conditions and hospitalization.Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 2's diagnoses included Chronic Obstructive Pulmonary Disease, unspecified ([COPD] a chronic lung disease causing difficulty in breathing).During a review of Resident 2'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 plan of care was re-evaluated and revised for one of three sampled residents (Resident 1) who had on-going rash with complaints of itchiness. These failures had the potential to result in Resident 1 not receiving the necessary care and placed Resident 1 at risk for discomfort, physical decline and worsening skin condition.Findings:During a concurrent observation and interview on 2/26/2026 at 12:50 p.m., with Resident 1, Resident 1 was observed with generalized rash on the resident's back. Resident 1 stated he has had the rash for about one year, with complaints of itchiness especially at night. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 1's diagnoses included atrial fibrillation (an irregular, rapid heart rhythm originating in the atria [the heart's upper chamber])…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure, one of three residents (Resident 2), was provided with an appropriate call light (an equipment used when calling for staff when assistance is needed) to use. This deficient practice resulted in the resident's feeling of being ignored and neglected, and the potential for the resident not being able to call for help when assistance is needed, and needs will not be met.Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included muscle weakness and hypertension (high blood pressure). During a review of Resident 2's Care Plan titled, Needs assistance with Activities of Daily Living (ADL) and mobility, dated 3/7/2025, one of the interventions indicated to have call light within reach and answer promptly. During a review of Resident 2's History and Physical (H&P) dated 5/23/2025, the H&P…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the physician and obtain an order to implement, when one of three sampled residents (Resident 1), was readmitted to the facility with a rash on bilateral (both) lower extremities (BLE, arms or legs). This deficient practice resulted in delayed treatment and could have led to worsening of rash. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included muscle wasting and atrophy (loss of muscle tissue, causing muscles to shrink and weaken), and lack of coordination. During a review of Resident 1's History and Physical (H&P) dated 10/9/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 10/16/2025, the MDS indicated Resident 1 was able to understand and be understood by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement infection control measures, for one of three residents (Resident 2) by failing to:1). Perform hand hygiene before putting on gloves (a personal protective equipment used when providing resident care).2). Remove used contaminated gloves prior to placing a clean diaper and clean linen and before touching Resident 2. These deficient practices had the potential to result in cross-contamination (process by which bacteria or other microorganisms are unintentionally transferred from one object or person to another, with harmful effect), severe infection and hospitalization. Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included muscle weakness and hypertension (high blood pressure). During a review of Resident 2's History and Physical (H&P) dated 5/23/2025, the H&P indicated Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure two of three sampled residents (Resident 1 and 2) rooms were equipped with functional ceiling suspended curtains.This deficient practice violated Resident 1 and Resident 2's rights to full visual privacy.During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 1's diagnoses included anxiety disorder (mental health condition characterized by excessive worry, fear and nervousness that can interfere with daily life), paranoid schizophrenia (a mental illness that is characterized by disturbances in thought), muscle wasting and atrophy (loss of muscle tissue, causing muscles to shrink and weaken), and lack of coordination.During a review of Resident 1's History and Physical (H&P) dated 10/9/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.During a review 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 observation, interview and record review, the facility failed to meet professional standards in preparing and administering medications to three of the five sampled residents' (Residents 1, 2, and 3). This deficient practice had the potential to violate residents' rights and placing the affected residents at risk for drug interactions.Findings: a). During an observation on 10/28/2025 at 9:32 a.m., in Resident 1's room, Licensed Vocational Nurse (LVN) 2 was observed preparing Resident 1'smedications, placed all the medications in a medication cup and told Resident 1, here are your medications. Resident 1 was heard asking LVN 2 the name of the medications before she took it. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing,) hypertension (HTN-high blood pressure) and encephalopathy (a disease…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, two of seven sampled residents, (Residents 6 and 7), were provided with a safe, clean and home-like environment.This deficient practice had the potential to result in violation of residents' rights.Findings:a). During a concurrent observation and interview on 10/29/2025 at 9:41 a.m. with Resident 6 in Resident 6's room, the bathroom wall had black and red spots, and bathroom door panel was damaged. Resident 6 stated 2 weeks ago, the Maintenance Supervisor (MS) had been notified about the broken bathroom door, and nothing was done about it. Resident 6 stated it was dangerous for his safety because when Resident 6 goes to the bathroom on his wheelchair, the door panel would come out and touch his leg. Resident 6 stated he got hurt (unspecified) 3 weeks ago because one of the paneling touched his foot and hurt Resident 6. Resident 6 stated the maintenance should fix it (the broken bathroom door) because he does not want to get hurt…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one of six sampled residents' (Resident 5) antipsychotic medication (medication that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior), which was given on an as needed basis (PRN), did not exceed 14 days.This deficient practice resulted in the lack of evaluation of Resident 5's medication.Findings:During a review of Resident 5's admission Record (Face Sheet), the admission Record indicated Resident 5 was admitted to the facility on [DATE] with diagnoses that included paranoid schizophrenia (a mental illness that is characterized by disturbances in thought) and anxiety disorder (overwhelming and uncontrollable fear and worry). During a review of Resident 5's Minimum Data Set (MDS- a resident assessment tool), dated 6/4/2025, the MDS indicated Resident 5's cognition (process of thinking) was moderately impaired. The MDS indicated Resident 5 required setup or clean-up assistance with eating, oral…

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

Based on interview and record review, the facility failed to complete and retain documentation of Background Reports for five of six sampled staff members (Registered Nurse [RN] 2, Licensed Vocational Nurse [LVN] 2, LVN 4, Treatment Nurse [TN] 1, and Certified Nursing Assistant [CNA] 2) in a timely manner.This deficient practice had the potential for RN 2, LVN 2, LVN 4, TN 1, and CNA 2's's undetected history of abuse, neglect, exploitation, or misappropriation of resident property, if any, and to allow access to the residents in the facility.Findings:1. During a concurrent interview and record review, on 8/26/2025 at 10:23 a.m., with Director of Staff Development (DSD) 1, Certified Nursing Assistant (CNA) 2's Employee File was reviewed. The Employee File did not contain documentation of CNA 2's Background Report. DSD 1 stated CNA 2's date of hire was 6/1/2018 and a background check should have been completed upon hire. DSD 1 stated the facility was bought into new ownership sometime in 2018 and many of the staff's documentation prior to the change-in-ownership was misplaced. 2.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement their policy and procedure titled Enteral Feedings-Safety Precautions to ensure one of four sampled residents, Resident 2 was in an upright 30-degree position during gastrostomy tube (G-tube- is a tube inserted through the belly that brings nutrition directly to the stomach) feeding. This failure had the potential to result in aspiration (occurs when food or liquid is breathed into the airways or lungs, instead of being swallowed), difficulty breathing, infections and impede progress to wellness.Findings: During a concurrent interview and observation on 08/20/2025 at 11:00 a.m. with the assigned Licensed Vocational Nurse (LVN 1), Resident 2 was observed lying in bed with the head of bed (HOB) at a 20-degree angle, while receiving gastrostomy tube (G-tube- is a tube inserted through the belly that brings nutrition directly to the stomach) feeding of Glucerna 1.2 calorie infusing at 60 cc (cubic centimeters) an hour. LVN 1 stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 2 and LVN 5 explained the medications being administered to two of three sampled residents (Resident 9 and 10).This deficient practice had the potential to result in Resident 9 and 10 not knowing what medications were administered to them.Findings:a. During a review of Resident 9's admission Record (Face Sheet), the admission Record indicated Resident 9 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements).During a review of Resident 9's Minimum Data Set (MDS- a resident assessment tool), dated 5/11/2025, the MDS indicated…

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

Based on observation, interview, and record review, the facility failed to implement infection control practices by not ensuring the shower room and toilet was clean after use. These deficient practices resulted in an unsanitary environment that increased the risks of infection among residents and staff. Findings: a. During a concurrent observation and interview on 6/24/2025 at 12:10 a.m. with the Maintenance Supervisor (MS), in Building A Shower Room B3, observed that the shower floor was wet. The MS stated the shower floor should not be wet and the staff should notify housekeeping to clean the shower room after use. During an interview on 6/24/2025 at 12:21 p.m. with Maintenance Staff 1, Maintenance Staff 1 stated the wet floor placed residents at risk for cross-contamination (the transfer of harmful substances, like bacteria, from one item or surface to another). During an interview on 6/24/2025 at 12:30 p.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated the nurses who used the shower room for resident showers should clean up the floor by picking up the dirty linen 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 observation, interview, and record review, the facility failed to provide a safe, sanitary, and comfortable environment for residents when the following occurred: 1. Six out of the eight Geri chairs (specialized chair designed to provide comfortable and supportive seating for individuals with limited mobility) were broken and/or ripped in Building A. 2. Two out of the eight shower chairs were broken and/or ripped in Building A. These deficient practices resulted in an unsafe and uncomfortable environment that increased the risk of injury among residents and staff. Findings: 1. During a concurrent observation and interview on 6/24/2025 at 11:57 a.m. with the Maintenance Supervisor (MS), in Building A Shower Room B1, a Geri chair was observed without a cushion on the backrest. The MS stated the Geri chair should have a cushion on the backrest for the residents' comfort. During a concurrent observation and interview on 6/24/2025 at 12:05 a.m. with the MS, in Building A Shower Room B4, observed two Geri chairs with broken footrests, handrests, and backrests. One Geri chair'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 implement the care plan for one of three sampled residents (Resident 3) by failing to monitor the effectiveness of treatment for the resident's rash. This failure had the potential for Resident 3's rash to worsen and lead to the resident's physical and psychosocial needs not being met. Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. The admission Record indicated Resident 3's diagnoses included Metabolic Encephalopathy (a brain disorder caused by problems in the body's chemistry, leading to changes in brain function) and Type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 3's Minimum Data Set (MDS- a resident assessment tool) dated 4/12/2025, the MDS indicated Resident 3 was cognitively intact (having the ability 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 interview and record review the facility failed to ensure pain management was effective for one of three sampled residents (Resident 3) by failing to: 1. Reassess Resident 3's pain after administering Hydrocodone-Acetaminophen (Norco- a medication used to relieve pain), in a timely manner on 5/26/2025. 2. Reassess Resident 3's pain after administering Norco on 5/27/2025. These failures had the potential to result in unresolved pain for Resident 3 and could negatively affect the resident's physical and psychosocial well-being. Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. The admission Record indicated Resident 3's diagnoses included Metabolic Encephalopathy (a brain disorder caused by problems in the body's chemistry, leading to changes in brain function) and Type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Licensed Vocational Nurse (LVN 5) documented the administration of Hydrocodone-Acetaminophen (Norco-a medication used to relieve pain) for one out of three sampled residents (Resident 3). This failure placed Resident 3 at risk for medication errors, drug overdose and could lead to adverse drug events for the resident. Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. The admission Record indicated Resident 3's diagnoses included Metabolic Encephalopathy (a brain disorder caused by problems in the body's chemistry, leading to changes in brain function) and Type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 3's Minimum Data Set (MDS- a resident assessment tool) dated 4/12/2025, the MDS 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 provide a refrigerator to store residents' food brought from visitors. This deficient practice resulted in staff disposing of residents' leftover food brought from visitors that could have been stored in a refrigerator. Findings: During an interview on 4/22/2025 at 8:54 a.m., with the Dietary Supervisor (DS), the DS stated there are no separate refrigerators available for residents' foods brought in from visitors. The DS stated leftover food brought in from visitors would be stored in the discretion of the nursing department. During an interview on 4/22/2025 at 9:05 a.m., with the Infection Preventionist (IP), the IP stated residents were allowed to receive food brought in from visitors or if they have the food delivered to the facility. The IP stated the leftover food that was shelf steady (food products that can be stored at room temperature for a prolonged period without spoiling or requiring refrigeration) would be stored at the resident's bedside, however, foods that required refrigeration to prevent spoiling would be…

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

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 implemented and/or maintained for 13 of 158 residents (Residents 58, 8, 87, 17, 84, 48, 114, 28, 22, 215, 90, 82, and 2) when the following occurred: 1. Enhanced barrier precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs, bacteria that are resistant to three or more classes of antimicrobial drugs]) were not implemented for 12 residents (Residents 58, 8, 87, 17, 84, 48, 114, 28, 22, 215, 90, and 82) who met the requirements for EBP. 2. Facility failed to maintain and implement a water management system (the facility's plan and activities for reducing risk of Legionella [a bacteria that can cause illness in the lungs and flu-like illness] and other opportunistic pathogens). 3. Resident 2 ate food from another resident's tray. 4. The Treatment Nurse (TN) did not perform hand hygiene (a way of cleaning one's hands that substantially…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) prior to administration of psychotropic medication (medications that affect the mind, emotions, and behavior) for five of seven sampled residents (Residents 41, 122, 114, 45, and 109) by failing to: 1. Obtain informed consent from Resident 41, who did not have the capacity to understand and make decisions, for the use of aripiprazole (an antipsychotic medication [a medication that affects the mind, emotions, and behavior]), Depakote (an anticonvulsant medication, a medication used to prevent or treat seizures and can be used to treat behavioral disorders), and Lexapro (an antidepressant [a medication used to treat depression, which is a mood disorder that causes a persistent feeling of sadness and loss of interest]). This deficient practice resulted in Resident 41, who was unable 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, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool) assessments for 5 of 32 sampled residents (Residents 82, 159, 39, 74, and 59) were completed and documented accurately. This deficient practice resulted in the transmission of inaccurate data to the Centers for Medicare and Medicaid Services (CMS) regarding the above residents' health status and unique healthcare needs. This deficient practice also created the potential for the above residents to not receive the care and interventions needed to reach their highest practicable physical and psychosocial well-being. Findings: 1. During a review of Resident 82's admission Record, the admission Record indicated the facility admitted Resident 82 on 1/18/2023, and most recently re-admitted Resident 82 on 4/4/2025. Resident 82's admitting diagnoses included end stage renal disease (irreversible kidney failure) and dependence on renal dialysis (a treatment to cleanse the blood of wastes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident-centered care plans were developed and implemented for seven of 32 sampled residents (Residents 70, 41, 122, 59, 101, and 114). This deficient practice placed Residents 70, 41, 122, 74, 59, and 101 at risk of not receiving care and resident-centered interventions to meet and address their needs. Findings: 1. During a review of Resident 70's admission Record, the admission Record indicated Resident 70 was originally admitted on [DATE] and was most recently readmitted on [DATE]. Resident 70's admitting diagnoses included paranoid schizophrenia (a type of schizophrenia characterized by the presence of delusions and hallucinations, particularly persecutory delusions [believing others are trying to harm or plot against them]), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review and revise the care plan for three of 18 sampled residents (Residents 134, 114, and 104), by failing to: 1. Revise Resident 134's care plan (a document that helps nurses and other team care members organize aspects of resident care) and interventions (actions a nurse takes to implement a care plan, intend to improve the resident's comfort and health) after Resident 134 had an unwitnessed fall on 12/18/2024. This deficient practice had the potential to result in Resident 134 sustaining a major injury after another fall. 2. Ensure the Interdisciplinary Team (IDT) meeting was held quarterly and after Resident 114 was sent to the GACH (General Acute Hospital (GACH)) due to bleeding gums. This deficient practice resulted in a year-long delay in the revision, re-evaluation and implementation of Resident 114's care plans without the input from members of the IDT and Resident 114's responsible party or public guardian. 3. Revise Resident 104's care plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. During a review of Resident 28's admission Record (Face Sheet), the Face Sheet indicated Resident 28 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included encephalopathy (a disorder or disease of the brain, often affecting its ability to function properly), multiple sclerosis (a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), and a Stage four pressure ulcer (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) on the right buttock. During a review of Resident 28's History and Physical (H&P), dated 3/11/2024, the H&P indicated Resident 28 could make needs known but could not make medical decisions. During a review of Resident 28's MDS, dated [DATE], the MDS indicated Resident 28's cognition was moderately impaired. The MDS indicated Resident 28 had functional limitation impairment on both sides of the upper and lower extremities. The MDS indicated Resident 28 was dependent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safety was maintained for three of five sampled residents (Resident 82, Resident 134, and Resident 2) by failing to: 1. Ensure Resident 82's call light was maintained within reach, and ensured Resident 82 was wearing non-slip footwear, as indicated in his fall risk care plan. 2. Ensure an Interdisciplinary Team ([IDT], a coordinated group of experts from several different fields) meeting was conducted after Resident 134 had an unwitnessed fall on 12/18/2024. 3. Ensure Resident 2, who had dysphagia (difficulty swallowing) did not eat from another resident's tray. These deficient practices placed Residents 82 and 134 at risk for falls and subsequent injuries. These deficient practices also placed Resident 2 at risk for choking and/or aspiration (the act of accidentally inhaling food, liquid, or other material into the airway and lungs) from consuming foods that were not a part of her mechanical-soft (chopped, ground or pureed foods…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Rehabilitation Department failed to perform formal physical therapy (PT) and occupational therapy (OT) evaluations (PT evaluations to assess a person's movement, strength, and range of motion. OT evaluation focuses on how those physical and cognitive skills impact daily activities) as ordered by the physician to prevent decline and maintain the functional status and, or functional levels for two of six sampled residents (Resident 114 and Resident 28). These failures resulted in a year-long delay of the initiation of treatment and services to prevent decline and maintain the functional status and levels of Resident 114 and Resident 28. These failures had the potential to increase the risk of the development or worsening of contractures (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff), which could have led to further functional decline for Resident 114 and Resident 28. Cross…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Complete and timely submit the referral for probate conservatorship application (referral to the court to appoint a conservator [an appointed person to act or make decisions for a person who cannot make decisions for themselves]) for two of 13 sampled residents (Residents 114 and 41), whom did not have the capacity to make decisions. This deficient practice resulted in a delay in the process of obtaining a conservator, a lack of sound oversite of Resident 114 and 41's medical care and treatments, and improper notification of changes. 2. Ensure the Minimum Data Set (MDS, a resident assessment tool) reflected Resident 159's and Resident 39's preference to use an interpreter, and Resident 39's preferred language of Cantonese. 3. Provide Resident 58 with a communication board (a visual aid, typically a laminated sheet or panel, that uses symbols, pictures, or illustrations to help people communicate their needs, wants, and thoughts).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 promote respect and dignity by failing to ensure dentures were provided for one of six sampled residents (Resident 40). This deficient practice negatively impacted Resident 40's quality of life and resulted in feelings of embarrassment due to her appearance and inability to chew her food. Findings: During a review of Resident 40's admission Record, the admission record indicated Resident 40 was initially admitted on [DATE] and readmitted on [DATE] with the following diagnoses which included diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), epilepsy (a brain condition that causes recurring seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and schizoaffective disorder (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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. During a concurrent observation and interview on 4/21/2025 at 12:22 p.m., with Resident 2, observed Resident 2 sitting in her wheelchair next to her bed. Resident 2's call light device was observed hanging on the wall behind the head of the bed and out of reach of the resident. Resident 2 asked for something to eat. Resident 2 was asked if she was able to reach her call light. Resident 2 stated that she could not reach her call light and asked if the nurse could be called. During a review of Resident 2's admission Record, dated 4/24/2025, the admission record indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses which included diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), congestive heart failure (CHF- a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), osteoarthritis (a progressive disorder of the joints, caused by 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of six sampled residents' (Resident 154) Advance Directive (a legal document indicating resident preference on end-of-life treatment decisions) Acknowledgement form (form that indicates whether an individual has an Advance Directive or if an Advance Directive would like to be formulated) was accurately completed. This deficient practice resulted in an inaccurate and incomplete Advance Directive Acknowledgement and had the potential to result in confusion whether Resident 154 had an Advance Directive and if not, if Resident 154 wanted to formulate one. This deficient practice placed Resident 154 at risk of not receiving necessary care based on Resident 154's wishes. Findings: During a review of Resident 154's admission Record (Face Sheet), the Face Sheet indicated Resident 154 was admitted to the facility on [DATE] with diagnosis of schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review 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 a resident's public guardian (PG- an appointed individual that is responsible for the care of individuals who are no longer able to make decisions or care for themselves) or responsible party (RP), and physician were notified when two of nine sampled residents exhibited a change of condition (Residents 114, and 104) by failing to: 1. Ensure Resident 114's PG or RP were notified when the resident exhibited a change of condition and was transported to the General Acute Care Hospital (GACH). This deficient practice resulted in the delay of proper verification of Resident 114's appointed RP or PG, which led to a lack of RP or PG notification when Resident 114 exhibited a change of condition and was sent to the GACH 2. Ensure Resident 104's physician was notified when Resident 104 was non-compliant with wearing the [NAME] cardiac monitor (a device that continuous monitors heart rate) and when the resident's heart rate was outside parameters, as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care and services to maintain good grooming and personal hygiene for one of six sampled residents (Resident 125) by failing to keep the resident's fingernails clean and neat. This failure had the potential to result in a negative impact on Resident 125's quality of life and self-esteem and had the potential to result in the development of an infection. Findings: During a concurrent observation and interview on 4/21/2025 at 10:41 a.m., with Resident 125, while in Resident 125's room, Resident 125's fingernails were long with a black substance underneath his fingernails. Resident 125 stated his fingernails looked long and that he would like to have his fingernails cut and cleaned. During a review of Resident 125's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 125 was originally admitted to the facility on [DATE] and readmitted on [DATE] with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure proper hand-off / shift report (a process where nurses exchange vital patient information between shifts to ensure continuity of care and patient safety) was provided between nursing staff for one of six sampled residents (Resident 8). This deficient practice resulted in Resident 8 being exposed while in bed and left covered in feces. Findings: During an observation on 4/21/2025 at 12:50 p.m., in Resident 8's room, Resident 8 was observed lying in bed undressed and completely exposed from the hallway. Resident 8 was observed with feces covering her left shoulder, right hand and upper thigh. Resident 8's sheets were soiled with feces and the feces were also observed on the floor next to the resident's bed. Resident 8 was observed flailing her hands and yelling out loudly in Spanish. During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was initially admitted to the facility on [DATE] 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 post-dialysis monitoring was conducted after one of one sampled resident (Resident 82) returned from hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). This deficient practice had the potential to place Resident 82 at risk for unidentified complications following hemodialysis, such as bleeding from the hemodialysis access site and low blood pressure. Findings: During a review of Resident 82's admission Record, the admission Record indicated the facility admitted Resident 82 on 1/18/2023, and most recently re-admitted Resident 82 on 4/4/2025. Resident 82's admitting diagnoses included end stage renal disease (irreversible kidney failure) and dependence on hemodialysis. During a review of Resident 82's Minimum Data Set (MDS, a resident assessment tool), dated 3/27/2025, the MDS indicated Resident 82 had some difficulty making decisions in new situations only. The MDS indicated Resident 82 required supervision or touch assistance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care plan for dementia (a progressive state of decline in mental abilities) for two out of six sampled residents (Residents 41 and 101). This failure had the potential to result in inappropriate care and delivery of medical services provided to Resident 41 and Resident 101. Findings: 1. During a review of Resident 41's admission Record, the admission Record indicated Resident 41 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and mood disorder (conditions that primarily affect a person's emotional state, causing significant distress or impairment in their daily life). During a review of Resident 41's Minimum Data Set ([MDS], a resident assessment tool), dated 2/7/2025, the 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 provide behavior monitoring for two of five sample residents (Residents 134 and 41) who received psychotropic medications (medication that affect the brain and alters mood, thoughts, emotions, and behaviors) by failing to: 1. Monitor Resident 134's behavior of yelling and screaming at others for no reason. 2. Monitor Resident 41's behavior of screaming. These deficient practices had the potential to result in the inaccurate assessment of the effectiveness of Residents 134 and 41's medication regimen. Findings: 1. During a review of Resident 134's admission Record, the admission Record indicated Resident 134 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), schizophrenia (a mental illness that is characterized by disturbances in thought), and bipolar disorder (sometimes called manic-depressive disorder; mood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the parameters for administering Glucotrol ([Glipizide] - lowers sugar levels in the blood) for one of six sampled resident (Resident 60). This deficient practice had the potential to cause hypoglycemia (low blood sugar [BS]) levels for Resident 60. Findings: During a review of Resident 60's admission Record, the admission Record indicated Resident 60 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) and hypertension (HTN - high blood pressure). During a review of Resident 60's Minimum Data Set (MDS - a resident assessment tool) dated 2/26/2025, the MDS indicated Resident 60's cognitive skills (ability to think, remember, and reason) was moderately impaired. The MDS indicated Resident 60 required supervision (helper assists only prior to or following the activity) with eating 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, the facility failed to ensure one of five sampled residents (Resident 144) was offered a pneumococcal vaccine (an injection that protects against pneumococcal disease, which is caused by Streptococcus pneumoniae bacteria). This deficient practice had the potential to place Resident 144 at risk for contracting pneumococcal disease (e.g. pneumonia [an infection/inflammation in the lungs]) and suffering potential death. Findings: During a review of Resident 144's admission Record, the admission Record indicated Resident 144 was admitted on [DATE] and most recently readmitted on [DATE]. Resident 144's admitting diagnoses included chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing) and atrial fibrillation (an irregular and often rapid heart rhythm). During a review of Resident 144's Minimum Data Set (MDS, a resident assessment tool), dated 2/14/2025, the MDS indicated Resident 144 had moderately impaired cognition (difficulties…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Licensed Vocational Nurse (LVN) 1 was provided with abuse prevention, identification, and reporting training prior to providing direct care to facility residents. This deficient practice placed facility residents at risk of not having their allegations of suspected abuse being identified and/or reported by LVN 1, as required by the facility's policy and procedure. Findings: During an interview on 4/23/2025 at 1:42 p.m., with the Director of Staff Development (DSD), the DSD stated he could not locate any abuse training records for Licensed Vocational Nurse (LVN) 1. During an interview on 4/23/2025 at 2:18 p.m., with LVN 1, LVN 1 stated she was a registry nurse (a nurse, employed by a nursing agency rather than directly by the healthcare facility, who is typically deployed to fill temporary staffing needs). LVN 1 stated her first shift was in March 2025. LVN 1 stated her nursing agency did not provide abuse training, and stated she did not receive any abuse training from the facility prior to her first shift in March…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and implement a plan of care for a resident that was at risk of elopement (the act of leaving a facility unsupervised and without prior authorization) for one of two residents (Resident 1). This deficient practice had the potential to delay the delivery of necessary care and services to minizine the risk of elopement. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN- high blood pressure), and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 11/14/2025, the MDS indicated Resident 1 had serious…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 adequate supervision for one of two residents (Resident 1) who were at risk of elopement (the act of leaving a facility unsupervised and without prior authorization) when Resident 1 eloped from the facility on 1/15/2025. This deficient practice had the potential to negatively affect Resident 1's physical, mental, and psychosocial well-being. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN- high blood pressure), and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 11/14/2025, the MDS indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure water temperatures for 3 of 6 resident restrooms (Rooms 66, 92 and 93) and one shower room did not exceed above 120 degrees Fahrenheit (deg f). This deficiency had the potential to cause burns (to injure by exposure to heat) for facility residents sharing the restroom sinks and shower room. Findings: During a review of the facility ' s water temperature log, dated 12/2024 and 1/2025, the logs indicated the water temperature should be between 105 degrees F and 120 degrees F. The logs indicated the water temperature in all the resident rooms and in the halls were 109 degrees Fahrenheit (deg F). During a concurrent observation and interview on 1/11/2025 at 8:52 a.m. with Maintenance Worker (Maint 1), Maint 1 stated, the water temperature in the restroom of room [ROOM NUMBER] was 125 deg F. During a concurrent observation and interview on 1/11/2025 at 8:56 a.m. with Maint 1, Maint 1 stated, the water temperatures of rooms [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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided a safe, functional, and comfortable environment by failing to ensure: 1. Resident 1 had a working bathroom sink with hot water. 2. Resident 1 ' s bathroom sink did not leak water onto the floor. This deficient practice caused Resident 1 to feel uncomfortable and had the potential to cause slips, falls for the resident and negatively affect the resident ' s psychosocial well-being. Findings: During a review of Resident 1s admission Record, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 ' s diagnoses included joint (area where bones meet) replacement surgery, depression (mood disorder that causes feeling of sadness and loss of interest) and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety or fear that interfere with daily living). During a review of 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 interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) had a representative acting on her behalf by failing to: 1. Ensure Resident 1's Responsible Party (RP) 1's telephone number was indicated on Resident 1's Face Sheet. 2. Seek RP 1's telephone number after Resident 1 had a fall on 6/21/2024 and 8/7/2024. 3. Refer Resident 1 to the Public Guardian (an appointed person who manages the property, finances, and personal care of a person who was unable to properly care for themselves) when RP 1 was unable to be contacted. These deficient practices resulted in RP 1 being unaware of Resident 1's falls and unable to participate in any decision-making regarding Resident 1's care. This deficient practice also resulted in Resident 1 not having a care representative who was actively involved in her care. Cross reference F580. Findings: During a review of Resident 1's Face Sheet, the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] 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, the facility failed to contact a resident's Responsible Party (RP) 1 for one of three sampled residents (Resident 1) after Resident 1 fell on 6/21/2024 and 8/7/2024. This deficient practice resulted in RP 1 being unaware of Resident 1's fall incidents and unable to participate in any decision-making regarding Resident 1's care. Cross reference F551. Findings: During a review of Resident 1's Face Sheet, the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), and hypertension (elevated blood pressure). During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool), dated 10/7/2024, the MDS indicated Resident 1's cognition (process of thinking) was moderately impaired. 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 provide pressure ulcer (damaged skin caused by staying in one position for too long) treatments as ordered by the physician for three of three sampled residents (Resident 83, Resident 16, Resident 9). This deficient practice had the potential to result in skin infections, delayed wound healing and worsening of pressure ulcers. Findings: During a review of the September 2024 Staff Assignment Sheets, the Staff Assignment Sheets indicated there was no treatment nurse assigned to perform wound care to residents on the following dates: 1. 9/1/2024 2. 9/2/2024 3. 9/3/2024 4. 9/4/2024 5. 9/7/2024 6. 9/8/2024 7. 9/9/2024 8. 9/12/2024 9. 9/13/2024 10. 9/14/2024 During a review of the Facility Assessment (document with resident population information and identified resources needed to provide the necessary person-centered care and services the residents require), dated 7/23/2024, the Facility Assessment indicated the facility would offer residents pressure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 sufficient nursing staff to ensure quality nursing care are rendered to the residents in the facility and ensure all medications were administered as ordered by the physician to the 3 of 3 sampled residents (Residents 65, 8 and 83). This failure had the potential to providing poor-quality resident care and services, which can affect in maintaining the highest practicable physical, mental, and psychosocial well-being of the residents under the facility ' s care. Findings: a). During a review of the Direct Care Service Hours Per Patient Day ([DHPPD], a metric that measures the average number of hours required to care for each patient in a healthcare facility) form, the following were identified: On 9/2/2024, the average patient census indicated 169- the actual Certified Nurse Assistant (CNA) DHPPD was 2.27. On 9/3/2024, the average patient census indicated 168- the actual CNA DHPPD was 2.32. On 9/9/2024, the average patient census indicated 172-…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 nursing staff closed the privacy curtain for four of ten sampled residents (Resident 5, Resident 6, Resident 7, and Resident 8) while receiving Activity of Daily Living (ADL) care. This deficient practice violated the resident's right for privacy and had the potential to affect the self-esteem, self-worth, and psychosocial well-being of Residents 5, 6, 7, and 8. Findings: a) During a review of Resident 5 ' s admission Record, the admission Record indicated Resident 5 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including muscle weakness (loss of muscle strength), anxiety disorder (intense, excessive, and persistent worry and fear), and major depressive disorder (depressed mood and loss of interest.) During a review of Resident 5 ' s History and Physical (H&P) dated 1/29/2024, the H&P indicated Resident 5 did not have the capacity to make decisions. During a review of Resident 5 ' s Minimum Data Set…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents' room temperature in a range of 71- and 81-degrees Fahrenheit (° F) for three resident rooms (rooms [ROOM NUMBER]). This deficient practice placed the residents in the affective rooms at risk for hyperthermia (overheating), dehydration (body loses too much fluid and sodium [salt]) and heat stroke (life-threatening heat-related illness that occurs when the body rises to a dangerous level and cause dizziness, confusion, and loss of consciousness). Findings: a)During a review of resident 2 ' s admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including metabolic encephalopathy (a problem in the brain due by a chemical imbalance in the blood), chronic obstructive pulmonary disease (restricted airflow and breathing), and essential hypertension (high blood pressure). During a review of Resident 2 ' s History and Physical (H&P) 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 provide one of ten sampled residents (Resident 1) proper incontinence care when a towel was left inside the resident ' s adult brief. This deficient practice had the potential to cause skin breakdown and infection to Resident 1. Findings During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), acute respiratory failure (a condition that makes it difficult to breathe on your own), and cerebral infarction (damage to brain tissues due to a loss of oxygen in the area). During a review of Resident 1 ' s History and Physical (H&P), dated 4/5/2024, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set ([MDS], a standardized assessment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 its policy and procedure (P&P) titled, Abuse, Neglect, and Exploitation which indicated the facility should report allegations of abuse immediately, but no later than two hours. This failure delayed the investigation by the California Department of Public Health (CDPH). Findings: 1). A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis of schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves). A review of Resident 2's Minimum Data Set (Minimum Data Set [MDS] a standardized assessment and care screening tool), dated 4/5/2024, indicated Resident 2 had moderate (not extreme, within proper limits) cognitive impairment (the ability to think and reason). The MDS indicated Resident 2 was independent with mobility. 2). A review of Resident 3's admission Record indicated Resident 3 was admitted to the facility on [DATE], with 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure adequate supervision was provided for one of three sampled residents (Resident 1), after a physical altercation with Resident 2 and Resident 3. This deficient practice led to Resident 1 striking out at Resident 2 and Resident 3, and caused Resident 2 to develop a contusion (a bruise as aresult of a direct blow or an impact) on her forehead. Findings: A review of Resident 1's, admission Record (Face Sheet), indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), restlessness (inability to sit still or be calm) and agitation (easily angered). A review of Resident 1 's MDS, dated [DATE], indicated Resident 1s cognitive skills (mental action or process of acquiring knowledge and understanding) was intact. The MDS indicated Resident 1 required supervision when walking, toileting, dressing 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's Quality Assessment and Assurance Committee (QAA, the coordinated application of two mutually-reinforcing aspects of quality management system, taking a systemic interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality) failed to monitor and ensure abuse allegations were reported within two hours to the State Survey Agency (Department of Public Health), the ombudsman, and the police department) prior to conducting a thorough investigation. This deficient practice placed the facility's residents at risk for not receiving the quality treatment necessary to adequately meet their highest practicable well-being. Cross Reference F600, F609, and F610. Findings: During an interview on 4/22/2024 at 4:31 p.m., with the Administrator (ADM), the ADM stated the determination of topics brought to the QAA Committee depends on what was occurring in the facility based on incident reports and other reports from the facility's staff. The ADM stated based on the amount of abuse allegations that 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 implement an effective infection prevention control program for 12 out of 12 sampled residents (Resident 10, 30, 35, 53, 54, 81,91, 117, 131, 209, 360, and Resident 361) when the facility failed to ensure the following: 1. Implement and maintain an effective infection surveillance program for Resident 10, Resident 30, and Resident 209. 2. Two of two cloth gait belts (assistive device used for lifting, transferring, and walking patients who have limited mobility issues) were sanitized and cleaned in accordance with the manufacturer's recommendations for bleach sanitizing wipes (pre-moistened towelettes that contain a sanitizing or disinfecting formula that kill or reduce germs on surfaces) after use with one of six sampled residents (Resident 91) with range of motion [ROM, full movement potential of a joint (where two bones meet)] limitations and mobility (ability to move). 3. A sanitary environment was provided for Resident 35, Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement and maintain an effective antibiotic stewardship program for three out of six sampled residents (Residents 10, 30, and 209). These deficient practices had the potential for Residents 10, 30, and 209 to be administered and prescribed antibiotics inappropriately and unnecessarily. Cross reference F880. Findings: a. A review of Resident 10's admission Record (Face Sheet) indicated Resident 10 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included but not limited to COVID-19 (a lung infection), diabetes (poor blood sugar control), and tachycardia (fast heart rate). A review of Resident 10's Minimum Data Set [MDS- an assessment tool], dated 2/1/2024, indicated Resident 10's cognition (ability to think and reason) was severely impaired. The MDS indicated Resident 10 was dependent on staff for performing activities of daily living, eating, dressing, and toileting. A review 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 implement and maintain an effective abuse training program when the facility did not ensure the following: 1. Ensure all Certified Nursing Assistants (CNA), Licensed Vocational Nurses (LVNs), and Registered Nurses (RNs) were in-serviced on abuse. 2. Ensure the correct information regarding abuse reporting was taught to the attendees of the in-services. These deficient practices led to the under reporting of incidences and allegations of abuse and had the potential to lead to further abuse and harm for all residents within the facility. Cross reference F600, F609, and F610. Findings: During a concurrent interview and record review, on 4/18/2024, at 12:04 p.m., with the Director of Staff Development (DSD), the In-service Training for Certified Nurse Assistants binders, dated 9/2023 to 4/2024, was reviewed. There were no abuse in-services found dated from 9/2023 to 12/2023. The DSD stated that abuse in-services needed to be provided to all staff at least twice every month to prevent instances of abuse and to educate staff on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect the two of 19 sampled residents (Resident 460 and 131), from abuse by failing to: 1. Ensure Resident 460 was free from Resident 156's physical abuse. 2. Protect Resident 131 from Resident 209's verbal abuse. These failures had the potential to lead to another physical altercation between Resident 156 and Resident 460, Resident 156's inflicting physical harm or serious bodily injury toward the other residents residing in Building B, and Resident 209's continued and intensified abuse toward Resident 131. Findings: a. A review of Resident 460's admission Record, indicated Resident 460 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but not limited to schizophrenia, bipolar disorder, anxiety disorder, and alcohol abuse. A review of Resident 460's MDS, dated [DATE], indicated Resident 460's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 460…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 b. A review of Resident 156's admission Record (Face Sheet), the admission Record indicated Resident 156 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but not limited to metabolic encephalopathy (a problem in the brain), hypertension (high blood pressure), major depressive disorder (mood disorder), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of Resident 156's MDS, dated [DATE], indicated Resident 156's cognition was severely impaired. The MDS indicated Resident 156 needed moderate assistance when performing toileting hygiene, showering, and bathing and lower body dressing. The MDS indicated Resident 156 required supervision when eating and performing personal hygiene. A review of Resident 156's Behavior Care Plan, dated 2/16/2024, indicated Resident 156 attempted to strike out at staff. The care plan indicated the facility was to approach the resident calmly, speak in a neutral way,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 evidence that abuse allegations were thoroughly investigated and failed to implement interventions to prevent further potential abuse for three of 33 sampled residents (Residents 32, 410, and 55) when: 1. Resident 32 expressed to the facility's staff that she was sexually abused (non-consensual contact of any kind). 2. Resident 55 alleged Resident 410 hit Resident 55 on the nose. These deficient practices had the potential to result in unidentified abuse in the facility and failure to protect residents from further potential abuse. Cross Reference F600, F609, and F943. Findings: a. A review of Resident 32's Face Sheet, indicated Resident 32 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included but not limited to bipolar disease (a mental illness that causes unusual shifts in mood, energy, and concentration), paranoid schizophrenia (a severe mental illness that causes disturbed or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the quarterly Minimum Data Set (MDS, a standardized screening and assessment tool) were completed within the required time frame for seven of 19 residents (Residents 19, 29, 38, 39, 105, 142, 157). This deficient practice had the potential to negatively affect the provision of necessary care and services provided to each resident. Findings: a. A review of Resident 157's Face Sheet, indicated Resident 157 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that include but not limited to psychosis (severe mental condition involving abnormal thinking, perceptions, and loss of contact with reality), insomnia (persistent problem falling and staying asleep), and a mood disorder (a mental condition in which a person has wide or extreme swings in their mood). A review of Resident 157's History and Physical (H&P), dated 1/8/2024, indicated Resident 157 did not have the capacity to understand and make…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurately assess the functional limitation (limited ability to move a joint that interferes with daily functioning) in range of motion [ROM, full movement potential of a joint (where two bones meet)] of both arms for one of six sampled residents (Resident 91) with limited ROM and mobility (ability to move) on 1/12/2023, 4/13/2023, 7/13/2023, 10/12/2023, and 1/11/2024. This deficient practice prevented Resident 91 from receiving services to improve ROM and provided inaccurate information to the Federal database. Cross reference F688. Findings: A review of Resident 91's Resident Status History List (record of hospitalizations and room changes), indicated the facility re-admitted Resident 91 on 4/21/2020. A review of Resident 91's Face Sheet (admission record), indicated the facility admitted Resident 91 on 1/1/2023 with diagnoses including chronic obstructive pulmonary disease ([COPD] lung disease that causes constriction of the airways making it…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY During an observation, interview, and record review, the facility failed to ensure staff provided the necessary care and services for two out of eight sampled residents (Resident 10 and Resident 53) that were bedridden by failing to: 1. Ensure Resident 10 and Resident 53 were repositioned every two hours. 2. Ensure Resident 10 and Resident 53 were offered to get out of bed. 3. Ensure Resident 10 and Resident 53 were up out of bed when requested. These deficient practices had the potential to cause a negative impact on Resident 10 and 53's health and psychosocial well-being by not meeting the resident's needs. Findings: a. A review of Resident 10's admission Record, indicated Resident 10 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including angina pectoris (severe pain in the chest) and esophageal obstruction (a malformation in which the esophagus is interrupted and forms a blind-ending pouch rather than connecting normally to the stomach). A review of Resident 10'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 ensure three out of eight sampled residents (Resident 79, Resident 103, and Resident 137) were seen by an optometrist (healthcare provider that examines, diagnoses, and treats diseases and disorders that affect eyes and vision). This deficient practice could have potentially caused a delay in treatment for Resident 79, 103, and 137. Findings: a. A review of Resident 79's admission Record indicated Resident 79 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (problem in the brain caused by a chemical imbalance in the blood) and paraplegia (paralysis [inability to move] of the legs and lower body, typically caused by spinal injury or disease). A review of Resident 79's History and Physical (H&P) dated 1/10/2024, indicated Resident 79 was able to make decisions for activities of daily living. The H&P indicated Resident 79 had a diagnosis of hypertension (high blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were free of accidents and hazards by failing to: 1. Ensure adequate supervision was provided to ensure safety and prevent accidents and/or hazards for five of five residents (Residents 17, 70, 77, 97, and 159) were unsupervised in the smoking patio. 2. Ensure residents did not have access to the Library Room, which had a ceiling leak, to prevent accidents and hazards. These deficient practices had the potential in an unusual occurrence or accident, such as an unwitnessed fall, a resident-to-resident altercation, elopement (leaving an institution without notice or permission) and/or other physical injuries. Findings: 1a. A review of Resident 17's Face Sheet, indicated Resident 17 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that include but not limited to major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss 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 observation, interview, record review, the facility failed to: 1. Ensure availability of Famotidine (a medication used to treat heartburn, acid indigestion and gastroesophageal reflux disease [GERD - a short medical term for a condition when stomach acid flows back into esophagus [the tube connecting mouth and stomach]) for one of four residents (Resident 98) during medication administration. This deficient practice had the potential to result in worsening of GERD symptoms and adverse consequences such as esophagitis, ulcer (medical term for a sore), bleeding complications and hospitalization. 2. Maintain and provide documentation of disposition of controlled medications. This deficient practice indicated the lack of accountability and oversight of controlled medications, and has the potential to result in misuse, drug loss, accidental exposure and/or potential diversion of controlled medications. Findings: 1. A review of Resident 98's admission Record, (a document containing demographic and diagnostic information), dated 4/22/2024, indicated that the resident was admitted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review, the facility failed to ensure the removal of undated and/or expired insulin (a medication used to treat high blood sugar), Fluticasone-Salmeterol inhalation device (a medication delivered in the form of inhalation powder through a device to treat breathing problems), and Latanoprost ophthalmic (a medical term for eye) solution (a medication in form of eye drops to lower eye pressure), per manufacturer's requirements affecting nine residents (Residents 43, 61, 70, 72, 79, 86, 95, 102 and 559) in three of five inspected medication carts (Medication Cart 2C, Medication Cart 3C and Medication Cart 1G). This deficient practice of failing to store medications per the manufacturers' requirements increased the risk that Residents 43, 61, 70, 72, 79, 86, 95, 102 and 559 could have received medications that had become ineffective or toxic due to improper storage or labeling possibly leading to health complications or hospitalization. Findings: 1. During an observation 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 observation, interview, and record review, the facility failed to ensure a safe and sanitary food storage practice in the kitchen that affected 168 residents out of 168 sampled residents when: 1. The dry storage room contained opened food items with no use by date (date the food item must be consumed by). 2. The freezer contained food with no in date (the date when the food was placed in the freezer) and no use by date. 3. The walk-in refrigerator had a tray with pork labeled with an unidentified date of 4/14/2024. 4. The walk-in refrigerator contained food with no in date and no use by date. 5. Dietary staff did not check food temperatures before serving food to residents. 6. The ice machine in the kitchen was not cleaned. These deficient practices had the potential to result in harmful bacteria growth and cross contamination that could lead to foodborne illness in residents that were medically compromised and that received food and ice from the kitchen. Findings: During an observation during the initial kitchen tour on 4/15/2024 at 8:50 a.m., observed food items in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess the need for modifications to the call light system for one out of 13 rooms (Room A) by failing to: 1. Ensure the call light for Bed A, Bed B, and Bed C lit up outside of the room when activated. 2. Ensure Certified Nursing Assistant (CNA) 14 reported the need for a call light repair in the maintenance repair logbook. These deficient practices had the potential to result in a delay in obtaining necessary care and services. Findings: During an observation on [DATE] at 8:56 a.m., in Room A, the call light outside of Room A did not light up when the call lights for Bed A, Bed B and Bed C were activated. During a concurrent observation and interview on [DATE] at 8: 59 a.m. with CNA 14, in Room A, CNA 14 activated the call light for Bed A, Bed B, and Bed C. The outside light did not turn on. CNA 14 stated it was her job to check that all call lights were within residents reach and in working order. CNA 14 stated she did not know that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 special accommodations to the call light system for one of eight sampled residents (Resident 30). This deficient practice resulted in Resident 30 being unable to use the call light for assistance resulting in Resident 30 calling out loud for assistance. Findings: A review of Resident 30's Face Sheet, indicated Resident 30 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included but not limited to encephalopathy (a broad term for any brain disease that alters brain function or structure), acute kidney failure (the sudden and rapid loss of kidney's ability to filter waste and balance fluid in blood), and depression (mood disorder that causes a persistent feeling of sadness and loss of interest in life). A review of Resident 30's Minimum Data Set (MDS, a standardized screening and assessment tool), dated 1/31/2024, indicated Resident 30 was able to understand and be…

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

Based on observation, interview, and record review, the facility failed to notify the primary physician of the change in condition (major decline or improvement in a resident's status that will not resolve itself without intervention) for one of six sampled residents (Resident 91) with limited range of motion [ROM, full movement potential of a joint (where two bones meet)] and mobility (ability to move) by failing to notify the physician of Resident 91's ROM decline in both arms and both legs on 3/27/2024. This deficient practice resulted in Resident 91 not receiving services to improve ROM and mobility. Cross reference F688. Findings: A review of Resident 91's Resident Status History List (record of hospitalizations and room changes), indicated the facility re-admitted Resident 91 on 4/21/2020. A review of Resident 91's Face Sheet (admission record), indicated the facility admitted Resident 91 on 1/1/2023 with diagnoses including chronic obstructive pulmonary disease ([COPD] lung disease that causes constriction of the airways making it difficult or uncomfortable to breathe),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and/or implement an individualized person-centered plan of care with measurable objectives, timeframe, and interventions to meet the residents' needs for one out of eight sampled residents (Resident 410). This deficient practice had the potential for Resident 410 not to receive individualized care and treatment to meet the resident's mental and psychosocial needs. Findings: A review of Resident 410's admission Record, indicated Resident 410 was admitted to the facility on [DATE] and with diagnoses including benign prostatic hyperplasia (BPH, a condition in men in which the prostate gland is enlarged and not cancerous) and bipolar disorder (a mental illness that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks). A review of Resident 410's General Acute Care Hospital (GACH) records, indicated an admission date on 3/28/2024. The GACH records indicated Resident 410 was admitted 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 interview and record review, the facility failed to develop a person-centered care plan (document that helps nurses and other team care members organize aspect of resident care) for one of 7 sampled residents (Resident 32) who had a sexual abuse allegation. This deficient practice had the potential to negatively affect the delivery of necessary care and services for Resident 32. Cross Reference F609 and F610. Findings: A review of Resident 32's Face Sheet, indicated Resident 32 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that include but not limited to bipolar disease (a mental illness that causes unusual shifts in mood, energy, and concentration), paranoid schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions), anxiety disorder (a group of mental disorders characterized by significant feelings of fear), and chronic pulmonary obstructive disease (COPD, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to: 1. Revise the Restorative Nursing Aide (RNA, certified nursing aide program that helps residents to maintain their function and joint mobility) care plan since 2/2023 for one of six sampled residents (Resident 91) with limited range of motion [ROM, full movement potential of a joint (where two bones meet)] and mobility. This deficient practice resulted in Resident 91 not receiving the care and services needed to prevent a decline in ROM and mobility. Cross reference F688. 2. Ensure the Interdisciplinary Team (IDT, a group of healthcare professionals with various areas of expertise who work together towards the goals of the residents) met for an IDT meeting (meeting to coordinate care and document communication between all members of the team related to residents' plan of care and treatment goal) for one of seven sampled Residents (Resident 32) who made allegations of sexual abuse. This deficient practice had the potential to negatively…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 date the oxygen and nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled) delivery systems for one out of three residents (Resident 360). This deficient practice had the potential to cause infection for Resident 360. Findings: A review of Resident 360's admission Record, indicated Resident 360 was admitted to the facility on [DATE]. Resident 360's admitting diagnoses included but were not limited to chronic obstructive pulmonary disease ([COPD] refers to a group of diseases that cause airflow blockage and breathing-related problems), respiratory failure (a condition in which your blood does not have enough oxygen, or has too much carbon dioxide), and pneumonia (an infection of the lungs). A review of Resident 360's History and Physical (H&P), dated 1/11/2024, indicated Resident 360 did not have capacity to understand and make decisions. A review of Resident 360's Minimum Data Set ([MDS] 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility's dietary staff failed to ensure a resident, who had a history of dysphagia (difficulty or discomfort in swallowing) and was edentulous (without teeth), was served the correct prescribed therapeutic diet for one out of eight sampled residents (Resident 69) This deficient practice had the potential for Resident 69 to choke on his food. Findings: A review of Resident 69's admission Record, indicated Resident 69 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including atrial fibrillation (irregular heartbeat) and muscle wasting (a weakening, shrinking, and loss of muscle caused by disease or lack of use). A review of Resident 69's History and Physical (H&P), dated 11/17/2023, indicated Resident 69 could make needs known but could not make medical decisions. A review of Resident 69's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 2/2/2024, indicated Resident 69's cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one out of three sampled resident ' s (Resident 3) was provided a homelike environment by failing to ensure missing and broken blinds on Resident 3 ' s sliding glass door was replaced or repaired. This failure had the potential to violate Resident 3 ' s right to privacy and negatively affect Resident 3 ' s comfort by not being able to properly adjust the amount of sunlight that entered the resident ' s room. Findings: During a review of Resident 3 ' s admission Record, the admission record indicated Resident 3 was admitted originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including protein-calorie malnutrition (not having enough protein and calories consumed and/or metabolized resulting in muscle loss), osteoarthritis (when cartilage that lines the joints are worn down) and major depressive disorder (persistent feeling of sadness and loss of interest that can interfere with daily life). 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of two resident beds (bed A) in room [ROOM NUMBER] was in a safe, operating condition. This failure had the potential to result in a resident being assigned to a bed that did not work and interfere with patient care. Findings: During a concurrent record review and interview on 4/4/2024 at 11:25 A.M. with the Maintenance Supervisor (MS), the facility Maintenance Log was reviewed. MS stated the Maintenance Log was used between the nursing staff and maintenance staff to communicate what needed to be addressed on the unit. MS stated, the log would also include the date Maintenance completed the correction. During a review of the facility ' s Maintenance Log, dated 3/2024, the Maintenance Log indicated a bed A in room [ROOM NUMBER] needed to be fixed on 3/28/2024. The Log did not indicate a completion date that the bed was repaired. During a concurrent observation and interview on 4/4/2024 at 2:20 P.M. with MS and Maintenance…

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