Bell Convalescent Hospital

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a PRN (as needed) order for Lorazepam (psychotropic medication- drug that affects mental processes, moods, and behaviors) indicated a stop date for one of six sampled residents (Resident 16). This deficient practice placed Resident 16 at risk for continued use of unnecessary psychotropic medication without timely physician reassessment and had the potential for Resident 16 to be chemically restrained by the administration of unnecessary psychotropic medication, and/or suffer extrapyramidal symptoms (a group of movement disorders that can occur because of certain medications, particularly antipsychotics) due to prolonged use. Findings: During a review of Resident 16's admission Record, the admission Record indicated Resident 16 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 16's diagnosis included depression (a mental disorder that affects how person thinks, feels, and acts), anxiety (a feeling of fear, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to complete an accurate Minimum Data Set (MDS, a resident assessment tool) assessment for one of six sampled residents' (Resident 18) oral and/or dental status. This deficient practice resulted in incorrect data transmitted to the Centers for Medicare and Medicaid Services (CMS) regarding Resident 18's missing natural teeth and had the potential to negatively affect the resident care plan and delivery of necessary care and services. Findings: During a review of Resident 18's admission Record, the admission Record indicated Resident 18 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 18's diagnoses included diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) and hypertension (HTN- high blood pressure). During a review of Resident 18's MDS, dated [DATE], the MDS indicated Resident 18's cognition (the ability to think and process information) was intact.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 services met professional standards when a medication for one of five sampled residents (Resident 63) was not handled according to instructions. This deficient practice had the potential to result in adverse side effects, absorption of medication, and birth defects for the nurse. Findings: During a review of Resident 63's admission Record, the admission record indicated Resident 63 was admitted to the facility on [DATE] with diagnoses that included but not limited to, benign prostatic hyperplasia (BPH- a noncancerous enlargement of the prostate gland), retention of urine, and chronic kidney disease (a long-term condition where the kidneys gradually lose their ability to filter waste and excess fluids from the blood effectively). During a review of Resident 63's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 12/19/2025, the MDS indicated Resident 63 cognitive skills (ability to think and reason) for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 36), who had hand tremors, was assisted during mealtimes. This deficient practice had the potential to cause a negative impact on Resident 36's overall health status. Findings: During an observation on 1/21/2026 at 12:30 p.m., in the dining room, Resident 36 was observed seated at a table. A cup of coffee and food tray was placed on top of the table. Resident 36 was observed not eating. Resident 36's hands were shaking. Resident 36 grabbed the cup of coffee and brought it toward her face. Resident 36 began to spill coffee over herself and she returned the cup coffee back to the table. During a review of Resident 36's admission Record, the admission Record indicated Resident 36 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included lack of coordination (inability to produce smooth, accurate, and voluntary muscle movements, resulting in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain good grooming and personal hygiene for two of 12 sampled residents (Resident 33 and Resident 3) by failing to keep their nails clean and neat. This deficient practice had the potential to result in a negative impact on Residents 33 and 3's quality of life and self-esteem and had the potential for development of infection. Findings: a. During a review of Resident 33's admission Record, the admission Record indicated Resident 33 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 33's diagnoses included enterocolitis (an infection causing inflammation of the small intestine and colon), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension (HTN- high blood pressure). During a review of Resident 33's Minimum Data Set (MDS- a resident assessment tool), dated 11/19/2025, the MDS indicated Resident 33's cognition (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 follow physician's orders, ensure medication parameters were followed, and orthostatic hypotension (sudden, sustained drop in blood pressure that occurs when standing up from a sitting or lying position) monitoring was performed for three of 12 sampled residents (Resident 84, Resident 2, and Resident 6). These deficient practices placed Residents 84 and 2 at risk for serious medication related complications, including potential overdose, underdose, or adverse effects due to unmonitored response to treatment, and placed Resident 6 at risk for undetected episodes of hypotension, falls, and injury for not being monitored. Findings: a. During a review of Resident 84's admission Record, the admission Record indicated Resident 84 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 84's diagnoses included hypertension (HTN- high blood pressure), dementia (a progressive state of decline in mental abilities) and epilepsy (a…

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

Based on observation, interview, and record review the facility failed to ensure one of three sampled residents (Resident 38) was provided active-assist range of motion [(AAROM), a physical therapy term for exercises where the patient moves a body part independently but a therapist or device assists further] as indicated in the physician's (MD, medical doctor) order.This failure had the potential for Resident 38 to exhibit range of motion (ROM, full movement potential of a joint) decline. Findings: During a review of Resident 38's admission Record, the admission Record indicated the facility admitted Resident 38 on 6/26/2025 with diagnoses including cerebral ischemia (reduced or blocked blood flow to the brain), hypertension (HTN-high blood pressure), dysphagia (difficulty swallowing), and lack of coordination. During a review of Resident 38's Minimum Data Set (MDS, a resident assessment tool) dated 1/02/2026, the MDS indicated Resident 38 had moderate cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). 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 observation, interview, and record review, the facility failed to ensure care and services related to urinary Foley catheter (a flexible tube inserted through the urethra [a hollow tube that lets urine leave the body] into the bladder to drain urine into a collection bag) management were provided for one of two sampled residents (Resident 11) by failing to:a. Irrigate (wash out) Resident 11's Foley catheter as needed as indicated by the physician orders.b. To Notify the Resident 11's physician of urine sediment (matter that settles to the bottom of a liquid), cloudiness and urinary pain.These deficient practices resulted in urinary catheter obstruction, and had the potential for increased infection, discomfort and decline in Resident 11's health status.Findings:During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was admitted to the facility on [DATE]. Resident 11's diagnoses included diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pain scale (an assessment tool used to rate pain level) was used when administering Tramadol (a narcotic medication used to treat moderate to severe pain) for one of one sample resident (Resident 33). This deficient practice had the potential to result in the resident having inadequate treatment, miscommunication between nurses and physicians, and poorly controlled pain. Findings: During a review of Resident 33's admission Record, the admission record indicated Resident 33 was admitted to the facility on [DATE] and was readmitted [DATE] with diagnoses that included but not limited to Type II diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (high blood pressure), and low back pain. During a review of Resident 33's Minimum Data Set (MDS- a resident assessment tool) dated 11/19/2025, the MDS indicated Resident 33's cognitive skills (ability to think and reason) for daily…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 physician orders for dialysis treatment (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed) on Sundays, Tuesdays, and Fridays, and failed to ensure staff assessed the dialysisaccess site (surgically created access allowing blood removal and return during dialysis) each shift for two of two sampled residents (Residents 90 and 102). These deficient practices placed Resident 102 at risk for undetected dialysis access site complications, including swelling, pain, bleeding, bruising, and access malfunction, and placed Resident 90 at an increased risk of missed or delayed dialysis treatments, potentially resulting in serious adverse health outcomes.Findings: 1. During a review of Resident 102's admission Record, the admission Record indicated Resident 102 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure physician face-to-face visits were conducted at least once every 30 days for the first 90 days following admission for two of six sampled residents (Residents 16 and 33).This deficient practice had the potential to result in undetected changes in Residents 16 and 33's medical, physical, mental, and psychosocial conditions, and potentially delay the provision of medically necessary care, treatment, and services.Findings:a. During a review of Resident 16's admission Record, the admission Record indicated Resident 16 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 16's diagnoses included epilepsy (a brain disorder), depression (a mental disorder that affects how person thinks, feels, and acts), anxiety (a feeling of fear, and dread), and hypertension (HTN-high blood pressure).During a review of Resident 16's History and Physical (H&P), dated 6/8/2025, the H&P indicated Resident 16 had the capacity to understand…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain complete and accurate medical records in accordance with accepted professional standards for three of sampled residents (Resident 12, 33, and 36) by not ensuring licensed staff documented:1. Resident 12's medication administration and pain reassessment in a timely manner.2. Resident 33's pain reassessment in a timely manner.3. Resident 36's hand tremors.These deficient practices resulted in incomplete resident medical care information and placed residents at risk for confusion in the provision of care and services.Findings 1. During a review of Resident 12's admission Record, the admission Record indicated Resident 12 was admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 12's diagnoses included Type II diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), disorder of muscle, and gout (a common, treatable form of inflammatory arthritis…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observation, and record review, the facility failed to implement and maintain an effective infection prevention and control program by failing to ensure the dialysis binder (used as a dialysis communication record and transported with the resident to and from dialysis appointments) used for one of one residents (Resident 90) was clean and free from visible contamination. This deficient practice increased the potential for the transmission of infectious agents and placed Resident 90, other residents, and staff, at risk for infections. Findings:During a review of Resident 90's admission Record, the admission Record indicated Resident 90 was admitted to the facility on [DATE]. Resident 90's diagnoses included diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), hyperlipidemia (high cholesterol), end stage renal disease (ESRD, the final, permanent stage of kidney failure) with dependence on renal (kidneys) dialysis ( a treatment to cleanse…

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

Based on interview and record review, the facility failed to ensure the Infection Preventionist (IP) completed ten hours of continuing education in Infection Prevention and Control on an annual basis. This deficient practice had the potential for the IP to be unaware and be unable to educate the facility's staff of updated information regarding Infection Prevention and Control practices.Findings:During an interview on 1/23/2026 at 11:30 a.m., with the IP, the IP stated she was not able to provide documentation indicating the completion of ten hours of continuing education in infection prevention and control for 2025. The IP stated she completed continuing education hours when she renewed her nursing license, however, those hours were not obtained in 2025. The IP stated it was her responsibility to complete ten hours of infection prevention and control education each year, as required, in order to stay informed on new guidance, evidence-based practices and emerging infectious disease threats. The IP stated that these ten hours were essential for her to remain up to date with current…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents (Resident 3), was weighed on admission and weekly for four (4) weeks, as indicated in its policy and procedure (P&P) titled, Weight Assessment and Interventions. This failure resulted in the facility not having resident's baseline weight on admission and placed Resident 3 at risk for unidentified weight loss and possible complications, like skin breakdown, other illnesses and possible hospitalization.Findings:During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 3's diagnoses included cellulitis (a skin infection that causes swelling and redness) of the right lower limb and acquired absence of other right toe(s) (a body part or organ that is missing because it was removed or lost after birth, typically due to surgery).During a review of Resident 3's History and Physical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review and act on the Medication Regimen Review (MRR, a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) conducted for all facility residents from 8/19/2024 to 8/20/2024. This deficient practice resulted in delays to adjustments to multiple residents' medications and/or plans of care due to lack of physician notification of the consultant pharmacist's recommendations. Findings: During a review of the MRR dated 8/9/2024 to 8/20/2024, the MRR indicated the facility's Consultant Pharmacist made recommendations for 35 of 91 facility residents reviewed. During a concurrent interview and record review on 12/4/2024 at 11:25 a.m., with the Director of Nursing (DON), the MMR dated 8/19/2024 to 8/20/2024 was reviewed. The DON stated the MRR indicated recommendations made by the facility's consultant pharmacist. The DON stated that the recommendations were not reviewed, reported to the…

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

Based on observation, interview, and record review the facility failed to ensure the inside gasket of the kitchen's ice machine was free of yellow and white build up components. This deficient practice placed all the residents who consumes ice in the facility, at risk for foodborne illnesses (diseases caused by consuming food or drinks that are contaminated with harmful bacteria, viruses, parasites, or chemicals). Findings: During a concurrent observation and interview on 12/2/2024 at 10:31 a.m. with the Dietary Supervisor (DS), in facility kitchen, the inside gasket of the ice machine (a rubber lining that creates a tight seal around the door of an ice machine) was observed with yellow and white buildup. The DS stated the yellow buildups should not be inside the ice machine, and nothing yellow should be inside the ice machine. The DS stated the yellow buildups could be mold. The DS stated ice are considered as food, and the yellow buildups could potentially contaminate the ice and cause food poisoning when ingested by the residents. The DS stated maintenance department are…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 garbage storage area was maintained in a sanitary condition, by failing to ensure: 1. There were no trash bags and cardboard boxes on the ground. 2. The outside trash dumpster lid was closed. These deficient practices had the potential to result in pests' inside the facility and pest-related diseases (like [NAME] virus [spread by mosquitoes], lyme disease [a bacterial infection spread by the bite of an infected blacklegged tick], and rabies [a preventable viral disease of mammals usually transmitted through the bite of an infected animal]). Findings: During a concurrent observation and interview on 12/2/2024 at 11:35 a.m. with the Dietary Supervisor (DS), at the facility outdoor garbage storage area, the area had trash bags and cardboard boxes on the ground. The DS stated she had no comments on the garbage area because the maintenance should be the one responsible for it. During a concurrent observation and interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement infection control practices for three out of three sampled residents (Resident 38, 62, 84) by failing to: 1. Change the nasal cannula (NC, a plastic medical device to provide supplemental oxygen therapy to resident who had lower oxygen levels; device went directly into the nostrils) tubing every seven days. 2. Ensure Resident 38 and 84's indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) tubing did not touch the floor. 3. Ensure Resident 84's indwelling urinary catheter tubing and drainage bag was free of sediments (gritty particles that settle at the bottom of a liquid). These deficient practices placed Resident 62, Resident 38, and Resident 84 at risk for infection which could increase the morbidity (the amount of disease in a population) and mortality (the state of being subject to death), and increased Resident 84's risk of an undiagnosed urinary tract infection (UTI- an infection…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 effective, ongoing pest control program was maintained in the facility. This deficient practice resulted in unresolved infestation of german cockroaches (a small, fast-moving, nocturnal cockroach that is a common household pest in the United States) and had the potential to affect the health and living conditions of the 91 residents residing in the facility. Findings: During an observation on 12/2/2024 at 8:45 a.m. in the Admission's Office (surveyor's work area), which was located directly next to the kitchen, the area was cluttered with three desks, a couch, a refrigerator, microwave, christmas decorations and cardboard boxes, stored on the floor filled with paper documents. The cardboard box was observed on the floor against the wall, next to the refrigerator. The cardboard box had water damage at the base of the box. On the wall adjacent to the kitchen was a square hole, which had an uncovered electrical outlet with exposed wires coming from the hole. During an observation on 12/2/2024 at 9:15…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain informed consent for psychotropic medications (drugs that affect a person's mental state) from one of five sampled residents (Resident 45) responsible party (RP), informed consent was obtained from Resident 45's family member (FM) 2, who was not Resident 45's RP. This deficient practice resulted in Resident 45 receiving sertraline (a medication used to treat depression) and aripiprazole (a medication used to treat mental disorders, including depression) without her knowledge or explicit consent. This deficient practice also placed Resident 45 at risk for experiencing unwanted adverse effects of the medication, including increased risk of suicidal thoughts and other mental status changes. Findings: During a review of Resident 45's admission Record, the admission Record indicated Resident 45 was admitted to the facility on [DATE], and most recently re-admitted Resident 45 on 4/16/2024. Resident 45's admitting diagnoses included depression (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 accommodate the needs of one of eight sampled resident's (Resident 23) by not placing the call within reach and not providing an appropriate call light device. This deficient practice prevented Resident 23 from communicating with staff and had the potential to delay appropriate care, treatment, and services. Findings: During a review of Resident 23's admission Record, dated 12/5/2024, the admission record indicated Resident 23 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 23's diagnoses included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or an inability to move on one side of the body) following cerebrovascular disease (CVA-stroke, loss of blood flow to a part of the brain) affecting the right dominant side, peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs), hypertension (HTN-high…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents' medical records were updated to show documentation clarifying if a resident has an advance directive (a legal document indicating resident preference on end-of-life treatment decisions) or not for two out of eight residents (Resident 6 and 35), when: 1. Facility did not complete the advance directive acknowledgement form (ADAF, part of an advance directive, a legal document that allowed a person to specify their medical care wishes and who should make decisions for them if they could not) for Resident 6. 2. Facility did not obtain the ADAF for Resident 35 within 24 hours of admission in accordance with the facility's Policy and Procedure (P&P) titled, Advance directives. These deficient practices had the potential to result in confusion in the care and services for Resident 6 and 35 and placed the residents at risk of receiving unwanted treatment and not receiving appropriate care based on wishes. Findings: 1. 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, facility staff failed to report an allegation of resident-to-resident verbal abuse to the State Agency, for two of four sampled residents (Resident 3 and Resident 30), after directly observing the abuse incident on 12/29/2024. This failure resulted in delayed notification of the State Agency, and the subsequent timeliness of their investigations. The failure also increased the potential for additional resident-to-resident abuse incidents to occur. Findings: During a review of Resident 3's admission Record, the record indicated Resident 3 was originally admitted to the facility on [DATE] and was most recently re-admitted on [DATE]. Resident 3's admitting diagnoses included dementia (a progressive state of decline in mental abilities) and lack of coordination. During a review of Resident 3's History and Physical (H&P), dated 11/4/2022, the H&P indicated Resident 3 did not have the capacity to understand or make decisions. During a review of Resident 3's Minimum Data 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.

Based on interview and record review, the facility did not ensure the Preadmission Screening and Resident Review (PASRR, a federal requirement to help ensure that individuals with a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) assessment was accurate, and that determination for necessity of potential necessary services, was completed for one of one sampled resident (Resident 45). This deficient practice had the potential for Resident 45 to not receive the required services and care needed for their diagnosed mental disorders. Findings: During a review of Resident 45's admission Record, the admission Record indicated the facility admitted Resident 45 on 3/19/2024, and most recently re-admitted Resident 45 on 4/16/2024. Resident 45's admitting diagnoses included depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and psychosis (a severe mental condition in which thought, and emotions are so affected 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 interview and record review, the facility failed to ensure care plans were developed for four of 21 sampled residents when the following occurred: 1. Resident 45 did not have a care plan addressing diagnoses of depression and psychosis. 2. Resident 58 did not have a fall risk care plan. 3. Resident 32 did not have a care plan for the use of a low air loss (LAL) mattress (a mattress designed to distribute body weight evenly and reduce pressure on specific areas of the body). 4. Resident 77 did not have a care plan for the use of a LAL mattress. These deficient practices placed Residents 45, 58, 32, and 77 at risk for avoidable complications due to staff not having defined and resident-specific interventions for provision of care. Findings: 1. During a review of Resident 45's admission Record, the admission Record indicated the facility admitted Resident 45 on 3/19/2024, and most recently re-admitted Resident 45 on 4/16/2024. Resident 45's admitting diagnoses included depression (a mental health disorder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to revise the care plans for two of 21 sampled residents when the following occurred: 1. Resident 44's fall care plan was not revised following his first fall on 5/19/2024. 2. Resident 17's fall care plan was not revised following her first fall on 6/14/2024, and second fall on 6/21/2024. These deficient practices resulted in Resident 44 sustaining a second fall on 8/22/2024, and a third unwitnessed fall on 9/14/2024. The above deficient practice also resulted in Resident 17 sustaining a third unwitnessed fall on 8/3/2024. Findings: 1. During a review of Resident 44's admission Record, the admission Record indicated Resident 44 was admitted to the facility on [DATE], and most recently re-admitted on [DATE]. Resident 44's admitting diagnoses included history of falling and anxiety disorder. During a review of Resident 44's History and Physical (H&P), dated 3/25/2024, the H&P indicated Resident 44 did not have the capacity to understand and make decisions.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 meet professional standards of quality of care for one out of eight residents (Resident 62) by failing to document the following on Resident 62's Medication Administration Record (MAR): 1. The administration of pantoprazole (medicine treated conditions that caused too much stomach acid) on 10/4/2024, 10/14/2024, and 10/16/2024 at 6:30 a.m. 2. The administration of insulin lispro (a fast-acting, human-made insulin [a hormone that removed excess sugar from the blood, could be produced by the body or given artificially via medication]) on 10/4/2024, 10/14/2024, and 10/16/2024 at 6:30 a.m. 3. Coronavirus disease (COVID-19, an infectious disease caused by the SARS-CoV-2 virus) and vital signs (measurements of the body's most basic functions) monitoring on 10/3/2024, 10/13/2024, 10/15/2024, and 10/21/2024 during the night shift; and on 10/7/2024, 11/17/2024, and 12/2/2024 during the evening shift. 4. Pain monitoring on 10/3/2024, 10/11/2024, 10/13/2024,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 low air loss mattress (LALM, a medical mattress that uses air to help prevent and treat pressure ulcers [localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence]) pressure levels were adjusted according to the resident's weight for two of six sampled residents (Resident 32 and Resident 77). This deficient practice had the potential to cause the development, worsening or reinjury of pressure ulcers to Resident 32 and 77. Findings: 1. During a review of Resident 32's admission Record, dated 12/5/2024, the admission record indicated Resident 32 was admitted to the facility initially on 8/31/2024 and readmitted on [DATE]. Resident 32's diagnoses included diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), atrial fibrillation (an irregular, often rapid heart rate that can cause poor blood flow, leading to blood clots, stroke, 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 observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 32), received the oxygen two (2) liters per minute (LPM) via nasal cannula (NC - a device used to deliver supplemental oxygen through the nose) as ordered by the physician. This deficient practice had the potential to result in oxygen desaturation (decreased amount of oxygen in the blood) which could lead to low levels of oxygen in the body tissue (hypoxia), difficulty breathing, rapid heart rate, and confusion, including hospitalization and death. 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 included atrial fibrillation (an irregular, often rapid heart rate that can cause poor blood flow, leading to blood clots, stroke, or heart failure), heart failure (a heart disorder which causes the heart to not pump the blood efficiently,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 who required dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) had failed) received services that were consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals, when the facility did not provide dialysis emergency kit (E-kit - contains supplies such as tape, clamp, and gauze to use in case the resident experienced bleeding from their dialysis access site) at the bedside, for three out of three residents (Resident 66, 36, and 63). These deficient practice placed the affected residents at risk for ineffective emergency treatment and complications of uncontrolled bleeding resulting in hospitalization and death. Findings: 1. During an observation on 12/2/2024 at 10:55 a.m., in Resident 66's room, observed Resident 66 was lying on bed with no dialysis emergency kit at bedside. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure unnecessary medications were not administered to two of five sampled residents (Resident 45 and Resident 62) when: 1. A gradual dose reduction (GDR, stepwise tapering of a medication to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) of Resident 45's sertraline (a medication used to treat depression) was not attempted. 2. Informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for the use of Trazodone (a drug used to treat depression [a constant feeling of sadness and loss of interest]) ordered on 10/8/2024, was not obtained for Resident 62 prior to use. This deficient practice created the potential for Resident 45 to suffer unwanted adverse effects from continued administration of sertraline, including increased risk of suicidal thoughts and other mental 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 observation, interview, and record review, the facility failed to ensure left over food, for four out of four residents (Residents 69, 66, 73 and 63), were stored, in accordance with the facility's policy and procedure (P&P) titled, Foods brought by family/ visitors. These deficient practices placed Residents 69, 66, 73 and 63 at risk for food-borne illnesses (food poisoning, with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever) and could lead to other serious medical complications and hospitalization. Findings: 1. During a review of Resident 69's admission Record, dated 12/5/2024, the admission record indicated Resident 69 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), heart failure (a heart disorder which caused the heart to not pump the blood efficiently), hypertension (HTN, high blood pressure), 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 conduct a rehabilitation screening and/or provide rehabilitation (therapy given to restore an individual back to their highest possible level of physical, mental, and psychosocial well-being) and restorative nursing services (RNS, nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible) for one of 21 sampled residents (Resident 45). This deficient practice prevented the facility Case Manager (CM) from advocating for Resident 45 to receive rehabilitative therapy services and led to a delay in the provision of RNS to Resident 45. This created the potential for a decline in Resident 45's mobility and ability to perform activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). Findings: During a review of Resident 45's admission Record, the admission Record indicated the facility admitted Resident 45 on 3/19/2024, and most recently…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 comprehensive Care Plan for three out of four sampled residents (Residents 1, 3, and 4) who were diagnosed with Covid-19 (a highly contagious respiratory disease caused by the SARS-CoV-2 virus). This failure had the potential to result in Residents 1, 3, and 4's needs not being met and unidentified interventions to address the resident's Covid-19 infection. Findings: During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including Diabetes Mellitus (abnormal blood sugar), hypertension (high blood pressure) and cerebral infarction (brain tissue dies due to blood flow to the brain). During a review of Resident 1's Minimum Data Set ([MDS] a federally mandated resident assessment tool), dated 7/23/2024, the MDS indicated Resident 1 had moderate (not extreme, but not within normal limits) cognitive impairment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 its infection prevention and control measures for Covid-19 (A highly contagious respiratory disease caused by the SARS-CoV-2 virus) by failing to: a. Ensure staff donned (put on) personal protective equipment ([PPE], equipment worn to prevent spread of infections or diseases such as a gown, face shield [cover/protection] and gloves) prior to entering a Covid-19 positive room (room [ROOM NUMBER]). b. Ensure staff doffed (removed) PPE prior to leaving Covid-19 positive Room (room [ROOM NUMBER]). c. Conduct close contact testing of exposed staff after one resident (Resident 1) tested positive for Covid-19 on 9/5/2024. d. Adequately screen facility visitors prior entering facility during a Covid-19 outbreak. e. Report the facility ' s Covid-19 outbreak to the California Department of Public Health (CDPH) on 9/8/2024. These failures had the potential to result in the spread of Covid-19 and placed residents, staff, and the community at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure infection prevention and control was maintained when the following occurred: 1. Enhanced barrier precautions (EBP; an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs] that employs targeted gown and glove use during high contact resident care activities) were not implemented for 15 of 16 residents who met EBP-implementation criteria (Residents 2, 3, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, and 18). 2. Facility failed to report three new cases of Covid-19 (an acute disease caused by a coronavirus, capable of progressing to severe symptoms, including death, especially in older people and those with underlying health conditions) to the local health department on 6/21/2024 and 6/24/2024 (Laundry Staff [LS] 1, Licensed Vocational Nurse [LVN] 1, and Resident 5), prior to closing an outbreak (the occurrence of more cases of disease than expected in a given area or among a specific…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P), titled Administering Medications, which indicated medications were to be administered in accordance with prescriber orders and within one hour of their prescribed time for one of three sample residents (Resident 19). This deficient practice resulted in Resident 19 being administered Hydrocodone-Acetaminophen (Norco – a medication to relieve moderate to severe pain) 3 hours earlier than the prescribed time. Findings: During an observation on 7/10/2024 at 9:58 a.m., in front of Resident 19's room, LVN 5 retrieved a bubble pack of Norco from the medication cart. LVN 5 removed one tablet from the bubble pack and placed the tablet in a medicine cup. LVN 5 went inside of Resident 19's room to administer the resident Norco for pain. A review of Resident 19's admission Record, dated 11/29/2023, indicated Resident 19 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 19'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 administer supplemental oxygen as ordered by the physician for one of two sampled residents (Resident 5). This deficient practice created the potential for Resident 5 to suffer from oxygen toxicity (lung damage that happens from breathing in too much extra [supplemental] oxygen, and can cause coughing, trouble breathing, and, in severe cases, death). Findings: A review of Resident 5's admission Record indicated Resident 5 was admitted to the facility on [DATE], and most recently re-admitted on [DATE]. Resident 5's admitting diagnoses included heart failure (when the heart muscle doesn't pump blood as well as it should), asthma (a chronic lung disease affecting people of all ages), and respiratory failure (condition in which your blood doesn't have enough oxygen or has too much carbon dioxide). A review of Resident 5's Minimum Data Set (MDS; a comprehensive assessment and care planning tool) dated 6/24/2024, indicated Resident 5 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P), titled Pain Assessment to ensure effective pain management assessment was conducted for one of three sampled resident (Resident 19), by: 1. Licensed Vocational Nurse (LVN 5) failing to promptly address Resident 19's pain, when the resident verbalized, he was in pain. 2. LVN 5 failing to use a standard pain assessment scale to determine Resident 19's pain level. 3. LVN 5 failing to ensure the licensed nurse further assessed Resident 19's pain to determine the location, frequency, quality, intensity, and duration of pain. 4. LVN 5 failing to document Resident 19's administration of Hydrocodone-Acetaminophen (Norco – a medication to relieve moderate to severe pain). 5. LVN 5 failing to ensure Resident 19 was assessed and re-evaluated for pain before administering more pain medications. These deficient practices caused Resident 19 to experience pain that interfered with his activities of daily living 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 two out of four sampled residents (Resident 1 and Resident 3) were provided assistance with Activities of Daily Living (ADL- such as using the restroom, oral hygiene, walking), by leaving Residents 1 and 3 wet with urine for an extended period of time. This failure placed Resident 1 and 3's needs unmet and the potential for skin breakdown and infections. Findings: a). A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including progressive supranuclear opthalmoplegia (a condition that affects the ability to control eye movements at will in all directions), history of falling, and other abnormalities of gait (a particular way of walking) and mobility (ability to move purposefully). A review of Resident 1's care plan titled, Needs assistance with Activity of Daily Living, dated 11/1/2023, indicated to provide assistance as needed. A review of Resident 1'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 interview and record review, the facility failed to implement its abuse policy and procedure (P&P) titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating to ensure an allegation of abuse was reported to the California Department of Public Health (CDPH) within two hours, for one of seven sampled residents (Resident 2). This deficient practice resulted to the delay in the abuse investigation by the CDPH and placed Resident 2 at risk for continuous abuse at the facility. Findings: During a review of Resident 2 ' s admission Record (face sheet), dated 1/22/2024, the face sheet indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cerebral infarction (interrupted blood flow to the brain), chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood properly), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews and record review, the facility failed to: 1. Ensure staff refrained from washing their hands utilizing the sink meant for obtaining resident's drinking water. 2. Ensure sink area utilized to obtain resident's drinking water was cleaned and free of rust and dirt. These deficient practices had the potential for cross contamination (transfer of harmful bacteria from object or place to another) and cause residents to be ill. Findings: During an interview with Certified Nurse Assistant (CNA 1) on 12/12/2023 at 2:11 p.m., CNA 1 stated one source of the resident's drinking water was from a sink in the employee lounge. CNA 1 stated that sink had a filter for the resident's drinking water. During an observation on 12/12/2023 at 2:59 p.m. in the employee lounge, CNA 2 was observed filling water pitchers to be dispensed for residents from from the sink in the employee lounge. CNA 1 was also observed washing her hands with soap and water after she finished filling the water pitchers…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 uphold the resident rights for three of six sampled residents (Resident 34, Resident 54, and Resident 59) when the facility failed to: 1. Follow up on the application to appoint a Public Guardian to aid in Resident 34's Medi-Cal (a public health insurance program which provides needed health care services for low-income individuals) application, assist with Resident 34's financial obligations, and help guide Resident 34's care. 2. Provide a dignity bag for Resident 54's and Resident 59's indwelling catheter bag (a drainage bag connected to a catheter inserted into the bladder to drain urine). These failures had the potential to cause emotional distress to Resident 34 regarding financial obligations to the facility without the aid of a Public Guardian, and the potential to cause psychosocial harm for Resident 54 and 59 due to lack of ensuring the resident's dignity was maintained. Findings: a. During a review of Resident 34'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 observation, interview, and record review, the facility failed to accommodate the needs of eight out of eleven sampled residents (Resident 6, 7, 12, 15, 34, 58, 59, and 74) by failing to: 1. Provide functioning call lights which enabled the light located outside of the residents' door to turn on when the call light was activated for Residents 6, 7, 15, 34, 58 and 74. 2. Ensure the call lights were within reach for Residents 12 and 59. These deficient practices had the potential to cause a delay in care and physical and psychosocial harm by not anticipating the needs of and accommodating Residents 6, 7, 12, 15, 34, 58, 59, and 74. Findings: During a review of Resident 6's admission Record, the admission record indicated Resident 6 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included seizures (burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities such as stiffness, twitching or limpness) and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and/or implement a comprehensive resident-centered care plan for four of 30 sampled residents (Resident 38, 46, 49, and 66) by failing to: 1. Implement Resident 49's care intervention to administer antibiotics (medication to treat an infection) for a urinary tract infection (UTI, infection in any part of the urinary system that includes the kidneys and bladder). 2. Implement Resident 46's care intervention to infuse enteral feeding (a special liquid food mixture containing protein, carbohydrates, fats, vitamins, and minerals). 3. Implement Resident 38's care intervention to apply padding to the side rails and a floor mattress. 4. Develop a resident-centered comprehensive care plan addressing Resident 66's diagnoses of generalized body weakness, degenerative joint disease (osteoarthritis, occurs when flexible tissue at the end of the bone wears down which occurs gradually and over time causing joint pain in the hands, neck, lower…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a registered nurse (RN) was scheduled to work in the facility to administer intravenous (IV, in the vein) antibiotics (medication to treat an infection) for two of 12 sampled residents (Resident 49 and Resident 70). This failure resulted in Resident 49 missing two doses and Resident 70 missing one dose of IV antibiotics. Findings: a. During a review of Resident 49's admission Record (Face Sheet), the admission Record indicated Resident 49 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included but not limited to urinary tract infection (UTI, infection in any part of the urinary system that includes the kidneys and bladder), extended spectrum beta lactamase resistance (ESBL, enzyme that makes bacteria difficult to treat with antibiotics), type 2 diabetes mellitus (high blood sugar), and dementia (a condition characterized by progressive or persistent loss of intellectual functioning).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record the medication room and refrigerator temperature for one of two inspected medication rooms (Medication Room B.) This failure increased the potential for residents in the facility to receive medications that were ineffective or toxic due to the inadequate storage monitoring, and potentially experience medication adverse consequences resulting in negative impact to residents' health and well-being. Findings: During a concurrent observation and interview on 11/13/2023 at 12:15 p.m., with Licensed Vocational Nurse (LVN) 4, in Medication Room Station B, the room and refrigerator temperature monitoring log for November 2023 was observed not containing documentation for the temperatures for several days and shifts. LVN 4 stated the missing documentation for the room and temperature logs for November 2023 implies the room and refrigerator temperatures were not monitored. LVN 4 stated the room and refrigerator temperatures should be monitored and logged every day during all shifts to ensure medications were…

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

Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%) due to three (3) errors observed out of 26 total opportunities (error rate of 11.54%). The medication errors were as follows: 1. Resident 50 received a form of vitamin D3 (medication used as a dietary supplement to promote bone health) and fish oil (medication used as a dietary supplement to help reduce blood triglyceride [form of fat in the body] levels) that was different than the one ordered by Resident 50's physician. 2. Resident 50 did not receive diclofenac (medication used to treat pain) 1% (strength of the medication) gel as ordered by Resident 50's physician. These failures had the potential to result in Resident 50 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) and the potential to result in Resident 50's health and well-being to be negatively impacted. Findings: During an observation on 11/30/2023 at 10:38 a.m., in medication cart A, Licensed vocational nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: 1. Remove and discard two expired inhalation (a form of a medication to be inhaled as a vapor or spray) treatments for Residents 26 and 72 in accordance with manufacturer's requirements in one of two inspected medication carts (Medication Cart C.) 2. Label two inhalation treatment foil packs (package made of foil protecting the inhalation solution from light and degradation) for Resident 28 and 72, with an open date in accordance with the manufacturer's requirements in one of two inspected medication carts (Medication Cart C.) 3. Store one lorazepam (a medication used to treat anxiety) oral solution bottle for Resident 43 in the refrigerator in accordance with the manufacturer's requirements in one of two inspected medication carts (Medication Cart Station C.) 4. Label five inhalation treatment foil packs for Resident 23, 31 and 73, with an open date in accordance with the manufacturer's requirements in one of two inspected medication…

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

Based on observation, interview, and record review, the facility failed to store food under sanitary conditions in one (1) of 1 kitchen, by failing to: 1. Ensure the food items in the refrigerator were dated. 2. Ensure there were no expired food items in the refrigerator. 3. Ensure the food items in the freezer were dated. 4. Ensure the refrigerator did not have meat thawing for an extended time. These deficient practices had the potential to result in the transmission of infectious agents that could lead to illness. Findings: 1. During an observation, of the Refrigerator, on 11/13/2023 at 8:53 a.m., observed a bag of lettuce, bag of serrano chilies, bag of parsley and cilantro without a date indicating when the items were placed in the refrigerator. During an interview with Dietary Aide (DA) 1 on 11/16/2023 at 8:17 a.m., in the refrigerator, DA 1 stated all food items that were placed in the refrigerator have to be labeled with the date that it was placed in the refrigerator. The DA stated food items must be labeled with the date to know which items should be used first used and 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 three of four Residents (Resident 9, 64, and 84) understood the arbitration (is a way of resolving a dispute without filing a lawsuit and going to court) agreement when entering a binding contract (an agreement between two or more parties that creates certain obligations that must be adhered to by law) by failing to: 1. Present the arbitration agreement in a language Residents 64 and 84 can understand or preferred language. 2. Ensure Resident 9, 64, and 84 understand the arbitration agreement. Findings: During a review of Resident 9's admission Record, dated 11/16/2023, the admission Record indicated Resident 9 was admitted to the facility on [DATE] with an admitting diagnosis of pneumonia (a lung infection). During a review of Resident 9's History and Physical (H&P), dated 10/11/2023, the H&P indicated Resident 9 had the capacity to understand and make decisions. During a review of Resident 9'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 failed to ensure infection control measures were implemented and maintained for three of 30 sampled residents (Resident 10, 38, and 49) by failing to: 1. Ensure Resident 49 was placed on contact isolation (resident is placed away from others when a resident has an infectious disease that could be spread by touching either the resident or objects handled by the resident; medical staff and visitors required to wear gowns and gloves when entering the room) until his antibiotic (medication to treat an infection) therapy was completed. 2. Label oxygen (a colorless, odorless reactive gas, and the life-supporting component of the air) tubing with the date of initiation for Resident 10 and Resident 38. These failures had the potential to affect all residents and cause avoidable spread of infection to residents and staff. Findings: 1. During a review of Resident 49's admission Record (Face Sheet), the admission Record indicated Resident 49 was initially…

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

Based on interview and record review, the facility failed to ensure one of ten residents (Resident 9) was informed of their right to formally complain to the State Agency (Department of Public Health) about the care they were receiving. This failure had the potential to result in Resident 9 being unable to voice her concerns and to advocate for herself and other residents in the facility. Findings: During a group interview on 11/14/2023 at 2:13 p.m., Resident 9 stated she was unaware that she could contact the State Agency to file a complaint regarding her care. During an interview on 11/15/2023 at 9:38 a.m., with the Director of Social Services (DSS), the DSS stated residents had the right to file a complaint to the State Agency and should be able to advocate for themselves. During an interview on 11/15/2023 at 10:45 a.m., with the Administrator (ADM), the ADM stated the residents had the right to file a complaint with the State Agency. The ADM stated the residents should be informed of their right, so the residents know there was oversight from an outside agency that oversaw their…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ten of ten residents (Resident 5, 9, 23, 45, 55, 56, 60, 73, 78, and 90), that attended the resident council group meeting, were aware of the availability and location of the facility's latest survey results. This failure had the potential to result in the residents and their representatives to not be fully informed of the facility's deficient practices and how they were corrected. Findings: During a group interview on 11/14/2023 at 2:10 p.m., with Resident 5, 9, 23, 45, 55, 56, 60, 73, 78, and 90, all ten residents stated they were not aware of the availability and location of the survey results and how the facility corrected the deficiencies in the past survey. During an interview on 11/15/2023 at 9:38 a.m., with the Director of Social Services (SSD), the SSD stated the results of the state inspection were in a binder on the wall near Nursing Station A. The SSD stated the residents never asked to see the results. The SSD stated since the topic never came up, she (SSD) never had to tell anyone. The SSD 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's Social Services Director (SSD) and nursing staff failed to ensure a resident received proper attention for hearing loss to the right ear for one of 24 sampled residents (Resident 18). The SSD and nursing staff failed to refer Resident 18 to allied professional services to assist with Resident 18's hearing needs, failed to provide a communication board, and failed to place a hearing impaired sign to indicate which ear Resident 18 could better communicate per the resident's care plan and physician order. These deficient practices resulted in a delay of services, and exposed Resident 18 to embarrassment of having staff repeat themselves when communicating. Findings: During a review of Resident 18's admission Record, the admission record indicated Resident 18 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation (Afib, irregular heart beat) and emphysema (a condition in which the air sacs of the lungs are damaged and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure padded siderails and a floor mattress were utilized for one of three sampled residents (Resident 38). This failure had the potential to result in injuries during a seizure (a disorder in which nerve cell activity in the brain is disturbed) by Resident 38 potentially hitting the resident's head or other body parts on the exposed siderails or falling onto the bare floor. Findings: During a review of Resident 38's admission Record (Face Sheet), the admission Record indicated Resident 38 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (damage to the tissues in the brain due to a loss of oxygen to the area), chronic obstructive pulmonary disease (COPD, lung disease that blocks airflow and make it difficult to breathe), epilepsy (a disorder in which nerve cell activity in the brain is disturbed), and dementia (a condition characterized by progressive or persistent loss of intellectual functioning).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 enteral feeding (a special liquid food mixture containing protein, carbohydrates, fats, vitamins, and minerals) was administered as ordered for one of four sampled residents (Resident 46). This failure had the potential to result in Resident 46 to not meet their nutritional requirements, placing the resident at risk for avoidable weight loss, malnutrition, and skin breakdown. Findings: During a review of Resident 46's admission Record (Face Sheet), the admission Record indicated Resident 46 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included but not limited to sepsis (life-threatening emergency where the body has an extreme response to an infection), dysphagia (difficulty swallowing), dementia (a condition characterized by progressive or persistent loss of intellectual functioning), and hypertension (high blood pressure). During a review of Resident 46's Minimum…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 tube feeding (a medical device used to provide nutrition to people who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation) water bag used for flushing (technique used to prevent blockage or clogging of the feeding tube) was labeled with the date for one of three sampled resident (Resident 59) receiving tube feeding. This deficient practice placed Resident 59 at risk for an infection. Findings: During a record review of Resident 59's admission Record, dated 11/15/2023, the admission Record indicated Resident 59 was initially admitted to the facility on [DATE] with diagnoses that included a gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often 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 provide respiratory care consistent with professional standards of practice for two of four residents (Resident 10 and Resident 140) by failing to: 1. Ensure the humidifier (water used to increase the moisture while providing oxygen therapy) bottle was filled with sterile water when oxygen therapy was provided for Resident 10. 2. Ensure oxygen therapy was administered to Resident 140 with a physician's order. These failures had the potential to result in dryness of Resident 10's mouth and nostrils, and the potential for Resident 140 to receive oxygen therapy unnecessarily. Findings: 1. During a review of Resident 10's admission Record (Face Sheet), the admission Record indicated Resident 10 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included but not limited to Parkinsonism (brain conditions that causes slow movements, stiffness, and tremors), dementia (a condition…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to complete annual performance evaluations for one of three sampled Certified Nurse Attendants' ([CNA] 3). This failure had the potential to allow CNA 3 to perform CNA 3's duties without being held accountable for CNA 3's performance when providing quality care for all the residents. Findings: During a review of Resident 9's admission Record, the admission record indicated Resident 9 was originally admitted to the facility on [DATE] with diagnoses that included pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) of the sacral region (tailbone) and chronic pain (long standing pain that persists beyond the usual recovery period or occurs along with a chronic health condition). During a review of Resident 9's Care Plan titled, Activity of daily living (ADL), dated 10/11/2023, the care plan indicated the goal was for all of Resident 9's ADLs needs to be met. The staff's intervention's 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 ensure one out of six sampled residents (Resident 70) was free from unnecessary medications when the facility continued to administer Hydroxyzine ([also known as Atarax] drug used to treat anxiety [feeling of fear, dread, and uneasiness], nausea, vomiting, allergies, and itching) after the physician discontinued the order on 10/30/2023. This failure had the potential to result in Resident 70 receiving unnecessary medications. Findings: During a review of Resident 70's admission Record, the admission Record indicated Resident 70 was admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 70 was admitted with diagnoses that included but not limited to fibroblastic disorders (tumors that affect connective tissue of the body), heart failure (condition in which the heart cannot pump enough oxygen-rich blood to meet the body's needs), chronic obstructive pulmonary disease (COPD, a group of diseases that cause…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Resident 70 was free from a significant medication error for one out of eight sampled residents (Resident 70) by failing to: 1. Ensure the right dose of Methadone (a powerful drug used for pain relief and treatment of drug addiction) was transcribed to the electronic Medication Administration Record ([eMAR]- an electronic record of medications administered to a resident) per physician order. 2. Accurately document the administration of Methadone 5 mg ([mg]- unit of measurement) on the Controlled Drug Administration Record and eMAR between 11/8/23 and 11/14/23. 3. Ensure the availability of Methadone 5 mg for Resident 70. These failures resulted in Resident 70 verbalizing symptoms of pain, inability to sleep, and anxiety (a feeling of fear, dread, and uneasiness) as evidenced by reporting 8 out of 10 (severe) pain throughout his entire body, shortness of breath, and feelings of anger. Cross Reference F684. Findings: During a review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility's Social Services Director (SSD) failed to ensure one of 24 sampled residents' (Resident 18) dental needs were identified and the resident received dental services. The facility also failed to ensure a referral for dental services was completed for Resident 18. This deficient practice resulted in a delay of dental services and complaints of discomfort while chewing. Finding: During a review of Resident 18's admission Record, the admission record indicated Resident 18 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation (Afib, irregular heart beat) and emphysema (a condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness). During a review of Resident 18's Order Summary Report dated 1/14/2023, the order summary report indicated Resident 18 was ordered for a dental consultation as needed. During a review of Resident 18's History and Physical (H&P) dated 1/21/2023, the H&P indicated Resident 18…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review, the facility failed to provide the appropriate textured diet for two out of three residents (Resident 29 and Resident 66). This deficient practice placed Resident 29 and Resident 66 at risk for choking. Findings: a. During a record review of Resident 29's admission Record, dated 11/15/2023, the admission Record indicated Resident 29 was initially admitted to the facility on [DATE] with an admitting diagnosis of wedge compression fracture (occurs when the bone collapses and the front part of the vertebral body forms a wedge shape) of the third vertebra (the third bone of the series of small bones forming the backbone, having several projections for articulation and muscle attachment, and a hole through which the spinal cord passes). During a review of Resident 29's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 7/28/2023, the MDS indicated Resident 29 was moderately cognitively impaired (ability to think and reason). 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 observations, interviews, and record review, the facility failed to follow their infection prevention and control program by failing to: 1. Isolate (separation of a sick resident with a contagious disease from a resident who was not sick) one of two sampled residents (Resident 1) who tested positive for coronavirus disease ([COVID-19], a highly contagious respiratory infection caused by a virus that can easily spread from person to person) in a timely manner; 2. Ensure Registered Nurse (RN 1) donned (put on) Personal Protective Equipment use of personal protective equipment ([PPE] specialized clothing or equipment worn to minimize exposure to serious illnesses) before going to a COVID-19 isolation room; and 3. Report the facility COVID-19 outbreak to licensing and certification. These deficient practices had the potential to cause the spread COVID-19 in the facility and cause other residents, staff and visitors to become ill. Findings: During a review of Resident 1's face sheet (admission Record), 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 observations, interview, and record review, the facility failed to manage a tube feeding pump properly for one out of three sampled residents (Resident 1). This deficient practice had the potential to cause dehydration, infection, and weight loss to Resident 1. Findings During a review of Resident 1's face sheet (admission record), dated 8/23/2023, the face sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including unspecified convulsions (a sudden, violent, irregular movement of a limb or the body), cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), and dysphagia (difficulty swallowing). During a review of Resident 1's History and Physical (H&P), dated 8/12/2023, 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 and care planning tool), dated 7/27/2023, 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 During an observation, interview, and record review, the facility failed to ensure the staff kept the urinary catheter bag off the floor for one of three sampled residents (Resident 1). This deficient practice had the potential to cause an infection to Resident 1. Findings During a review of Resident 1's face sheet (admission record), dated 8/23/2023, the face sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including unspecified convulsions (a sudden, violent, irregular movement of a limb or the body), cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), and dysphagia (difficulty swallowing). During a review of Resident 1's History and Physical (H&P), dated 8/12/2023, 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 and care planning tool), dated 7/27/2023, the MDS indicated 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.