Bellflower Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure food served was palatable (food or drink that is pleasant, savory, or agreeable to the taste) and/or at the preferred temperature for three of 54 sampled residents (Resident 19, Resident 60, and Resident 53).This failure had the potential for residents' poor meal intake and which could lead to weight loss. Findings:A. During a review of Resident 19's admission record, the admission record indicated Resident 19 was admitted to the facility on [DATE] with diagnosis including Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dysphagia (difficulty swallowing), and essential hypertension (high blood pressure that is not due to another medical condition).During a review of Resident 19's History and Physical (H&P), dated 1/1/2026, the H&P indicated, Resident 19 had the capacity (ability) to understand and make decisions.During a review of Resident 19'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 follow their antibiotic stewardship policy for one of three sampled residents (Resident 5) when the facility did not inform the physician when Resident 5, who was prescribed gentamicin (antibiotic to treat bacterial infections) eye drops did not meet McGeer's criteria (criteria used to detect infections based on symptoms and laboratory values).This resulted in Resident 5 receiving inappropriate antibiotic eye drops and the potential to develop antibiotic resistance.Findings: During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including end stage renal disease (ESRD - chronic kidney disease that causes gradual loss of kidney function), dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine), and cellulitis (infection of the skin).During a review of Resident 5'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.

Based on interview and record review, the facility failed to educate and offer the COVID-19 vaccination for the 2025-2026 respiratory season for two of five sampled staff (Physician 1 and Physician 2).These failures had the potential to result in spreading the COVID-19 virus throughout the facility. Findings:During a concurrent interview and record review on 4/15/2026 at 10:26 a.m. with the Infection Prevention Nurse (IPN), the staff vaccination records were reviewed. The IPN stated there was no documentation that Physician 1 and Physician 2 were offered the COVID-19 vaccination for the 2025-2026 respiratory season and educated on the risks and benefits of receiving the vaccination. The IPN stated both Physician 1 and Physician 2 actively cared for current residents.During an interview on 4/16/2026 at 1:52 p.m. with Registered Nurse Supervisor (RNS) 1, RNS 1 stated it was important to offer the COVID-19 vaccine and educate all staff to prevent the spread of the COVID-19 virus to residents. RNS 1 state the COVID-19 consent form is proof that the facility encouraged and educated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation. interview and record review, the facility failed to implement infection control measures by failing to:A. Ensure implementing the water management plan (comprehensive plan aimed to prevent waterborne illnesses by controlling germs in the water) by monitoring and documenting control measures (actions taken to eliminate or reduce the likelihood or severity of exposure to a hazard) and limit (a specific, measurable, and quantitative range for a particular parameter that indicates when a water system is operating acceptably).B. Identify, follow through, and report Resident 1's positive result of Legionella (a type of bacteria that is naturally found in [NAME] environments) Urine Antigen Test [UAT-a diagnostic test used to detect Legionella (bacteria in the urine of individuals suspected of having Legionnaires' disease (a severe form of a lung infection called pneumonia that is caused by a bacterium known as legionella)] to California Department of Public Health (CDPH-the state department…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Jello items were stored and maintained at the required temperature of 41-degree Fahrenheit (a temperature scale, range for cold food is below 41 degrees). This failure had the potential to result in food spoilage, compromised taste for residents as proper temperature control is essential to ensure food safety and quality. Findings: During an observation on 2/18/2025 at 11:35 a.m., in the kitchen, observed that the Dietary Supervisor (DS) pulled out one cup of Jello from the refrigerator and checked its temperature, which measured 54 degrees. During an observation on 2/18/2025 at 11:48 a.m., in the kitchen, observed that the DS checked temperature of another Jello, which measured 48 degrees. During an observation on 2/18/2025 at 12:22 p.m. in the kitchen, observed that Dining cart #1, #2 were being transported from the kitchen with the Jello items. Before cart #3 left the kitchen, the DS checked temperature of Jello again, and the thermometer indicated at 48 degrees. During an interview on 2/19/2025,…

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

Based on interview and record review the facility's Quality Assessment and Assurance (QAA) Committee, thereby affecting 47 out of 47 residents, failed to identify and implement corrective action to the systemic problems identified: a. Ensure medication parameters are followed when administering medication to residents b. Ensure dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) residents are assessed before departing for dialysis and after residents return from outpatient dialysis. c. Ensure the kitchen store, prepare and distribute food in accordance with professional standards for food service safety. These deficient practices placed the residents at risk for not receiving the quality treatment necessary to adequately meet their highest practicable well-being. Findings: During an interview on 2/21/2025 at 9:26 a.m., with the Administrator (ADM), the ADM stated the following systemic issues identified were not identified by the QAA committee: a) ensure medication parameters are followed wen medicating…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 nurses would document resident's pain level before removing pain medication from inventory, and document resident's refusal of administration, for one of one residents (Resident 43). This deficient practice had the potential of medication error and/or narcotic diversion. Findings: During an observation at the medication cart 1 on 2/19/25 at 3:45 PM, there was a multiple-dose blister pill pack (bubble pack) for Resident 43. The medications in the bubble pack were labeled as oxycodone with acetaminophen (generic for Percocet, a potent opioid to treat severe pain) 10/325 milligrams (mg, an unit of measuring mass). During an interview and a concurrent review of Resident 43's controlled drug record (an accountability record or count sheet for narcotics) for Percocet, the licensed vocational nurse (LVN 3) stated the count sheet indicated there were two doses marked wasted, one each on 12/4/24 (no time noted) and 2/13/25 (6 AM). LVN 3 reviewed Resident 43's electronic medication administration record (eMAR) and stated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to appropriately assess and monitor one of one sampled resident (Resident 15) during the use of an abdominal binder (a wide belt that provides light compression around the stomach) placed over Resident 15's a gastrostomy (g-tube: a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). This deficient practice had the potential to place the resident on unnecessary restraints. Findings: During a review of Resident 15's admission Record, the admission Record indicated Resident 15 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including gastrostomy, dysphagia (difficulty swallowing), and Huntington's Disease (a progressive inherited neurodegenerative disorder that affects the brain). During a review of Resident 15's History and Physical (H&P), dated 6/22/2024, the H&P indicated Resident 15 did not have the capacity to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one of two sampled resident's (Resident 37) care plans were reviewed and updated on a quarterly basis. This deficient practice had the potential to result in poor quality of care and a delay in care and services. Findings: During a review of Resident 37's admission Record, the admission record indicated Resident 37 was admitted to the facility on [DATE] with diagnosis including acute respiratory failure (when the air sacs of the lungs cannot release enough oxygen into the blood), type 2 diabetes (long-term condition in which the body has trouble controlling blood sugar and using it for energy), hypertension (condition in which the force of the blood against the artery walls is too high), and dementia (a progressive state of decline in mental abilities). During a review of Resident 37's Minimum Data Set ([MDS] a resident assessment tool) dated 11/8/2024, the MDS indicated Resident 37's cognition (ability to think and reason) was moderately…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 onobservation, interview and record review, the facility failed to 1.Ensure nurses would document resident's pain level before removing pain medication from inventory, and document resident's refusal of administration, for one of one residents (Resident 43). These deficient practices had the potential of medication error and/or narcotic diversion. 2. Ensure one of one sampled residenst (Resident 48) had a urology (a medical specialty that focuses on the diagnosis, treatment, and prevention of diseases and disorders related to the urinary system) consult and received services to meet professional standards of practice. These failures had the potential for Resident 48's penile (located on the penis) open wound to get infected. Findings: 1. During an observation at the medication cart 1 on 2/19/25 at 3:45 PM, there was a multiple-dose blister pill pack (bubble pack) for Resident 43. The medications in the bubble pack were labeled as oxycodone with acetaminophen (generic for Percocet, a potent opioid to treat…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two sampled residents' (Resident 5) foley catheter (a device that drains urine from your urinary bladder into a collection bag outside of your) drainage bag was changed as ordered. This deficient practice had the potential to result in complications that can negatively affect the resident's wellbeing. Findings: During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was readmitted to the facility on [DATE] with diagnoses including acute kidney failure (A condition in which the kidneys suddenly can't filter waste from the blood), and acute cystitis (infection of the bladder - organ that holds the urine). During a review of Resident 5's Minimum Data set (MDS), A resident assessment tool, dated 1/15/2025, the MDS indicated Resident 5's cognitive skills (functions your brain uses to think, pay attention, process information, and remember things) for daily decision-making was intact. The MDS indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility did not provide care and services consistent with professional standards of practice to three of three residents (Resident 5, 30, 49) receiving supplemental oxygen (element essential for life) when the facility failed to: a. Ensure Resident 5 had visible signage warning others oxygen was in use to prevent hazardous practices. b. Ensure Resident 30 and 49's nasal canula (device that delivers oxygen through the nostrils) was labeled with a date to ensure it was changed timely. c. Ensure Resident 30's oxygen use was being documented in the Medication administration record. These deficient practices had the potential to result in unsafe and unsanitary administration of oxygen in the facility. Findings: a) During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was readmitted to the facility on [DATE] with diagnoses including acute respiratory failure (life-threatening condition that occurs when the lungs and blood 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 interview and record review, the facility failed to ensure three of three Residents on hemodialysis ([HD]a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) , received dialysis care and services based on professional standards (Resident 17, 27, and 113). The facility failed to: a. Ensure staff assessed Resident 113 prior to sending Resident 113 to dialysis. b. Ensure Resident 17 had equipment and supplies necessary to manage emergencies such as bleeding at the bedside. c. Ensure staff assessed Resident 27 and 113 after the residents returned from the dialysis center. These deficient practices had the potential to result in undetected complications from dialysis, or delayed treatment of complications. Findings: a.During a review of Resident 113's admission Record, the admission Record indicated Resident 113 was originally admitted to the facility on [DATE] with diagnoses including end stage renal disease (ESRD -irreversible kidney…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one of three Licensed Vocational Nurse (LVN 9 ) had the specific competencies and skills sets necessary to care for residents by failing to ensure LVN 9's SNF (Skilled Nursing Facility) Licensed Nurse Orientation Annual Competency checklist (a systematic evaluation of nursing staff's competency levels in various areas of practice) was up to date. This deficient practice had the potential for residents not to receive appropriate nursing services and care which had the potential for injury to residents. Findings: During a record review LVN 9 was hired on 8/22/2023, on 9/18/2023 the form titled SNF Licensed Nurse Orientation Annual Competency Checklist was completed by LVN 9 . During a record review and interview on 2/20/2025 at 11:27 a.m., with the Director of staff Development (DSD), the DSD stated LVN 9's last annual competency check list was completed on 9/18/2023 with an expiration date of 3/31/2024 . The DSD stated LVN 9 was 11 months past due. The DSD stated it was important to make sure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations, interviews, and record review, the facility failed to develop a facility policy that matched the facility's current method of documentation, specifically in the relations to medication administration record. This deficient practice had the potentials of inaccurate records, drug loss and/or diversion. Findings: A review of the facility policy and procedures, Medication Administration-General Guidelines (dated 10/2017), indicated .An explanatory note is entered on the reverse side of the record provided for PRN documentation . During a concurrent interview on 2/20/25 at 12:28 PM, the director of nursing (DON) stated the facility did not have a more updated version of the aforementioned policy. DON stated the facility had been using electronic medication administration records (MAR) and not the paper MAR. DON stated the policy was referred to the paper MAR that was no longer in use. DON stated the current practice is for the nurse to initiate a text box that will populate in the eMAR for documentation. DON agreed the aforementioned policy needs to be updated.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to hold (not administer) the hypertensive medications (drugs used to treat high blood pressure - condition where the force of blood against the artery walls is too high) for two of three residents (Resident 27 and 112) when the residents blood pressures were below given parameters (sets the condition of providing the medication). This deficient practice had the potential to result in hypotension (condition where the blood pressure falls below normal levels) which can cause fainting or dizziness because the brain does not receive enough blood. Findings: During a review of Resident 112's admission Record, the record indicated Resident 112 was admitted to the facility on [DATE] with a diagnosis including essential hypertension (a condition characterized by persistently high blood pressure without an identifiable underlying cause). During a review of Resident 112's Minimum Data Set (MDS), a resident assessment tool, dated 2/11/2025, the MDS indicated Resident…

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

Based on observation, interview, and record review, the facility failed to: 1. Ensure active medications for current residents would not be stored in a cabinet labeled for discontinued medicines. 2. Ensure multiple dosed medication container had an open date and outdated medications would not be stored in the medication cart. These deficient practices had the potentials of medication errors, delay in receiving medications, and/or receiving outdated medications. Findings: 1. During an observation on 2/19/25 at 2:59 PM in the medication room located in the nursing station 1 with a licensed vocational nurse (LVN 3), there was a cabinet above the sink and labeled discontinued medicines. Inside the aforementioned cabinet, LVN 3 confirmed there were 17 multiple-dose blister pill packs (bubble packs) in the middle shelf. LVN stated these bubble packs were refill medications appeared to have been delivered within the last week. LVN stated newly delivered medications would be stored in the medication carts. LVN 3 stated this cabinet is for the storage of discontinued or discharged…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two sampled resident's (Resident 37) lab test was completed timely. This deficient practice resulted in a delay of care that had the potential to result in a continued undiagnosed problem that may be harmful for Resident 37. Findings: During a review of Resident 37's admission Record, the admission record indicated Resident 37 was admitted to the facility on [DATE] with diagnosis including acute respiratory failure (when the air sacs of the lungs cannot release enough oxygen into the blood), type 2 diabetes (long-term condition in which the body has trouble controlling blood sugar and using it for energy), hypertension (condition in which the force of the blood against the artery walls is too high), and dementia (a progressive state of decline in mental abilities). During a review of Resident 37's Minimum Data Set ([MDS] a resident assessment tool) dated 11/8/2024, the MDS indicated Resident 37's cognition (ability to think and reason) was…

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

Based on observation, interview, and record review, the facility failed to: a. Label food items properly. -One opened bottle of 'Thick and Easy' (thickener-a substance which can increase the viscosity of a liquid without substantially changing its other properties) -Two cups of chicken noodle soup -One bag of Seven Zucchinis -Two bunches of Celery -Four lettuces and the Five tomatoes in one container -One bag of cookie dough b. Remove expired items. -Diabetisource AC (a tube feeding formula) -Two bags of bread c. Test and document the concentration of the sanitizing solution and dish machine prior to use. These failures had the potential to result in contamination, or improper sanitation, compromising resident safety, infection control and food borne illness. Findings: a. During a concurrent observation and interview on 2/18/2025 at 8:12 a.m., with the Dietary Supervisor (DS), in the kitchen, the following items were found without proper labeling or date marking in the refrigerator and freezer: -One opened bottle of 'Thick and Easy' (thickener-a substance which can increase the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the licensed nursing staff failed to maintain and complete accurate medical records in accordance with accepted professional standards for one of three sampled residents (Resident 27) by failing to: 1.Ensure Resident 27's Dialysis (mechanical removal of waste from the body due to kidney failure) Communication Record DCR (a medical document about a patient's dialysis treatment) was completed. 2. Ensure Licensed Vocational Nurse (LVN) 8, did not falsify Resident 27's Dialysis Communication Record for dates 1/23/2025, 1/28/2025, 2/4/2025 and 2/11/2025 when he (LVN 8) documented about Resident 8 even though he (LVN 8) was not working on those days. This deficient practice of falsifying Resident 27's Dialysis Communication Record indicated an inaccurate state of the resident's condition, and placed Resident 27 at risk of not receiving appropriate care due to inaccurate and incomplete resident medical care information. Findings: During a review of Resident 27's admission Record,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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: a. Ensure Resident 7's, foley catheter ( a thin, flexible tube inserted into the bladder [an organ that stores urine] to drain urine) was not touching the floor. b.Ensure facility staff used the correct Personal Protective Equipment (PPE: equipment worn (gown, gloves, goggles) to help create a barrier between a healthcare worker and germs) when caring for one of two sampled residents (Resident 15) that was on Enhanced Barrier Precautions (EBP: infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs)) and not performing hand hygiene prior to entering room. c. Ensure the facility staff had access to PPE d. Conduct annual Legionella (a severe form of lung infection that causes lung inflammation caused by bacteria) facility risk assessment. These deficient practices had the potential to transmit infectious microorganisms and increase the risk of infections for the residents. During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to offer and monitor the immunization (a process whereby a person is made resistant to a disease through medication administration) status for the Influenza (flu: a contagious respiratory illness) and Pneumococcal (bacterial infection that causes serious lung infections) vaccinations (medication to prevent a particular disease) for one of five sampled residents (Resident 9). This deficient practice resulted in Resident 9's medical records being incomplete. Findings: During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was admitted to the facility on [DATE] with diagnoses including gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), cerebral palsy (group of disorders that affect muscle tone and movement), and asthma (chronic lung disease that causes inflammation in the airway). During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to involve one of three sampled resident's (Resident 26) in the resident's initial Interdisciplinary Team (IDT-team of health care professionals that work together toward and prioritize the resident 's needs) care conference. This deficient practice violated Resident 26's rights to be informed and the right to participate in resident's plan of care. Findings: During a review of Resident 26's admission Record, the admission Record indicated Resident 26 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (brain problem), type 2 diabetes (disorder characterized by difficulty in blood sugar control and poor wound healing), and muscle weakness. During a review of Resident 26's Minimum Data Set (MDS), a resident assessment tool, dated 2/20/2025, the MDS indicated Resident 26's cognition was severely impaired. The MDS indicated Resident 26 was dependent on staff for all activities of daily living (ADLs- routine…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for one of two sampled residents (Resident 37) addressing Resident 37's anticoagulant (medications that prevent blood from clotting) use. This deficient practice had the potential to result in poor quality of care and a delay of care and services. Findings: During a review of Resident 37's admission Record, the admission record indicated Resident 37 was admitted to the facility on [DATE] with diagnosis including acute respiratory failure (when the air sacs of the lungs cannot release enough oxygen into the blood), and atrial fibrillation (irregular heartbeat). During a review of Resident 37's Minimum Data Set ([MDS] a resident assessment tool) dated 11/8/2024, the MDS indicated Resident 37's cognition (ability to think and reason) was moderately impaired. The MDS indicated Resident 37 was dependent on staff for all activities of daily living (ADLs- activities such as bathing, dressing and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one of three sampled resident's (Resident 5) informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for psychotropics (drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) was obtained prior to administration. This deficient practice violated Resident 5's rights to receive all information, in advance, of risks and benefits of proposed care, treatment, treatment alterative, and choose the alterative of choice which includes information for administration of psychotropic drugs. Findings: During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was readmitted to the facility on [DATE] with diagnoses including acute kidney failure (A condition in which the kidneys suddenly can't filter waste from the blood), acute cystitis (infection of…

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

Based on interview and record review, the facility failed to provide documented evidence of all employees screening, education, offering, and current Corona virus disease, COVID-19 (contagious infectious disease), vaccination (medications used to prevent diseases usually given by injection or by mouth) status. This failure had the potential to place staff and residents at risk for negative health outcomes such as being hospitalized due to COVID-19. Findings: During a concurrent interview and record review of the Covid-19 Staff Vaccination Status (document that reflects staff employee vaccination status) on 2/19/2025 at 4:36 p.m., with the Infection Prevention Nurse (IPN), the IPN stated she does not know the facility physicians and consultants Covid-19 immunization status. During an interview on 2/20/2025 at 4:42 p.m., with the Director of Nursing (DON), the DON stated the Covid-19 vaccination status for all employees including doctors, rehabilitation departments, and consultants that come in contact with residents must be known as they put the residents they are incontact with 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.

Based on observation, interview and record review, the facility failed to ensure to store food with open date (date food package was opened for use) label and food expiration date. This practice put the facility residents at risk for infection by ingesting expired foods and can result in foodborne illnesses and symptoms such as nausea, vomiting, stomach cramps, and diarrhea. The expired foods are at risk for decreased flavor and taste. Findings: During a concurrent observation and interview with Kitchen Assistant (KA) 1, on 2/24/2024 at 6:58 a.m., of there was a seal plastic container with white powder thickener with a peeled label, on the kitchen counter. Surveyor was unable to observe any received-on, opened-on or expiration date. KA stated, there should be a label on the container. KA 1 stated, we need to know the date that container was opened. KA 1 stated, the kitchen staff need to know until when the product can be used. KA 1 stated, the label is very important, so residents do not eat any expired product. During a concurrent observation and interview with the Kitchen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pharmaceutical services that meet the needs three of 11 sampled residents (Resident 29, 32 and 202): 1. Resident 29 and Resident 32 did not receive medication at the scheduled time and with food as ordered by the physician. 2. Resident 202 received a crushed enteric coated medication. These deficient practices had the potential for avoidable physical harm related to residents not receiving their medications on time, or experiencing potential adverse drug reactions from medications being administered differently from how they were ordered. Findings: During a review of Resident 32's admission Record, dated 2/25/2024, the admission record indicated Resident 32 was admitted to the facility on [DATE] with diagnoses including hypertension (when the pressure in your blood vessels is too high), schizoaffective disorder (a mental disorder with symptoms of hallucinations or delusions and mood disorder like depression), and 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 staff failed to ensure they were free of medication error rate of five (5) percent (%) or greater as evidenced by the identification of three (3) medication errors out of 29 opportunities for errors, to yield a facility medication error rate of 12 % for three of 11 sampled residents (Residents 29, 32, and 202). 1. Resident 202 receive a crushed extended release (ER-designed to slowly release a drug in the body over an extended period of time especially to reduce dosing frequency) medication administration of metoprolol succinate (medication for high blood pressure) 2. During medication administration of metoprolol tartrate (medication to manage high blood pressure) for Resident 32 and metformin HCL (medication used to treat diabetes [abnormal sugar]) for Resident 29. Residents did not receive medication at the scheduled time and with food as ordered by the physician. These deficient practices had the potential to result in ineffectively managed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 control policy for five out of 29 sampled residents (14, 32, 40, 153, and 202) by failing to: A: Properly put on personal protective equipment (PPE, equipment used to prevent or minimize exposure to hazards) upon entering Resident 153's contact isolation room. B. Ensure oxygen tubing (plastic tubing applied to the nostrils that delivers life sustaining gases) was not on the ground for Resident 14. c. Disinfect the blood pressure cuff (tool used to measure blood pressure) after each use for Residents 32, 40, and 202. Findings: A. During a review of Resident 153's admission Record dated 2/27/2024, the admission Record indicated Resident 153 was admitted to the facility on [DATE] with diagnoses including urinary tract infection (UTI, an infection of the urinary system), extended spectrum beta lactamase (ESBL) resistance (bacterial infection resistant to a class of antibiotics), and multiple fractures (broken bones)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 protect the dignity of one out of 29 sampled residents (Resident 1) by not providing a dignity bag (conceals the urinary drainage bag [a bag that collects urine] from public view to maintain the residents' dignity) over the urinary catheter bag. This deficient practice had the potential to compromise Resident 1's privacy and dignity. Findings: During a review of Resident 1's admission Record, dated 2/25/2024, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including sepsis (a life-threatening complication of an infection), obstructive and reflux uropathy (a condition when urine cannot drain through the urinary tract and backs up), and acute kidney failure (a condition in which the kidneys cannot filter waste from blood). During a review of Resident 1's History and Physical (H&P), dated 10/10/2023, the H&P indicated Resident 1 could make needs known but…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to assess the urine in the foley catheter tubing (a plastic device inserted inside the body to drain urine from the bladder [an organ that is part of the urinary system] into an outside bag) for sediments and cloudiness for one of two sampled residents (Resident 8). Resident 8 had an indwelling foley catheter with noticeable sediment (accumulation of white blood cells) and cloudiness in the urine tubing. This deficient practice placed Resident 8 at risk for a urinary tract infection ([UTI] when bacteria enter the urinary system and infect the urinary tract). Findings: During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was admitted on [DATE] and readmitted on [DATE], with diagnoses that included Benign prostatic hyperplasia (a noncancerous enlargement of the prostate gland [a part of the urinary system], retention of urine unspecified (inability to completely empty the bladder of urine), and disorder of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 14 and Resident 103) received respiratory care consistent with professional standards of practice when: 1.Resident 14's oxygen (life sustaining gas in air) nasal cannula (a device used to deliver supplemental oxygen) tubing, and humidifier (liquid that moistens the air) bottle was not labeled with the date of change to be used as reference for changing humidifier bottles every seven days. These failures had the potential to result in unsafe use or storage of oxygen equipment, respiratory infection, and/or hospitalization for Resident 14 . 2.Resident 103's Bilevel positive airway pressure (BIPAP - a device that helps a patient breath) machine was not set up for Resident 103's use, as ordered by physician. This deficient practice had the potential to result in Resident 103 being unable to breathe comfortably, and/or hospitalization. Findings: During a review of Resident 14's admission Record,…

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