Bishop Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the call light (a device that allows a resident to communicate with nursing staff when a resident needs assistance) was within resident reach for one of six sampled residents (Resident 49 ) when Resident 49's call light was hanging off the side of the bed and out of the reach. This failure had the potential to place Resident 49 at risk for safety and well-being.Findings:A review of Resident 49's admission Record (contains demographic and medical information), indicated Resident 49 was admitted to the facility on [DATE], with diagnoses which included acute respiratory failure with hypoxia ( the lungs are suddenly unable to adequately transfer oxygen into your bloodstream), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), osteoarthritis( a degenerative joint disease where the protective cartilage covering the ends of your bones gradually wears away). During a concurrent observation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an allegation of abuse with an injury of unknown origin was reported to the State Survey Agency within the required time frame for one of one sample resident (Resident 11). This failure had the potential to put at risk the health and safety of Resident 11. Findings: During a review of Resident 11's admission Record (contains demographic and clinical information) the admission Record indicated Resident 11 was admitted to the facility on [DATE], with the diagnosis of paraplegia (partial or complete paralysis affecting the lower part of the body, resulting in impaired mobility and increased dependence on staff assistance for movement and transfers), cognitive communication deficit (difficulty understanding, processing, or expressing information which may affect the residents ability to communicate needs, report concerns or request assistance) and anoxic brain damage (brain injury caused by a lack of oxygen to the brain, which may…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one sampled residents (Resident 11) had access to a functioning resident's call light in the bathroom. This failure had the potential for Resident 11 to experience delayed assistance and increased the risk for unmet care needs, falls, injury, and inability to request help during an emergency. Findings: During a review of Resident 11's admission Record (contains demographic and clinical information), the admission Record indicated Resident 11 was admitted to the facility on [DATE] with the diagnosis of paraplegia (partial or complete paralysis affecting the lower part of the body, resulting in impaired mobility and increased dependence on staff assistance for movement and transfers), cognitive communication deficit (difficulty understanding, processing, or expressing information which may affect the residents ability to communicate needs, report concerns or request assistance) and anoxic brain damage (brain injury caused by a…

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

Based on observation, interview, and record review, the facility failed to ensure a written response was provided timely and in accordance with the facility's policy when the Family Council (also known as Resident Council; an organized group of relatives and friends of residents who meet regularly to discuss and address concerns about quality of care in the nursing home) submitted a grievance on November 9, 2025, and have not received any response until December 29, 2025. This failure has the potential to impact on the facility's ability to ensure grievances were promptly addressed and resolved, which could negatively affect 99 highly vulnerable residents residing in the facility. Findings:During a review of the facility's document titled Resident Council Town Hall Minutes, dated November 20, 2025, it indicated the meeting was held at 1:59 PM. Further review indicated there were new concerns discussed in the meeting which included residents waiting two hours for a incontinence pad change, and residents not being checked every two hours by the staff.During an interview on December…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 F 725: Sufficient Staffing - [NAME] Care Center S/S D [NAME] S483.35 Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at S483.70(e). S483.35(a) Sufficient Staff. S483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans: Intent:To assure that there is sufficient qualified nursing staff available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 sufficient number of nursing staff when the 3.5 direct care service hours per patient day (DHPPD- the total number of hours worked per patient day divided by the average daily number of residents in the facility) staffing requirement was not met. This failure had the potential to result in unmet resident's needs, such as psychosocial, physical needs, and safety concerns for 95 vulnerable residents. Findings: An unannounced visit was conducted on June 9, 2025, to investigate a complaint with allegations that included quality of care and staffing concern. During a telephone interview on June 9, 2025, at 4:08 PM, with the License Vocational Nurse (LVN 1), LVN 1 reported that on May 18, 2025, she observed the call light was activated for 40 minutes without the Certified Nursing Assistant (CNA) present to respond to it. During a concurrent telephone interview and record review on June 11, 2025, at 3:30 PM, with the Director of Staff Development (DSD), the facility's staffing waiver for Certified Nursing Assistant (CNA),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report for one of 3 sampled residents (Resident 1) per there policy and procedure to the state agency and the local ombudsman for an alleged abuse/ injury of unknown cause. This failure has the potential to put (Resident 1) health, safety and well-being at risk. Findings: During review of Residents 1's admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: Alzheimer's (disease destroys memory and mental functions), osteoarthritis (bones wear down), benign prostatic hyperplasia (enlargement gland causing urination difficulty), lack of coordination. During a review concurrent interview and record review of Resident 1's Medical Record reviewed are as follows: 1. March 01,2025, at 0612 Nurse Note: 1cm redness noted to resident Right side of face above eyebrow. No s/s of trauma, no bleeding, no drainage noted at this time. Will endorse to AM nurse. 2. March 01, 2025, 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 interview and record review, the facility failed to provide sufficient numbers of staff when 52 sampled days from October ' 2024 till March ' 2025 had less than 3.5 direct care service hours per patient day (DHPPD- the total number of hours worked per patient day divided by the average daily number of residents in the facility). This failure had the potential to result in unmet needs, such as psychosocial, physical needs, and safety concerns for 97 residents. Findings: During an interview with Certified Nurse Assistant 1 (CNA 1) on April 1. 2025, at 3:10 PM. CNA 1 stated we are unable to provide 1:1 care to one of our residents who wander off to other resident ' s room due to not having enough staff. We also have 2 CNA ' s that recently quit, and they have not found any replacement. CNA 1 also stated We recently had a meeting, and we were told by management that we are not using registry anymore. We have not had any registry in the facility. During an interview with Certified Nurse Assistant 2 (CNA 2) on April 1,2025 at 3:20 PM, CNA2 stated We are short staff on PM and NOC,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review, and facility document and policy review, the facility failed to ensure there was registered nurse (RN) coverage eight consecutive hours, seven days a week for 6 days (10/23/2024, 11/17/2024, 11/24/2024, 12/01/2024, 12/08/2024, and 12/22/2024) during Fiscal Year (FY) 2025, Quarter 1 (October 2024, November 2024, and December 2024) and 3 days (02/23/2025, 03/01/2024, and 03/02/2025) during the timeframe from 02/11/2025 through 03/11/2025. Findings included: A facility policy titled, Staffing, Sufficient and Competent Nursing, revised 08/2022, specified, Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. The policy indicated, 3. A registered nurse [RN] provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week. RNs may be scheduled more than eight (8) hours depending on the acuity needs of the resident. A PBJ [Payroll-based…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 sufficient numbers of staff when 3 out of 5 sampled days (January 9, 2025-January 13, 2025) had less than 3.5 direct care service hours per patient day (DHPPD- the total number of hours worked per patient day divided by the average daily number of residents in the facility). This failure had the potential to result in unmet needs, such as psychosocial, physical needs, and safety concerns for 93 residents. Findings: During interview with the Administrator (Admin) on January 22. 2025, Informed issues of staffing, (Admin) states, It's up to me to admit residents, I rely on my staff also, we have said no to admitting residents due to staffing. I listen to the staff; I never want the quality of care to go down. I'm not halting any hiring; we are hiring and have registry. During a concurrent interview and record review on January 22,2025 at 9:20 AM, with Director of Nursing (DON), the facility's policy and procedure (P&P), titled, Staffing, revised October 2017, was reviewed. The P&P indicated, Our facility provides…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 five residents (Residents 1,2, and 3) received or were offered fluids during the day and night. This failure had the potential in putting Residents 1, 2 and 3's health and safety at risk when not receiving fluids to meet daily requirements consistent with resident's comprehensive assessment. Findings: 1. During review of Residents 1's admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: contracture of left and right lower leg (tightening of muscle, tendon, prevents normal movement), thyrotoxicosis (life threatening condition, overactive thyroid), blindness in one eye (unable to see). During a concurrent observation and interview on January 21, 2025, with Resident 1 (R1), R1 stated, It happened 3 times, left me in soiled dirty diapers. All three times the CNA came in told me I will be back to change you. They never empty my urinal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Activities of Daily Living ADLs policy and procedure for 3 of 3 sampled Residents (Resident's 1,2 and 3) when: 1. Resident 1 used call light to get staff attention for help, waiting over an hour. 2. Resident 2 was left soiled for a long period of time. 3. Resident 3 used call light along with roommates to help call to get assistance that took over an hour. This failure has the potential to cause (Resident's 1,2, and 3) health and safety at risk for skin break down. Findings: During interview and Records Reviewed with (Resident 1,2, and 3) indicates as followed: 1. During review of Residents 1's admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: chronic pulmonary disease (lung disease that block airflow and makes difficult to breath), idiopathic peripheral autonomic neuropathy (damage to nerves causing dizziness, sweating, bladder problems),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 adhere to its food and nutrition services policy when three of three sampled residents (Resident 1, 2, & 3) were served meals that were not presented at an appetizing temperature. This failure may decrease resident ' s appetite and has the potential to adversely affect the well-being of clinically compromised Residents (Residents 1, 2, & 3) when their meals were served cold. Findings: During a review of Resident 1 ' s admission record (It contains important information about the patient such as their personal details, the reason for their admission, and their medical history),the document indicated Resident 1 admitted to the facility on [DATE], with a diagnosis that included hyperlipidemia (also known as a high cholesterol, a condition where too many fats, or lipids in the blood). During a review of the clinical record for Resident 1 ' s the Brief Interview for Mental Status (BIMS- screening tool to identify and monitor cognitive…

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

Based on observation, interview, and record review, the facility failed to adhere to its food-related garbage disposal policy when four outdoor dumpsters were left open. This failure had the potential to attract vermin (pest or animals that spread diseases) which could pose a significant health risk to the 89 clinically compromised residents currently residing in the facility. Findings: During a concurrent observation and interview, on October 14, 2024, at 1:39 PM, with the Maintenance Director (MD) 1, it was observed that some of the dumpsters outside of the facility were left open. During an interview on October 14, 2024, at 4:09 PM, with the Director of Nursing (DON) 1, I presented pictures of the open dumpsters located outside of the facility and pointed out the risk they pose to the residents as a breeding ground for rodents, DON 1 acknowledged and agreed with my observation. During a review of the facility ' s policy and procedure (P&P) titled, Food-Related Garbage and Rubbish Disposal, dated April 2006, the P&P indicated, .7. Outside dumpsters provided by garbage pickup…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 adhere to its pest control policy, affecting 89 residents, after reports of mice sighting inside the facility. This failure had the potential to pose a significant health risk to the 89 clinically compromised residents currently residing in the facility. Findings: During an interview on October 14, 2024, at 1:20 PM, with one of the residents (Resident) 1. Resident 1 reported that she is aware of a mouse running around inside the facility, describing it as a kangaroo mouse. This incident occurred two days ago and had been reported to the maintenance staff. During an interview on October 14, 2024, at 1:39 PM, with Maintenance Director (MD) 1, MD 1 confirmed that there was one recent reported occurrence of mice at the nursing station. During an interview on October 14, 2024, at 4:09 PM, with the Director of Nursing (DON) 1, DON 1 confirmed the presence of mice in one of the nursing stations. When asked whether the facility should be a rodent-free, DON 1 stated rodents could be a potential source of diseases.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 follow its policy and procedure to provide care and services for residents and ensure call lights are answered in a timely manner for all four sampled residents (Residents 1, 2, 3, and 4). This failure has the potential to jeopardize the health and safety of clinically compromised Residents (Residents 1, 2, 3, and 4) when their requests for assistance with activities of daily living were not responded to promptly. Findings: During the review of Resident 1 ' s admission record (It contains important information about the patient such as their personal details, the reason for their admission, and their medical history), the document indicated Resident 1 was admitted on [DATE], with a diagnosis that included lack of coordination (poor muscle control and clumsy body movement), difficulty in walking, pain in the leg, and history of falling (had incident of falling in the past). During interview and observation with Resident 1 on 9/09/2024, at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy and procedure in preventing, reporting, and investigating an allegation of suspected physical abuse for one of three sampled resident (Resident 3), when: 1. The facility employed Certified Nursing Assistant 1 (CNA 1, who was Resident 3 ' s alleged abuser) before the completion of her background check. 2. The facility Administrator did not respond immediately to initiate an investigation and promptly report the incident to the state agency and to other required agencies within specified timeframes after Resident 3 reported an alleged abuse by CNA 1 to the Administrator on April 24, 2024. These failures have the potential to jeopardize Resident ' s 3 health, safety, and well-being at risk and the other vulnerable population of 89 residents. Findings: 1. A review of State of California Form 341 [Suspected Dependent Adult/Elder Abuse form], dated May 1, 2024, indicated . Resident [Resident 3] reported . that last Friday the 24 of April…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 immediate measure was put into place to provide protections to one of three sampled resident (Resident 3) when a Certified Nurse Assistance 1 (CNA 1) was not placed on administrative leave immediately after an alleged abuse to Resident 3 was reported on April 24, 2024. This failure had the potential for further abuse, neglect, exploitation, or mistreatment as the alleged perpetrators, CNA 1, continued to have access to the alleged victim, Resident 3, and to the other vulnerable population of 89 residents. Findings: During a review of Resident 3 ' s admission Record (clinical record with demographic information), it indicated, Resident 3 was admitted to the facility on [DATE], with diagnoses of rheumatoid arthritis (a condition that can cause pain, swelling and stiffness in joints) and hypertension (when your blood pressure is higher than the recommended level). During a review of Resident 3 ' s Minimum Data Set assessment [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 follow its policy and procedure when: 1.One of three residents (Resident 1) did not receive medications timely as prescribed by the physician. 2.Three of three sampled residents, Resident 1, Resident 2, and Resident 3, experienced a delay in response to their call lights. These failures had the potential to put the health and safety of three clinically compromised residents (Resident 1, Resident 2, and Resident 3) at risk. Findings: 1. During a review of Resident 1's admission record (contains important information about the patient such as their personal details, the reason for their admission, and their medical history), the document indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis that included unspecified peripheral vascular disease (a condition which narrowed blood vessels slows blood flow to the limb). During an interview and observation with Resident 1 on June 12, 2024, at 2:07 PM, Resident 1 stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Certified Nursing Assistant 1 (CNA 1) reported an allegation of suspected physical abuse towards a resident (Resident 1) within the timeframe specified by their policy and procedures when the staff member (Certified Nursing Assistant 1 - CNA 1) was aware of the alleged abuse on April 2, 2024, but did not report it to the facility administration until two days later on April 4, 2024. This failure resulted in a delay in the facility ' s ability to promptly investigate the allegation of abuse and had the potential for Resident 1 to be at continued risk for ongoing physical abuse which may have been prevented had the allegation been reported timely. Findings: A review of Resident 1 ' admission Record, (contains medical and demographic information), indicated the resident was admitted [DATE], with diagnoses which included unspecified dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 2 of 3 residents (Residents 1, and 2) received safety devices to prevent accidents from occurring when staff did not ensure the pad alarm (a device applied to the bed surface that beeps when the resident tries to get up) was applied and turned on. This failure had the potential to place Resident 1, and Resident 2 at risk for falls and serious injury. Findings: An abbreviated survey was conducted on February 21, 2024, at 2:45 PM to investigate a complaint related to Quality of Care. 1. A review of Resident 1 ' s face sheet (contains demographic information) indicated, Resident 1 was admitted to the facility on [DATE], with diagnosis which included: Encephalopathy (disturbance in the way the brain functions), Dementia (gradual and progressive decline in memory, and thinking), dependence on wheelchair and difficulty in walking. During a resident room observation, on February 21, 2024, at 2:55 PM, Resident 1 is observed to be in bed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews, and record reviews, the facility failed to provide sufficient numbers of direct care (staff who directly provide nursing services to residents) staff when eleven out of 15 sampled days (for the period of January 23, 2024, to February 07, 2024) had less than 2.4-3.5 direct care service hours per patient day (DHPPD- the total number of hours worked per patient day divided by the average daily number of residents in the facility). This failure had the potential to result in unmet needs, to include assisting residents who requiring feeding or incontinence care to prevent skin breakdown; delay in needed pain medications; prevention of falls or resident to resident altercations; and social isolation by not being able to get to activities of their choice in a universe of 90 residents. Findings: 1. During an interview on February 07, 2024, at 3:40 PM with Resident 1, (R1) stated, The facility needs more in Certified Nursing Assistant (CNA) and nursing staff. They stopped passing snacks, it ' s been a long time, the kitchen puts them out, but staff don ' t…

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

Based on observation, interview, and record review, the facility failed to follow their policy when they delivered snacks to the nursing station with no labels, to include residents name with no dates and time. These failure had the potential for residents who have orders for snack to be subjected to foodborrn Illness (any illness resulting from food spoilage, pathogenic bacteria (a germ that causes disease), viruses (a small organism that causes disease), or parasites ( a creature that lives off another organism) that can contaminate the food. Findings: During an observation of the walk-in refrigerator in the kitchen on February 7, 2024, at 2:45 PM. There were fruit cocktails, yogurts, puddings, gelatins that were removed from the original containers and transferred to an individual container with no name of the food item, no date and time the food was removed from its original container. During a concurrent interview and observation with the Director of Nursing (DON), on February 7, 2024, at 3:10 PM of the snacks delivered to the Nursing Station inside the blue Ice Chest. Every…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 take precautionary measures to provide protection to one of three sampled Residents (Resident 1) when an allegation of sexual abuse was made against a Certified Nursing Assistant 1 (CNA 1) but CNA 1 was not suspended or removed from patient care during the facility's investigation into the allegation. This failure resulted in the facility to not provide protection for Resident 1 from potential sexual abuse by CNA 1. Findings: A review of Resident 1's face sheet (contains medical and demographic information) indicated Resident 1 was admitted on [DATE], with diagnoses which included fracture of lower end of left femur (leg bone), alcohol abuse, difficulty in walking, and major depressive disorder. During an interview on September 26, 2023, at 3:25 pm, with the Director of Nursing (DON), the DON stated on September 18, 2023, she received notification from the Ombudsman (an advocate for residents of nursing homes) of an alleged abuse allegation where…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medication administration of drugs was in accordance with the physician's orders for two of three Residents (Resident 1 and Resident 2). This failure resulted in increased pain and psychosocial (emotional) harm for Resident 1 and Resident 2. Finding: An abbreviated survey was conducted on October 25, 2023, at 11:48 AM to investigate a complaint related to quality of care. 1. During a review of Resident 1's clinical record, the face sheet indicated Resident 1 was admitted on [DATE], with diagnoses, which included cachexia (weakness and wasting of the body due to severe chronic illness), Neuropathy (nerve damage leads to pain, weakness, numbness or tingling), Dorsalgia (pain in the back), and migraine (headache with severe throbbing pain). During an interview with Resident 1 on October 25, 2023, at 12:37 PM, Resident 1 stated, Pain meds? They ' re always late. In the nurses own words somebody ' s medication is going to be late. I ' m…

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

Based on interview and record review, the facility failed to provide sufficient numbers of staff when 5 out of 8 sampled days (July 16, 2023- July 23, 2023) had less than 3.5 direct care service hours per patient day (DHPPD- the total number of hours worked per patient day divided by the average daily number of residents in the facility). This failure had the potential to result in unmet needs, such as psychosocial and physical needs, and safety concerns for 88 residents. Findings: During a concurrent interview and record review on August 28, 2023, at 3:00 PM, with the Staff Developer ( DSD) , the facility ' s document titled, Census and Direct Care Service Hours Per Patient Day (DHPPD- the number that results from dividing the actual nursing hours perform by direct caregivers per patient day and the number of residents in the facility), for dates: July 16, 2023, July 17, 2023, July 20, 2023, July 21,2023, and July 23, 2023, were reviewed. The DHPPD indicated, the Actual DHPPD was 2.12 (facility was short of 1.38) on July 16, 2023, Actual DHPPD was 2.53 (facility was short of 0.97)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policy and procedure to ensure call lights were answered in timely manner to provide care and services for one of three sampled residents (Resident 1). This failure had the potential to place a clinically compromised Resident (Resident 1) health and safety at risk when residents ' activities of daily living were not met in timely manner. Findings: During review of Residents 1 admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include Traumatic Subdural Hemorrhage without loss of consciousness ( pool of blood between the brain and its covering), Myocardial Infarction ( heart attack ), Hypoxic Ischemic Encephalopathy ( Brain Damage), Post traumatic stress disorder( a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event, Paraplegia (Paralysis of the legs and lower body, anoxic brain damage (cessation 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 the services of a Registered Nurse (RN) for 8 consecutive hours for multiple sampled days during the fiscal year Quarter 3 of 2022 (April 2 - June 30). This failure had the potential for all residents living in the facility to not receive services and advanced care activities specifically performed by a registered nurse including resident assessments, administration of intravenous medications, and general oversight of the residents' clinical needs either directly by the RN or indirectly by the Licensed Vocational Nurses or Certified Nursing Assistants for whom the RN was responsible for overseeing resident care. Findings: During an interview on May 11, 2023, at 8:07 AM, with the Director of Staff Development (DSD), the DSD stated the facility was supposed to have an RN scheduled for eight (8) hours each day (seven days a week) but has had difficulties with staffing an RN for 8 consecutive hours during the weekends on Saturdays and Sundays. During a concurrent interview and record review on May 11, 2023, at 2:12 PM,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 it met minimum staffing requirements of 3.5 Direct Care Service Hours Per Patient Day (DHPPD - number of hours of direct care service hours per patient day based upon the facility census [total resident count] and staff working within a 24 hour period) for multiple sampled days during the fiscal year 2022 Quarter 2 (January 1 - March 31), fiscal year 2022 Quarter 3 (April 1 - June 30), and fiscal year 2022 Quarter 4 (July 1 - September 30). This failure had the potential to result in unmet care needs for all residents who resided in the facility. Findings: During an interview on May 11, 2023, at 8:07 AM, with the Director of Staff Development (DSD), the DSD stated staffing levels each day were based on the facility census, and acuity of the residents and total staffing calculations were supposed to meet 3.5 DHPPD. During a concurrent interview and record review on May 11, 2023, at 2:12 PM, with the Director of Nursing (DON), the DON stated the facility was supposed to maintain a staffing level of 3.5 DHPPD 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 a baseline care plan (resident-specific plan of care necessary to properly provide care immediately upon their admission) within 48 hours for one of 18 sampled residents (Resident 286). This failure had the potential to delay medical care and wound healing for Resident 286. Findings: During a review of Resident 286's clinical record, the face sheet (contains demographic and admission information) indicated Resident 286 was admitted on [DATE], with a diagnosis of non-pressure chronic (long term) ulcer (wound) of the left foot, and had just underwent surgery for amputation (surgical removal) of her left first and second toes. During an observation on May 8, 2023, at 4:35 PM, Resident 286 was observed in her room, lying in bed, with her left foot wrapped in a gauze bandage. A review of Resident 286's baseline care plan titled Baseline Care Plan Person-Centered Care Planning - V3.0, dated May 8, 2023, was conducted. The baseline care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a comprehensive and personalized care plan for one of five sampled residents (Resident 13). This failure had the potential to prevent Resident 13's medical and psychosocial needs from being met. Findings: During a review of Resident 13's clinical record, the face sheet (contains demographic and admission information) indicated Resident 13 was admitted on [DATE], with diagnoses of depression (mood disorder characterized by extreme sadness) and anxiety (mood disorder characterized by fear, nervousness, or panic). Further review of the clinical record indicated Resident 13 was being given medication to treat his depression and anxiety, since admission. During a concurrent observation and interview with Resident 13 on May 8, 2023, at 3:16 PM, Resident 13 was observed lying in bed, quietly watching television. Resident 13 stated he had been dealing with depression and anxiety for years. A review of Resident 13's plan of care was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide quality care according to professional standards of practice for 3 of 18 sampled residents (Resident 22, 232, and 78), when: 1. The facility failed to provide wound treatment as ordered for Residents 22 and 232. This failure had the potential for Resident 22 and 232's delayed wound healing. 2. The facility failed to complete a skin assessment and obtain treatment orders upon admission for Resident 78. This failure had the potential for Resident 78 to have serious infection or other complications to occur. Findings: 1. During a review of Resident 22's admission Record (a record that provides the demographic data of the resident), undated, indicated Resident 22 was re-admitted to the facility on [DATE], with a diagnosis of type 2 diabetes mellitus (high blood sugar in the blood), hypocalcemia (low calcium in the blood) and hypokalemia (low potassium in the blood). During an observation on May 8, 2023, at 3:18 PM, in Resident 22's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide evidence for one of two sampled residents (Resident 15) reviewed for pressure ulcers (bedsores - also called pressure ulcers - are injuries to skin and underlying tissue resulting from prolonged pressure on the skin) received care and monitoring for skin breakdown as was specified in the resident's care plan (an individualized plan for the medical care of a resident) and physicians orders when: Resident 15's clinical record did not indicate the residents low air loss mattress (LAL mattress - a special mattress designed to prevent and treat pressure ulcers) was monitored for proper settings and functioning for multiple shifts in January, February, and March of 2023. Resident 15's clinical record did not indicate the resident's sacral area was monitored for dressing dislodgement, redness, warmth and signs and symptoms of infection for multiple shifts in January and February of 2023. Resident 15's clinical record did not indicate the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to monitor the dialysis (process of filtering out the blood through a machine, to remove excess fluid and toxins) access site for one sampled resident (Resident 13). This failure had the potential for serious bleeding or other complications to occur for Resident 13. Findings: During a review of Resident 13's clinical record, the face sheet (contains demographic and admission information) indicated Resident 13 was admitted on [DATE], with diagnoses which included end stage renal disease (impairment in kidney function which is irreversible and permanent, and requires dialysis or kidney transplantation to maintain life). Further review of the clinical record indicated Resident 13 had a left upper arm arteriovenous (AV - pertaining to the arteries and veins) shunt (a surgically made connection between an artery and a vein, for access to the blood during dialysis process). During a concurrent observation and interview with Resident 13 on May 8,…

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

Based on interview and record review, the facility failed to ensure staff were evaluated for competencies when three of five sampled staff members did not have annual competency assessments for 2019, 2020, and 2021. This failure resulted in the facility to not have regular competency evaluations of staff to determine if staff had the required knowledge and skills needed to care for the residents in the facility as identified in the facility assessment. Findings: During an interview on May 11, 2023, at 10:20 AM, with the Director of Staff Development (DSD), the annual competency assessments for five randomly selected staff were requested. Amongst the five staff selected, three of them included Licensed Vocational Nurse 2 (LVN 2), Licensed Vocational Nurse 3 (LVN 3), and Certified Nursing Assistant 1 (CNA 1). During an interview on May 11, 2023, at 12:20 PM, with DSD, the DSD stated the facility ensured staff were competent with their skills and knowledge by performing annual competency evaluations. The DSD further stated the facility had not been able to perform annual competencies…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 monitor for side effects and behavior related to the prescription of an anti-anxiety medication (medication to treat anxiety - a mood disorder characterized by fear, nervousness, or panic) for one of five sampled residents (Resident 13). This failure had the potential for Resident 13 to experience serious side effects or psychosocial distress without proper monitoring or treatment. Findings: During a review of Resident 13's clinical record, the face sheet (contains demographic and admission information) indicated Resident 13 was admitted on [DATE], with a diagnosis of anxiety. Further review of the clinical record indicated a current physician's order for Lorazepam [anti-anxiety medication] Oral Tablet 1 mg [mg - milligram - a unit of measurement] Give 1 tablet by mouth one time a day for anxiety. During further review of Resident 13's clinical record, there was no indication Resident 13 was being monitored for how many episodes 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 perform annual dental reevaluation for two of five sampled residents (Resident 29 and 49). This failure had the potential for residents 29 and 49 to develop oral diseases which may impact their physical, psychological, and social well-being through pain, diminished function, and may reduce quality of life. Findings: 1. During a review of Resident 29's admission Record (a record that provides the demographic data of the resident), undated, indicated Resident 29 was re-admitted to the facility on [DATE], with diagnoses which included lack of coordination, traumatic brain injury (Brain dysfunction caused by an outside force, usually a violent blow to the head), and old myocardial infarction (A blockage of blood flow to the heart muscle). During a concurrent observation and interview on May 9, 2023, at 10:24 AM, with Resident 29, by the nurse's station, Resident 29 had yellowish to brownish stains and dental tartar buildup on several of his…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to properly document blood sugar levels as ordered for one of 18 sampled residents (Resident 13). This failure caused Resident 13's medical record to be incomplete, and for Resident 13's blood sugar levels unable to be assessed. Findings: During a review of Resident 13's clinical record, the face sheet (contains demographic and admission information) indicated Resident 13 was admitted on [DATE], with a diagnosis of Type II Diabetes (difficulty in controlling blood sugar levels). Further review of the clinical record indicated a current physician's order for Novolog [insulin - medication used to lower blood sugar levels] . Inject 10 unit subcutaneously [below the skin, into the fat tissue] before meals for diabetes check blood sugar only give for BS [BS - blood sugar] over 200 or above . During a concurrent observation and interview with Resident 13 on May 8, 2023, at 3:16 PM, Resident 13 was observed lying in bed, quietly watching…

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