Blythe Post Acute LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure oxygen therapy was administered as ordered for one of three sampled residents (Resident 50), when the nasal cannula (NC- flexible tube to deliver oxygen into the nose) tubing was not positioned in the resident's nares (openings of the nose).This failure had the potential to result in ineffective oxygen therapy and potential respiratory compromise for Resident 50. Findings:A review of Resident 50's admission Record (demographic clinical information), indicated Resident 50 was admitted to the facility on [DATE], with diagnoses which included, chronic obstructive pulmonary disease (a progressive lung disease that makes it difficult to breathe), Type 2 diabetes (a long term condition that causes high blood sugar levels), and muscle weakness (a reduced ability to move or exert force).A review of Resident 50's Order Summary Report dated 4/27/25, indicated, O2 [oxygen] at 2L per NC PRN [as needed] for shortness of breath.During an…

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

Based on observation, interview, and record review, the facility failed to ensure one of ten residents (Resident 2) was free of a significant medication error when the facility did not give lacosamide (generic for Vimpat, seizure medication) doses to Resident 2 as ordered on four of 10 days. This failure had the potential for Resident 2 to experience worsening of her medical conditions, including seizures.Findings: During a medication pass observation on 2/9/26 at 9:03 AM in the dining room, Licensed Vocational Nurse 3 (LVN 3) was observed administering five medications to Resident 2. LVN 3 stated she could not administer Resident 2's lacosamide because the facility was out of the medication.A review of Resident 2's Order Summary Report, dated 2/1/26, indicated Resident 2 had an active physician's order, dated 12/10/25, for lacosamide 50 milligram (mg) tablet, Give 1 tablet by mouth two times a day for anticonvulsant [seizure prevention].During an observation on 2/10/26 at 10:20 AM at Medication Cart 1, the Medication Cart 1 locked narcotic drawer was opened with LVN 1. The drawer…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 properly close one of four metal dumpsters which exposed the overflowing trash inside.This deficient practice had the potential to attract pests which could spread disease to residents and staff in the facility.Findings:During a concurrent observation tour and interview, on 2/9/26, at 7:53 AM, with the Kitchen Staff (KS) at the facility's outside garbage area, one metal dumpster was not completely closed and had trash piled above the top of the container. KS confirmed the metal dumpster was partially opened with trash exposed. KS also stated the dumpsters must always be closed to prevent harboring rodents.A review of the facility's policy and procedure (P&P) titled, Food-Related Garbage and Refuse Disposal, revised 10/2017, indicated, . 5. Garbage and refuse containing food wastes will be stored in a manner that is inaccessible to pests. 7. Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a comprehensive care plan was developed for one of one resident reviewed for tobacco use (Resident 1) following her re-admission to the facility, despite a documented history of marijuana use. This failure had the potential to place the resident at risk for adverse health effects related to medical diagnoses, unsafe use or storage of marijuana, and smoke-related safety hazards. Findings:On June 10, 2025, Resident 1's admission record was reviewed. Resident 1 was initially admitted on [DATE] and re-admitted on [DATE], with diagnoses which included heart failure (when the heart doesn't pump blood effectively), chronic obstructive pulmonary disease (lung disease) and nicotine dependence (smoker). Resident 1 had a history of marijuana use while in the facility.A review of Resident 1's History and Physical, dated June 22, 2025, indicated Resident 1 had the capacity to understand and make decisions.A review of Resident 1's Minimum Data Set (MDS - an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of four Certified Nursing Assistants reviewed (CNA 1) maintained an active State-approved CNA certification and current CPR certification (cardiopulmonary resuscitation - an emergency lifesaving procedure performed when the heart stops beating) before providing direct care to residents. This failure had the potential to result in unsafe and inadequate care to residents. Findings:A review of CNA 1's Employee file indicated, CNA 1's license was issued on [DATE], and expired on [DATE].A further review of CNA 1's employee file indicated no documentation of a current CPR certificate. A review of facility's Staffing Assignment dated [DATE] and [DATE], indicated CNA 1 was scheduled to work on both dates.On [DATE], at 3:50 p.m., a concurrent interview and record review of staffing schedule and employee personnel file was conducted with the Director of Staff Development (DSD). The DSD stated she assists with the facility's hiring process and is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a safe water system was in place for 44 residents when: 1. The high temperature alarm (a mechanism to alert the staff when water temperatures exceed 120 degrees Fahrenheit [°F]) was not working. This failure had the potential to place the residents at risk of scalding from high temperature water. 2. The facility did not monitor hot water temperature for three out of 12 days for the month of June 2025. This failure had the potential to contribute to unsafe conditions without timely staff awareness. Findings: 1. On July 3, 2025, at 10:30 a.m., during an interview with the Maintenance Supervisor (MS). The MS stated, the facility's procedure was to monitor hot water temperatures daily. The MS stated, the high temperature alarm was used to ensure that water used by residents did not exceed 120°F. The MS further stated, the high temperature alarm at the nurses station was currently not working. On July 3, 2025, at 1:30 p.m., during an interview with the Administrator (ADM), the ADM stated to ensure resident safety, the MS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assess and document residents' vital signs (an assessment of resident's physiological stability, including a blood pressure, pulse, temperature and oxygen saturations) prior to non-emergent transport to a general acute care hospital (GACH) for two of three sampled residents (Residents 1 and 2). This failure had the potential to result in unrecognized changes in condition and adverse outcomes during transport. Findings: On May 8, 2025, at 10:25 a.m., an unannounced visit was made to the facility for a quality-of-care issue. 1. A review of Resident 1's, Personal Information, dated May 8, 2025, indicated, resident was admitted to the facility on [DATE], with a diagnosis of chronic obstructive pulmonary disease (a lung disease that cause airflow obstruction). Further review indicated Resident 1 had a Brief Interview for Mental Status (short structured tool to assess cognitive function) score of 15 (intact cognition). On May 8, 2025, at 1:40 p.m., an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed for one of three sampled residents (Resident 1) to conduct a thorough investigation into Resident 1's allegation of abuse involving Certified Nursing Assistant (CNA 1) before allowing the alleged perpetrator to return to work. This failure had the potential to expose Resident 1 to further abuse and compromised the integrity of the abuse investigation process. Findings: On March 28, 2025, at 10:50 a.m., an unannounced visit was made to the facility to investigate an allegation of abuse. On March 28, 2025, at 11:10 a.m., an interview was conducted with Resident 1, who stated, CNA 1 was rough while changing her brief, pushing her against the bed railing and causing pain and a bump on her left wrist on March 15, 2025. Resident 1 stated It upset me at the time. A Review of Resident 1's medical record, title, Resident Information, dated, March 18, 2025, at 11:50 a.m., indicated, resident was admitted to the facility on [DATE], with a diagnosis of hemiplegia and…

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

Based on interview and record review, the facility failed to ensure a dietary staff was able to accurately verbalize the proper cool down process (proper method of cooling cooked foods to safe temperatures). This failure had the potential to expose a population of 44 residents to foodborne illnesses (illnesses resulting from eating contaminated food). Findings: On February 27, 2025, at 2:40 p.m., an interview was conducted with the [NAME] regarding the cool down process. The [NAME] stated the cooling process from hot food temperature of 135 degrees Fahrenheit (°F- unit of measurement) to ambient temperature of 70°F would take one hour and from 70°F to a cold temperature of 40°F, it would take less than an hour. The [NAME] further stated when she had questions about the cool-down process, she would refer to the cool down log. A review of the facility policy and procedure titled, Food Preparation and Service, dated April 2019, indicated .Potentially hazardous foods are cooled rapidly. This is defined as cooling from 135 degrees F to 70 degrees F within 2 hours and then to 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 safe and sanitary food preparation and storage practices when: 1. Turkey and bologna were not maintained at safe temperatures within the refrigerator; 2. One dietary staff was observed preparing milk for residents without wearing a beard net; 3. The airconditioning unit air inlet /outlet grill was dirty; 4. An unlabeled juice container, intended for cleaning the grill, was stored alongside food items; and 5. A quaternary (quat) sanitizer test kit readily available in the kitchen was expired. These failures had the potential to cause foodborne illness (stomach illness acquired from ingesting contaminated food) among a vulnerable population of 44 out of 45 residents who received food prepared in the facility's kitchen. Findings: 1. On February 25, 2025, at 10:10 a.m., during the initial tour of the kitchen, with Dietary Manager (DM), turkey and bologna in the reach-in refrigerator were warm to the touch. Temperature measurements indicated: -Turkey deli slices (20 slices): 46.7°F -Bologna slices (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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure expired medications were not available for use for one resident (Resident 99) and in an E-Kit (a kit containing urgently needed medications to quickly treat the residents without delay) This failure resulted in Resident 99 receiving an expired medication. This failure also had the potential for facility residents to receive sub-therapeutic medication therapy from expired medications. Findings: 1. On February 26, 2025, at 8:35 a.m., during a medication pass observation, LVN 1 prepared morning medications doses which included Atrovent (medication for shortness of breath) inhaler for Resident 99. The expiration date on the manufacturer's label on the canister of the Atrovent inhaler indicated, 12/2024, It was observed LVN 1 did not check the expiration date of Atrovent inhaler during the morning medication preparation for Resident 99. In a concurrent interview, LVN 1 confirmed the expiration date. LVN 1 stated the medication 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 ensure multi-resident bedrooms provided the required minimum of 80 square feet per resident in seven out of 17 rooms (Rooms 5, 6, 8, 9, 10, 11, and 12). This failure had the potential to negatively affect the residents' quality of life. Findings: A review of the facility's, Census, dated, February 25, 2025, indicated, all resident bedroom assignments, and the number of resident's sharing each room. During initial tour of the facility on February 25, 2025, Rooms 5, 6, 8, 9, 10, 11, and 12 were observed to contain three beds each, with three residents per room. On February 25, 2025, at 10:52 a.m , an interview was conducted with the Administrator (AM). The AM stated, the facility had to provide residents with bedrooms measuring at least 80 square feet per resident in a multi-resident rooms. The AM further stated that Rooms 5 through 12 each measured 239 square feet, accommodating three residents per room, resulting in approximately 79.6 square feet per resident. The AM stated, these rooms did not meet the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure, for three residents (Resident 3, 18, and 32), the consultant pharmacist identified, and made recommendations on, non-standardized and inconsistent procedures by nursing staff for holding blood pressure medications that were ordered by the physician without holding parameters to residents. This failure had the potential for ineffective management of the residents' hypertension (high blood pressure (BP). Findings: On February 27, 2025, during a record review for Resident 3, 18, and 32, the following was noted: 1. Resident 3 was admitted on [DATE], with diagnoses which included, hypertensive heart disease with heart failure; A review of the physician order on January 30, 2025, for lisinopril (BP) medication 40 mg (milligram, unit of measurement) with the direction to give one tablet by mouth one time a day for hypertension with no hold parameters; A review of the physician order on January 30, 2025, for carvedilol (BP) medication 3.125 mg with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure antipsychotic medications (medication to treat thought disorder that changes sense of reality) were used after non-pharmacological interventions were tried and the residents were assessed to be distressed and a danger to self or others. This failure resulted in one resident (Resident 18) with dementia receiving an unnecessary antipsychotic medication with a boxed warning issued by the Food and Drug Administration (FDA, a federal agency that regulates drugs and other products). A boxed warning is the strongest warning the FDA requires and signifies the drug carries a significant risk of serious events. Findings: A review of Resident 18's medical record was conducted: Resident 18 was admitted on [DATE], with diagnoses which included, unspecified dementia with psychotic disturbance; A review of the physician order on March 6, 2024, for Seroquel 50 mg (milligram, unit of measurement) with the direction to give one tablet by mouth two times a day for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility had a medication error rate of 11.11% when three medication errors occurred out of 27 opportunities during the medication administration for two out of seven residents (Resident 99 and 39). The deficient practice resulted in medications not given in accordance with the prescriber's orders and had the potential for residents not receiving the full therapeutic effects of medications with the potential for worsening of residents' medical conditions. Findings: 1. On February 26, 2024, at 8:35 a.m., during a medication pass observation, Licensed Vocational Nurse (LVN 1) was observed preparing five medications to Resident 99. LVN 1 was observed handing the fluticasone/salmeterol (generic for Advair 250/50, used for chronic obstructive pulmonary disease [COPD], a lung disease causing breathing problems) inhaler to Resident 99 with an instruction, in English, to spit out the water in the cup on the bedside tray. Resident 99 did not positively acknowledge…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 honor Resident 35's dietary preference by serving fish during a meal. This failure had the potential to negatively impact Resident 35, affecting the resident's nutritional status and overall well-being Findings: A review of Resident 35's admission Record indicated Resident 35 was admitted to the facility on [DATE], with diagnoses which included muscle weakness and failure to thrive (physical decline in older adults). A review of Resident 35's MDS (Minimum Data Set an assessment tool) dated November 28, 2024, indicated a BIMS (Brief Interview for Mental Status) score of 14 (cognitively intact). A review of Resident 35' s meal ticket indicated .Lunch .NO: FISH .Dinner .NO: FISH . On February 27, 2025, at 11:42 a.m., during tray line observation, Resident 35 's tray ticket was reviewed and indicated the NO FISH preference for both lunch and dinner. On February 27, 2025, at 12:15 p.m., the [NAME] placed a slice of fish on Resident 35's tray.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the required Personal Protective Equipment (PPE) usage was clearly indicated before entering rooms of residents on Enhanced Barrier Precautions [EBP - a set of infection control measures using gowns and gloves to reduce the spread of multidrug-resistant organisms (MDRO)]. This failure had the potential to result in staff and visitors being unaware of necessary PPE requirements prior to entering rooms requiring isolation precautions. Findings: A review of the facility document titled, RESIDENTS WITH ENHANCED BARRIER PRECAUTIONS, undated, indicated, Residents 4, 6, 7, 8, 18, 21, and 37 were on Enhanced Barrier Precautions. On February 27, 2025, at 2:51 p.m., Residents 4, 6, 7, 8, 18, 21, and 37 rooms did not have EBP signage posted by the door. There was no indication of which bed was on EBP. On February 26, 2025, at 9:24 a.m., during concurrent interview and observation with Resident 7 and Certified Nurse Assistant (CNA) 1, CNA) 1 stated Resident 7 had a wound on the right foot and was on EBP. 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.

Based on observation, interview, and record review, the facility failed to conduct and complete neurological assessment (neuro checks - assessment of neurological function and [LOC]-level of consciousness) for the first hour after an unwitnessed fall for one out of three sampled residents (Resident 1). This failure had the potential to result in serious consequences, including loss of consciousness, seizures (uncontrolled movements), and coma (unable to wake up) which could go undetected. Findings: On January 16, 2025, at 9:25 a.m., an unannounced visit was made to the facility for a quality-of-care issue. On January 16, 2025, at 9:35 a.m., a concurrent observation & interview with Resident 1 was conducted. Resident 1 was observed in her room, lying face down on the floor next to her bed. Resident 1 was turned over onto her back, then helped to sit on her bed, by Licensed Vocational Nurse (LVN 1) and a Certified Nursing Assistant (CNA). Observation of Resident 1, indicated, a small pinkish, discolored area of resident's right forehead. Resident 1 stated she had fallen, hit her head,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a care plan (Identified healthcare conditions, including individualized goals and interventions) addressing the use of an illegal drug (marijuana- mind-altering [psychoactive] drug) while at the facility, for two of three sampled residents (Residents 1 and 2). This failure has the potential to result in mismanagement of resident's medical health issues for Resident 1 and 2. Findings: On October 30, 2024, at 11:40 a.m., an unannounced visit was made to the facility for a quality-of-care issue. On October 30, 2024, at 1:45 p.m., an interview was conducted with the Maintenance Supervisor (MS), who stated, on October 25, 2024, at approximately 4:00 p.m., she witnessed Resident 1 outside, who stated, I feel weird, like I'm having a stroke. The MS stated, she assisted Resident 1 into the facility and notified the nursing staff. A review of Resident 1's admission records undated, indicated the resident was admitted to the facility on [DATE], with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to assess and monitor the change in condition for one of two residents (Resident 1). This failure had the potential to delay necessary treatment for Resident 1. Findings: On October 30, 2024, at 1:45 p.m., an interview was conducted with the Maintenance Supervisor (MS), who stated, on October 25, 2024, at approximately 4:00 p.m., she heard Resident 1 saying she felt weird and felt like she was having a stroke. The MS stated, she assisted Resident 1 into the facility and notified nursing staff. A review of Resident 1's admission record, undated, indicated, resident was admitted to the facility on [DATE], with diagnoses which included embolism (a vascular clot) and thrombosis (blood clot). A review of Resident 1's Minimum Data Set (an assessment tool) dated July 20, 2024, indicated Resident 1 had a Brief Interview for Mental Status (a cognitive assessment) score of 15 (cognitively intact). On October 30, 2024, at 3:26 p.m., an interview was conducted with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents' admission orders included all current medications, and the correct dosages for two out of three sampled residents (Residents 4 & 5) when: 1. Resident 4 ' s admission order for Sertraline (an anti-depressant medication) had an incorrect dosage; and 2. Resident 5 ' s admission orders did not include her asthma (a lung disease that causes difficulty breathing) inhalers, Symbicort (medication to help manage and prevent symptoms in residents with asthma) and albuterol (medication used to treat asthma). This failure resulted in: 1. Resident 4 receiving an incorrect dosage of Sertraline on September 6, 2024, which could result in worsening of depression. 2. Resident 5 not receiving physician orders for her asthma medications, which could result in breathing difficulties and worsening asthma symptoms. Findings: On September 24, 2024, at 9:25 a.m., an unannounced visit was made to the facility for a quality-of-care issue. 1. 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 provide an effective pest control program to address the presence of flies in the building. This failure resulted in flies in the facilities common areas and resident bedrooms potentially leading to infections, increase in health issues such as gastrointestinal infections or skin irritations to vulnerable population in the facility. Findings: On September 24, 2024, at 9:25 a.m., an unannounced visit was made to the facility for a quality-of-care issue. 1. On September 24, 2024, at 9:50 a.m., a concurrent interview with Resident 1 and an observation of the resident's bedroom were conducted. Resident 1 stated, he had noticed an increase in flies in the facility and in his bedroom. Resident 1 stated, Sometimes they bother me. Resident 1 was observed swatting at a fly in the air as he spoke. Resident 1 further stated, staff had given him a fly swatter to help with the flies. A review of Resident 1 ' s medical records, titled, Face Sheet,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an alleged abuse involving three of three residents reviewed (Residents 1, 2, and 3) were reported to the California Department of Public Health (CDPH) immediately or within 24 hours. This failure resulted in a delayed investigation of the alleged abuse causing a delay in implementation of corrective actions which placed the residents at risk for further abuse. Findings: On September 5, 2024, at 9:25 a.m., an unannounced visit was made to the facility to investigate an abuse allegation. A review of Resident 1 ' s Face Sheet, indicated the resident was admitted to the facility on [DATE], with diagnoses which included urinary tract infection (an illness in any part of the urinary tract, the system of organs that makes urine.) A review of Resident 1 ' s Change of Condition (COC) Assessment form, dated August 30, 2024, indicated, .allegedly (sic) verbally abused by CNA (Certified Nursing Assistant) . A review of Resident 1 ' s progress notes, dated…

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

Based on observation, interview and record review, the facility failed to treat Resident 1's possessions with respect for one of four sampled residents (Resident 1), when facility did not store resident's electric wheelchair in a manner which would keep it clean and damage free. The failure had the potential to damage Resident 1's electric wheelchair, while in storage. Findings: On July 01, 2024, at 8:20 a.m., an unannounced visit was made to the facility for a Quality-of-Care issue. On July 01, 2024, at 10:57 a.m., an interview was conducted with Resident 1, who stated, her electric chair was being stored at the facility, while not in use. On July 16, 2024, at 10:42 a.m., a concurrent interview with the Maintenance Supervisor (MS), and observation of Resident 1's electric wheelchair in the storage room were conducted. The MS stated, Resident 1's electric wheelchair was being stored in the maintenance/supply office. The MS stated, Resident 1's wheelchair was not protected with any type of cover, and a large roll of silver window insulation was sitting on top of the wheelchair. 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 and interview, the facility failed to provide for one of five sampled residents (Resident 2), services within reasonable accommodation of the resident's needs and preferences: 1. The facility did not have a working electric Hoyer lift, preferred by Resident 2 for transfer assists; and 2. The facility has one large Geri-chair which was unavailable for use by the resident because it was shared among multiple residents. These failures had the potential to exclude Resident 2 from being transferred out of bed, and sitting comfortably in a chair, while out of bed. Findings: On July 16, 2024, at 8:45 a.m., an unannounced visit was made to the facility to investigate a quality-of-care issue. On July 16, 2024, at 10:20 a.m., a concurrent observation of Resident 2 and interview was conducted. Resident 2 was observed lying in bed, watching t.v. with a disheveled appearance, as his hair appeared uncombed. Resident 2 stated, he relies on staff to transfer him via a Hoyer lift (A lift device used by…

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

Based on interview and record review, the facility failed to coordinate cardiology specialty (specialty doctor that treats conditions related to the heart) care for one of three sampled residents (Resident 3), after a new diagnosis of atrial fibrillation (an irregular and often very rapid heart rhythm) on May 4, 2024. This failure had the potential to result in worsening cardiac (heart) function, stroke (occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts), and/or other serious medical complications. Findings: During an interview on July 1, 2024, at 12:05 p.m., with Resident 3, Resident 3 stated she was diagnosed with atrial fibrillation during a recent admission to the hospital several weeks ago. Resident 3 stated it was a new diagnosis that she never had before. Resident 3 stated about a week after she returned to the facility, she asked the DON (Director of Nursing) to notify the physician about the need to follow up with cardiology. Resident 3 stated she reminded the DON again last week of the need for an appointment with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure for two of four sampled residents (Residents 1 and 3), were free of significant medication error when the prescribed Augmentin (amoxycillin and potassium clavulanate - drug used to treat bacterial infections in many different parts of the body (ear, lungs, sinus, skin, urinary tract) was not administered on three occasions for Resident 1 and on two occasions for Resident 3. This failure had the potential to worsen both residents' infections, leading to prolonged illness and discomfort. Findings: On June 8, 2024, at 11:50 a.m., an unannounced visit to the facility was conducted to investigate a quality of care and treatment issue. 1. During an interview on June 8, 2024, at 1:26 p.m., with Resident 1, she stated it takes three days for her to receive Augmentin. Resident 1 stated last night (June 7, 2024), she did not receive her antibiotics because the facility ran out. Resident 1 further stated the antibiotics would not be effective in killing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the diet order was followed according to the physician's order, for two of three sampled residents (Residents 2 and 3), when Residents 2 and 3 did not receive lemon pound cake on lunch meal tray on 7/1/2024 according to the diet ordered by the physician. These failures had the potential to result in compromising Resident 2 and 3's nutritional and medical condition. Findings: 1. On July 1, 2024, at 12:30 p.m., a concurrent meal tray observation and review of Resident 2's Meal Tray Card, on July 1, 2024, were conducted. Resident 2 was observed being served cheesecake with cherry topping. A review of Resident 2's admission RECORD, printed July 1, 2024, indicated, Resident 2 was admitted to the facility on [DATE], with diagnoses which included type 2 diabetes mellitus (a disease in which the pancreas does not produce enough insulin [a hormone that regulates the movement of sugar into the cells] and cells respond poorly to insulin and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the required 80 square feet (sq ft) per resident (80 sq ft/resident) in a multi-resident bedroom, was met for 8 out of 18 rooms (Rooms 5, 6, 7, 8, 9, 10, 11, & 12). This failure had the potential to negatively affect the quality of life of the residents. Findings: On July 1, 2024, at 8:40 a.m., an unannounced visit was made to the facility for a Quality-of-Care issue. On July 1, 2024, at 930 a.m., a concurrent interview with Resident 1 and an observation of room [ROOM NUMBER] bed C were conducted. Resident 1 stated, her room size was Ok, but sometimes she had difficulties navigating her wheelchair through the room. room [ROOM NUMBER] was observed to have three residents sharing the room, with an unobstructed path from each bed to the bedroom door. One staff member was observed attending to roommates' needs without difficulty due to room size. A review of Resident 1's, Face Sheet, dated, July 1, 2024, indicated, resident 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 interview and record review, the facility failed to provide written notice to resident of a pending room change for one of three sampled residents (Resident 3). This failure had the potential for Resident 3 to develop anxiety, confusion, and emotional distress. Findings: A review of Resident 3's medical records, titled, Face Sheet, dated July 1, 2024, indicated, Resident 3 was admitted to the facility on [DATE], with a diagnosis of bipolar disorder (a mental health condition that causes shifts in moods and concentration). A review of Resident 3's Minimum Data Set (an assessment tool), dated May 18, 2024, indicated, Resident 3 has a Brief Interview of Mental Status (mental cognition assessment) score of 15 (cognitively intact). On July 1, 2024, at 12:33 p.m., an interview was conducted with Resident 3, who stated her room was recently changed to a new room. Resident 3 stated, she liked her previous room more. A review of Resident 3's medical records, titled, Progress Notes, indicated the following: -…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain temperatures between 71 to 81 degrees Fahrenheit (F), with resident room temperatures in three of six sampled resident rooms, reaching 84.7 degrees F. This deficient practice resulted in discomfort for two of eleven sampled residents (Residents 1 and 2), and potential adverse health effects for residents, staff and visitors including dehydration (loss of body fluids), heat stress (a series of conditions where the body is under stress from overheating), and heat stroke (when the body can no longer control its temperature). Findings: An unannounced visit was conducted on June 25, 2024, at 12:32 p.m. to investigate a complaint related to the facility 's physical environment. On June 25, 2024, at 1:41 p.m., an observation and concurrent interview was conducted with Resident 1. Resident 1 was observed lying in bed near the window with the shades closed, perspiring with a small fan running on his bedside table. Resident 1 stated he 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 implement infection control practices when: 1. The laundry staff transported the clean laundry uncovered; 2. Facility did not sanitize washer in between laundering. 3. The facility did not monitor for legionella (bacteria that can cause a severe from of pneumonia [lung condition]) in the water system annually. These failures potential to increased cross-contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another) which could result to increse infections to facility residents. Findings: 1. On January 31, 2024, at 8:25 a.m. a staff member was observed exiting the laundry room with clean clothes and linens on an uncovered laundry cart. On January 31, 2024, at 8:48 a.m., during an interview was with Laundry Staff (LS) 1, she stated, she put clean, folded clothes of the resident in the the laundry cart uncovered. LS 1 further stated, she transported the uncovered laundry cart through the dirty area to deliver the clean laundry to the residents. LS 1 stated, the…

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

Based on interview and record review, the facility failed to ensure the residents were provided information on how to file a grievance. This failure had the potential for residents to not be able to address their issues and voice their concerns which could worsen the existing problems. Findings: During an interview on January 30, 2024, at 9:33 a.m., with the resident council, multiple residents (Residents 12, 26, 30, 31, 33, and 39) stated they were not given information on how to file a grievance. During an interview on February 2, 2024, at 12:01 p.m., with the Director of Staff Development (DSD), the DSD stated, Social Service Director was responsible for the resident's grievances. During an interview on February 2, 2024, at 12:12 p.m., with the Social Service Director (SSD), the SSD stated, If the resident will ask about the grievance process, they will be taught how to file a grievance, but the facility does not inform all residents on admission. During a review document titled, The Facilty admission Agreement, Facility Rules and Grievance Procedure, dated, May, 2011, indicated,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure three of four residnets sampled (Residents 14, 24 and 33's) skin was monitored and assessed in accordance with the facility's policy and procedures. This failure had the potential for Residents 14, 24, and 33 to develop skin breakdown and or pressure injury (PI's- localized damage to the skin and underlying soft tissue over a bony prominence or from a medical device) affecting the residents overall health and wellbeing. Findings: 1. On February 1, 2024, at 10:40 a.m., during a concurrent observation and interview with the Director of Nursing (DON) inside Resident 14's room. The coccyx (tailbone) area was observed to have an open skin and had no dressing in place. The DON stated, the coccyx had an open wound with a red base and has a small serosanguinous drainage (blood and clear yellow liquid.) The DON further stated, the wound measured four centimeters (cm - unit of measurement) in length, 4 cm in width and 0.25 cm in depth. 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 document and record review, the facility failed to ensure medication irregularities were identified during monthly medication regimen review (MRR) by the Consultant Pharmacist (CP) and recommendations were made to ensure appropriate use of medications when the CP did not make recommendations on the use of medications that were on the Beers Criteria for potentially inappropriate medications for elderly over the age of 65 for three of the five residents reviewed (Residents 5, 9 and 43). In addition, the facility failed to employ CP services for monthly review of all facility residents' medication regimen in October 2023. This had the potential to expose residents to severe adverse events from inappropriate medication use. According to, American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults by the 2023 American Geriatrics Society Beers Criteria Update Expert Panel, in the May 7, 2023's issue of Journal of the American…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record reviews the facility failed to ensure dietary staff were able to carry out the functions of food and nutrition services safely and effectively when the Dietary Supervisor (DSS) and [NAME] (CK) 1 was unable to accurately verbalize the cool down process for hot food and ambient food temperatures. This failure had the potential to place residents at risk for food borne diseases (illness that result from ingestion of contaminated food) that can cause sickness and or death. Findings: On January 30, 2024, at 10:15 a.m., during an interview with CK 1 of the cool down process for hot food and ambient food temperatures inside the kitchen. CK 1 stated the hot food cooldown temperature starts at 165 degrees, then check every 30 minutes for one and a half hours with a goal temperature of 145 degrees. CK 1 further stated as long as the food reaches 145 degrees, she does not check the temperature of the food again. CK 1 stated the cool down process for ambient food temperature is after food 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 ensure sanitary environment, prepare, and served food in accordance with professional standards for food service safety when: 1. There were multiple areas in the kitchen and kitchen equipment that were not clean; 2. Multiple wet and moist pans and pots were stored and stacked on top of each other; 3. Multiple chopping boards had brown-yellowish discoloration and multiple deep cuts and indentations; 4. There was a 1/3 open container of salsa found on the kitchen preparation counter left at room temperature; 5. The inside of the ice machine had a black goo-like grime; and 6. The resident refrigerator had no thermometer gauge and no temperature monitoring. These failures had the potential to place residents at risk for food borne diseases (illness that result from ingestion of contaminated food) that can cause sickness and or death. Findings: 1. On January 29, 2024, at 10:10 a.m., during a walk-through observation inside the kitchen with the Director of Staffing Development (DSD), the following were observed: a.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure, one (1) microwave oven, two (2) bottom oven shelves, four (4) oven door hinges, and one (1) dry storage room shelf were maintained in a safe operating condition. These failures had the potential to place residents at risk for food borne diseases (illness that result from ingestion of contaminated food) that can cause sickness and or death. Findings: On January 29, 2024, at 12:15 p.m., during a concurrent observation and interview inside the kitchen of the small and large oven bottom shelves and the oven door hinges with the Director of Staff Development (DSD) and [NAME] (CK) 1. The two (2) bottom shelves inside the oven and the four (4) oven door hinges were observed to have a brown-copper discoloration. The DSD and CK 1, both stated, the brown-copper discoloration is rust. The DSD and CK 1 further stated, rust should not be there and the oven should be clean to prevent food cross-contamination and foodborne illness. On January…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 inform the resident's share of cost and amount of charges for the items and services covered by Medicare (federal health insurance for anyone aged 65 and older)/Medicaid (federal and state program that gives health coverage to some people with limited income and resources), for one of four residents reviewed (Resident 43). This failure had the potential to result in confusion and frustration for Resident 43, affecting his psychosocial and mental wellbeing. Findings: During an interview on January 29, 2024, at 3:37 p.m., with Resident 43, he stated, They (the name of the facility) were taking all my money. Resident 43 stated, he was getting 35 dollars a month. Resident 43 further stated, he cannot live with 35 dollars, he had monthy bills to pay. During an interview on January 31, 2024, at 10:36 a.m., with the Business Office Manager (BOM) 2, she stated, she should have informed Resident 43 about the share of cost and charges to services covered by Medicaid. BOM 2 further stated, she should have informed Resident 43 upon…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure an accurate assessments were conducted for two of three residents reviewed for resident assessment (Resident 33 and 42), 1. Resident 33's functional impairment of the upper extremities and lower extremities. This failure had the potential to affect management of care for Resident 33's current functional impairment which could cause further decline in mobility; and 2. Resident 42 had no natural teeth. This failure resulted for Resident 42 not receiving the appropriate level of care and treatment. Findings: 1. During a concurrent observation and interview on January 31, 2024, at 9:03 a.m., with Resident 33, in his room, Resident 33's left wrist was flexed inward, and could raise about two inches high from the bed. Resident 33 could not raise his left foot but could move his left big toe. Resident 33 stated that's the best he can do. During a review of Resident 33's HISTORY AND PHYSICAL EXAMINATION (H&P), dated January 2, 2024, the…

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

Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was scheduled for eight consecutive hours in a 24-hour period for January 21, 2024, and January 28, 2024. This failure had the potential to adversely affect oversight and direction regarding residents' quality of care and quality of life directly impacting overall health and well-being. Findings: During a review of the RN monthly schedule, dated January 2023, indicated there was no RN coverage for January 21, 2024, and January 28, 2024. During a review of January 2024 payroll records indicated there was no RN coverage for January 21, 2024, and January 28, 2024. On February 1, 2024, at 10:53 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated there was no RN scheduled to cover the facility on January 21, 2024, and January 28, 2024. The DON stated the policy is we staff RNs for 8 hours per day. On February 6, 2024 at 9:23 a.m., an interview was conducted with the facility Administrator (ADM), he stated we have to meet requirements for state and federal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility's policies and procedures were developed and implemented to track accurately the movement of controlled substances (CS) and to fully account for use of all CS to minimize the time and loss of diversion. Two out of three residents' medical record did not accurately account for removal and administration of CS. This had the potential for drug diversion by impaired staff caring for the residents. Findings: On January 30, 2024, at 11:45 a.m., during the medication cart inspection with Licensed Vocational Nurse (LVN) 1, blister cards containing controlled substances (CSs) stored in the locked drawer of the cart were audited to determine the accuracy of CS use documentation. The discrepancies in the documentation of CS use were as follows: 1. Resident 38's blister card indicated there were 23 doses of oxycodone (narcotic pain medication) 10 mg remaining. The label on the blister card had the direction to give one tablet by mouth every six hours as needed for severe pain; The resident's Controlled Substance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow the physician order when the medication Humalog Injection Solution (Insulin Lispro) a rapid-acting insulin was administered to the resident at a lower dose, for one of one resident reviewed for insulin (Resident 26). This failure had the potential for the medication to inadequately control resident's blood sugar level leading to hyperglycemia (high blood sugar). Findings: A review of Resident 26's record, indicated, Resident 26 was admitted to the facility on [DATE], with diagnoses which included type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). A review of Resident 26's physician order dated January 23, 2024, indicated, .HumaLOG Injection Solution (Insulin [medication used to lower blood glucose] Lispro) inject as per sliding scale . If 60 - 200 = 0 units (unit of measurement); 201 - 250 = 2 units; 251 - 300 = 4 units; 301- 350= 6 units; 351 - 400 = 8 units; 401 - 500 = 8 units & (and) call MD…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dental appointment for dentures to a resident without dentition for one of one resident reviewed for dental (Resident 42). This failure had the potential to result in inadequate chewing, oral health issues such as gum disease. Findings: During a concurrent observation and interview on January 30, 2024, at 2:37 p.m., with Resident 42, she had no teeth. She stated, she had been without teeth since admission. She stated, she missed eating an apple. Resident 42 stated, she was not asked if she needed a denture. A review of Resident 42's record indicated, Resident 42 was admitted to the facility on [DATE], with diagnoses which included spondylolisthesis (a displacement of a bone in which the bone slides out of its proper position). A review of Resident 42's record titled, Order Summary Report, for the month of October 2023, indicated, .DENTAL CONSULT FOR EVALUATION AND TREATMENT AS NEEDED . A review of the facility document titled,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to: 1. Provide a safe environment to help prevent falls, as Resident 3's bedrails were not up, per doctor's (Dr's) orders, prior to his unwitnessed fall on October 12, 2023. 2.The facility failed to identify Dizziness, as a resident specific fall risk, prior to Resident 4's unwitness fall on October 9, 2023, and failed to incorporate Resident 3's history of Feeling Dizzy, into his resident-centered ' Falls care plan, per facility's Policy & Procedure (P&P), Falls and Fall Risk, Managing. These failures could have resulted in Resident 3 & Resident 4, experiencing additional falls, resulting in injuries. Findings: 1. On November 1, 2023, at 9:35 a.m., an unannounced visit was made to the facility for a Quality-of-care visit. On November 1, 2023, a review of Resident 3's admission records was conducted. Resident 3's facesheet (A document that gives a resident's medical information at a glance), indicated, Resident 3 was admitted to the facility on [DATE],…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assure a pain re-assessment was completed, after Resident 2 received Tylenol 650mg for complaints of back pain, after an unwitnessed fall on October 24, 2023. This failure could have led to Resident 2 continuing to experience unrelieved back pain. Findings: On November 1, 2023, a review of Resident 2's admission records was conducted. Resident 2's facesheet indicated she was admitted to the facility on [DATE], with a diagnosis of Muscle weakness, reduced mobility and Parkinson's disease (A progress disease of the nervous system marked by tremors and muscle ridgidity). Further review indicated Resident 2's BIMS score was 15 (Cognitive intactness). A review of Resident 2's SBAR, dated, October 24, 2023, at 3:02 a.m., by LVN1, indicated, resident had experienced a fall, and her vital signs were taken and withing normal limits. A pain assessment was not completed by LVN1. A review of Resident 2's progress notes, dated October 24, 2023, at 3:02 a.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 observation, interview, and record review, the facility failed to provide a properly functioning call light system in Resident1's bathroom, which did not activate each time the call light cord was pulled. This failure had the potential to delay staff's assistance in Resident1's bathroom, when the improperly functioning call light cord was pulled. Findings: On November 1, 2023, an unannounced visit was made to the facility to investigate a Quality-of-Care issue. On November 1, 2023, at 9:45 a.m., an interview was conducted with Resident1, who indicated, his bathroom call light did not work, stating, They (staff members) keep jiggling it (Bathroom call light), it'll work for a minutue, then (Bathroom call light) doesn't work again. On November 1, 2023, at 3:40 p.m., an observation of Resident1's bathroom was conducted. The call light was pulled in the bathroom to engage the call light system, indicating the call light and alarm did not turn on or alarm. The call light did not function. On November 1, 2023, at 3:50 p.m., a concurrent interview with CNA1, and observation 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 provide monitoring on a resident who wandered to other resident's room, for one of three sampled residents (Resident 1). This failure resulted in an allegation of physical abuse. Findings: On September 5, 2023, at 11:35 a.m., an unannounced visit was conducted to the facility to investigate an allegation of abuse. a. Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses of dementia (memory loss). A review of Resident 1's document titled History and Physical (H&P), dated March 15, 2023, the H&P indicated, .This resident .does NOT have the capacity to understand and make decisions . During a review of Resident 1's Minimum Data Set (MDS – an assessment tool), dated July 27, 2023, indicated, Resident 1 had severe cognitive impairment. During review of Resident 1's Progress Notes (PN), dated August 24, 2023, the PN indicated, .Notified .that resident (name of Resident 2) came into Resident's room .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 ensure the licensed nurse conducted an assessment and monitoring of the purplish black discoloration (bruise) observed on the right hand, for one of three sampled residents (Resident A). This failure had the potential to result in delayed provision of care and treatment for Resident A's skin condition. Findings: On October 9, 2023, at 10:50 a.m., an unannounced visit to the facility was conducted to investigate an allegation of quality of care/treatment. On October 9, 2023, at 1:05 p.m., in a concurrent interview and observation of Resident A in the room with Certified Nurse Assistant (CNA), he stated Resident A had a bruise measuring 6 centimeters (cm) by 8 cm on the right hand. The CNA stated, she observed the bruise on Monday (October 2, 2023). The CNA stated, Resident A's bruising should have been recorded. Resident A's record was reviewed. Resident A was admitted to the facility on [DATE], with diagnoses which included dementia…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Certified Nursing Assistant (CNA) who observed a new skin discoloration (bruise) on the resident's left thigh documented and notified the licensed nurse of a change of condition, for one of three residents reviewed (Resident 1). This failure had the potential for the resident to experience a delay in treatment and further compromise resident's physical and emotional wellbeing. Findings: On September 21, 2023, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnosis which included unspecified cirrhosis of liver (a type of liver damage where health cells are replaced by scar tissue). During a review of Resident 1's Care Plan (CP), dated August 22, 2023, indicated: - .Poor safety awareness .monitor and document any skin tears, abrasions, lacerations, bruising, or c/o pain . - .Be free of injury r/t falls prevention of injury is goal .monitor and document any skin tears, abrasions, lacerations,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 The facility failed to complete a 5 day summary and an abuse investigation in a timely manner, after accusations of verbal abuse towards Resident 1 which were reported to the facility Administrator. This failure had the potential to subject Resident 1 to further incidents of verbal abuse. Findings: On July 26, 2023, at 10:30 a.m., an unannounced visit was made to the facility for an abuse issue. A Review of Resident 1 ' s medical records, face sheet, indicates, Resident 1 was admitted to the facility on [DATE], with a diagnosis of Diabetes mellitus (A disease which cause high blood sugars), Obesity (Weight higher than what ' s considered health), and high blood pressure. Further review indicated Resident 1 had a Brief Interview Mental score of 15 (intact mental cognition). On July 26, 2023, at 2:22 p.m., and interview was conducted with Resident 1. Resident 1 stated, The other day (CNA1) was arguing with me, because she wouldn ' t touch her own cell phone because, she said her hands were dirty, so I said, don '…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 The facility failed to maintain an effective pest control program, to prevent the presence of flies within the building.This failure had the potential to result in flies infestation inside the facility, which could negatively impact the health and safety of the residents. Findings: On May 23, 2023, at 10:20 a.m., an unannounced visit was made to the facility to investigate a quality-of-care issue. During concurrent observation, flies were observed in the facility lobby, hallway, and were observed crawling on a resident. On May 23, 2023, at 11:36 a.m., two staff members were observed walking the facility hallways, and into the resident rooms with fly swatters. A record review of Resident 1 ' s medical record, indicated Resident 1 was admitted to the facility on [DATE], with a BIMS (Brief Interview for Mental Status) score of 09, and diagnoses which included squamous cell carcinoma (cancer of the skin) of the (Forehead of the top of head), muscle weakness and reduced mobility. On May 23, 2023, at 10:50 a.m., an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain the required air temperature ranging from 71 to 81 degrees Fahrenheit inside the resident's rooms on multiple occasions. This failure increased the risk for dehydration and could negatively affect the residents' already compromised health condition. Findings: On July 18, 2023, at 9:55 a.m., an unannounced visit to the facility was conducted to investigate a physical environment issue. On July 18, 2023, at 10:00 a.m., during a concurrent observation and interview with the Maintenance Director (MD), the MD stated the facility air conditioning contractor instructed her not set the thermostat below 75 degrees F. The MD acknowledged the facility thermostat near the nursing station was set at 79 degrees F and reading 79 degrees. She stated the Director of Nursing (DON) increased the temperature to 79 degrees. She stated she was not in the facility at the time. On July 18, 2023, at 10:10 a.m., during an observation with the MD, the…

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

Based on interview and record review the facility failed to regularly maintain and inspect the oven within the facility. This failure had the potential to affect the overall safety of the vulnerable residents of the facility. Findings: On June 7, 2023, at 11:05 a.m., an unannounced visit to the facility was conducted to investigate an issue on physical environment. On June 7, 2023, at 11:45 a.m. the Director of Staff Development (DSD) was interviewed. The DSD stated yesterday (June 6, 2023), at 8:30 a.m., there had been a gas odor throughout the building. The DSD stated, the staff promptly guided the residents outside of the building. On June 7, 2023, at 12:05 p.m. the Maintenance Director (MD) was interviewed. The MD stated the gas leak from the oven was caused by a broken gas connector tubing. A review of the (Name of Gas Company) document titled Job Order, dated June 6, 2023, indicated .Check House line no leaks. Found connector leaking on Range. Replaced connector . On June 7, 2023, at 1: 15 p.m., the MD was again interviewed. The MD stated, the oven did not receive regular…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure, for one of the six sampled residents (Resident 2), the call light button within his reach and easily accessible. This failure has the potential to result in Resident 2 not getting the help he needed. Findings: On June 29, 2023, an unannounced visit was conducted at the facility to investigate a complaint allegation. On June 29, 2023, at 11:00 a.m. an observation with a concurrent interview was conducted with Resident 2. Resident 2 was in bed, alert, and conversant. Resident 2' s call light button was observed to be wrapped around the call light box that was attached to the wall on the right side of the bed. Resident 2's call light button was not within his reach. Resident 2 stated he did not know where his call light button was. On June 29, 2023, Resident 2's record was reviewed. Resident 2 was admitted to the facility on [DATE], with diagnoses that include Muscle Weakness, Other Reduced Mobility, Osteoarthritis (a joint disease,…

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