Alameda Care Center

Based on interview and record review, the facility failed to ensure three of three sampled facility staff (Treatment Nurse [TxN] 1, TxN 2, and Infection Preventionist Nurse [IPN]) were competent to provide nursing services to the residents by failing to ensure competency skill assessments that included skin scraping (a procedure done to collect skin cells to diagnose skin conditions) were completed upon hire and annually. This deficient practice had the potential to negatively impact the residents' safety and prevent the residents from attaining or maintaining their highest practicable physical, mental, and psychosocial well-being.Findings: During a review of TxN 1's employee file indicated the hire date of 11/13/2024 and her most recent competency skills assessment was completed on 1/14/2025. There was no documented competency skills assessment done that included skin scraping procedures. During a review of TxN 2's employee file indicated the hire date of 2/11/2025 and his most recent competency skills assessment was completed on 2/12/2025. There was no documented competency skills…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical records of four of six sampled residents (Resident 1, Resident 2, Resident 5, and Resident 6) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to:1. Ensure TxN 1 documented the level of care provided to Resident 1 while the resident was in the facility when TxN 1 documented the level of care she provided to Resident 1 on 1/17/2026 but Resident 1 was discharged to the General Acute care Hospital (GACH) 1 on 1/16/2026.2. Ensure licensed nurses documented Resident 2's skin condition accurately when the resident was readmitted in the facility on 12/25/2025.3. Ensure Treatment Nurse (TxN) 1 accurately and timely documented Resident 2, Resident 5, and Resident 6's skin scraping procedures. Resident 2, 5, and 6's Treatment Administration Records (TARs) were signed two days after the procedures were done. 4. Ensure the licensed nurse that performed the skin…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interventions to prevent falls were in place for one of four sampled residents (Resident 1) when Resident 1 had a fall on 11/6/2025, by failing to: 1. Ensure interventions were developed through a care plan after Resident 1's fall on 11/6/2025. 2. Update Resident 1's Fall Risk Evaluation (a process used by healthcare providers to determine a person's likelihood of falling).3. Ensure monitoring was provided after Resident 1's fall. These deficient practices had the potential to place Resident 1 at risk for more falls in the facility. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 9/12/2025 with diagnoses including dementia (a progressive state of decline in mental abilities), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), muscle weakness (general), and difficulty in walking. During a review of Resident 1's Fall Risk Evaluation (a process used by healthcare providers to determine a person's likelihood 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 inform the Medical Doctor (MD) and the Resident Representative (RR) for one of four sampled resident (Resident 1) when on 11/6/2025 at 3 p.m. Resident 1 had a fall. This deficient practice had the potential to negatively affect the care and services provided to Resident 1. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 9/12/2025 with diagnoses including dementia (a progressive state of decline in mental abilities), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), muscle weakness (general), and difficulty in walking. During a review of Resident 1's Fall Risk Evaluation (a process used by healthcare providers to determine a person's likelihood of falling), dated 9/12/2025, the Fall Risk Evaluation indicated Resident 1's fall risk score was 16 (a total score of 10 or greater, the resident should be considered at high risk for potential falls). During a review of Resident 1's Physician History and Physical (H&P- a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an allegation of an employee-to-resident physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) to the State Survey Agency (SSA), the ombudsman (advocates for residents of nursing homes), and local law enforcement for one of three sampled residents (Resident 1) in accordance with the facility's policy and procedure (P&P) titled, Abuse & Mistreatment of Residents, when on 11/6/2025 at 3 p.m. Activities Assistant (AA) 1 alleged Certified Nursing Assistant (CNA) 1 pushed Resident 1.This deficient practice increased Resident 1's risk for further abuse, which could have led to additional unreported incidents and failure to protect other residents from potential harm. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 9/12/2025 with diagnoses including dementia (a progressive state of decline in mental abilities), Alzheimer's disease (a disease…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety by failing to ensure:1. A container of thickener on the coffee tray was dated.2. A creamer with use by date of 8/15/2025 and a can of open fruit cocktail covered with saran wrap was labeled with an open date.3. A water pitcher with water and thickener (a substance which can increase the viscosity of a liquid without substantially changing its other properties) was labeled with the date it was poured on the pitcher.4. A pitcher with punch dated 6/27/25 and a can of opened sliced jalapenos dated 6/25/25 were discarded.5. A block of ham, a pan of packaged chicken. and bologna in the kitchen refrigerator was dated with the received date.6. A box of popsicle and fruit bars were labeled with an open date.7. A container of strawberry pudding and two 2 cups of uncovered milk, with an open date.8. 1 cup of uncovered fruit punch, with the date poured.9. A pitcher of fruit punch dated 6/20/2025, a pitcher of water…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dispose of garbage and refuse properly. This deficient practice had the potential to attract pests that can bring diseases to all the residents in the facility. Findings: During an observation on 6/30/2025, at 6:46 a.m., observed the facility's blue trash bin's lid was not totally shut due to overfilled trash and the box/cardboard bin was left open with no lid. Pictures taken for reference. During an observation on 7/1/2025, at 7:01 a.m., observed the facility's blue trash bin's lid was not totally shut due to overfilled trash and the box/cardboard bin was left open with no lid. Pictures taken for reference. During an interview and record review on 7/1/2025, at 3:40 p.m., with the Dietary Service Supervisor (DSS), the DSS reviewed the pictures taken on the facility's trash bins. The DSS stated the blue trash bin was not closed shut, and the bin for cardboard boxes were overflowing and not shut closed. The DSS stated the trash bins should be shut closed to prevent attracting rodents to the trash and spreading…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to:1. Develop and implement a comprehensive person-centered care plan (is a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for one (1) of two (2) sampled residents (Resident 22) reviewed for dignity care area by failing to develop and implement a care plan on the resident's disrobing behavior.2. Ensure to have person-centered care by failing to implement the care plan for one (1) of five (5) residents (Resident 32) reviewed for unnecessary medications (any drug in excess) by failing to implement monitoring for adverse effects (also known as adverse consequences - unwanted, uncomfortable, or dangerous effects that a drug may have) with the use of carbidopa-levodopa (a medication used for Parkinson Disease [a condition that affects movement causing tremors, stiffness, and difficulty with balance and coordination]) for Resident 32, starting 2/3/2025.These deficient practices had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards:1. For one of one sampled resident (Resident 35) reviewed for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq - beneath the skin) insulin administration sites.2. For one of five sampled residents (Resident 25) reviewed for unnecessary medications by failing to rotate sq insulin administration sites.The deficient practice had the potential for adverse effect (unwanted, unintended result) of the same site sq administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Cross-reference F760 Findings: a. During a review of Resident 35’s admission Record, the admission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for seven of seven sampled Residents (Residents 24, 12, 45, 10, 34, 57, and 59) reviewed for accidents by failing to ensure:1. Residents 24, 12, 45, 10, and 34's fall mattress/floor mat (a cushioned floor pad designed to help prevent injury should a person fall) did not have any furniture or medical equipment on top of them.2. Residents 57's and 59's bed controller (device used to change the height and angle of the bed) cord did not have visible wires. (Cross Reference F908)These deficient practices increased the risk of accidents such as falls with injuries and electric shock on residents.Findings: 1. During a review of Resident 24’s admission Record, the admission Record indicated the facility admitted the resident on 4/28/2017, and readmitted the resident on 2/27/2022, with diagnoses including Alzheimer’s disease (a disease characterized by a progressive decline in mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological) for two of eight sampled residents (Residents 60, and 32) and for one of one inspected medication room (Medication Room Station 1) by:1. Failing to ensure Medication Disposition Log (a record that documents the handling and disposal of medications, ensuring compliance with regulations and maintaining accountability. It details the type of medication, the quantity, the reason for disposal, and the individuals involved in the process) was completed. Resident 60's one extra Augmentin (medication that treats infection) tablet was not logged in the Medication Disposition Log and bubble pack (medications are pre-sorted and sealed into individual compartments) was missing.2. Failing to administer carbidopa-levodopa (a medication used for Parkinson Disease [a condition that affects…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Pharmacy Consultant (PC) failed to identify and report any irregularities in the monthly drug/medication regimen review (MRR) to the attending physician and director of nursing (DON) for one (1) of five (5) sampled residents (Resident 25) reviewed for unnecessary medication (any medication in excessive dose, excessive duration, without adequate indication for its use and monitoring) use by failing to ensure:1. Resident 25 had monitoring for specific, measurable target behaviors related to the use of valproic acid (a psychotropic medication [any medication capable of affecting the mind, emotions, and behavior] used for bipolar disorder [mental health conditions characterized by periodic, intense emotional states affecting a person's mood, energy, and ability to function,]) starting 5/22/2025. 2. Resident 32 had monitoring for medication adverse effects (undesired, unwanted, uncomfortable, or dangerous effects that a drug may have) with the use of carbidopa-levodopa (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that resident's drug regimen was free from unnecessary drugs (any drug in excess) for one (1) of five (5) sampled residents (Resident 32) for unnecessary medication review by failing to:1. Monitor for adverse effects (also known as adverse consequences - unwanted, uncomfortable, or dangerous effects that a drug may have) with the use of carbidopa-levodopa (a medication used for Parkinson Disease [a condition that affects movement causing tremors, stiffness, and difficulty with balance and coordination]) for Resident 32, between 6/1/2025 and 6/30/2025. This deficient practice had the potential to cause Resident 32 to receive suboptimal (less than the highest standard or quality) care leading to the use of unnecessary medications causing potential adverse effects and negatively impacting their physical, mental, and psychosocial well-being. Cross-reference F656 and F756Findings: During a review of Resident 32’s admission Record (a document…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that its medication error rate was less than five (5) percent (%). Four (4) medication errors out of 26 total opportunities contributed to an overall medication error rate of 15.38% affecting one (1) of 15 residents observed for medication administration (Resident 81.) The medication errors were as follows:1. Resident 81 received famotidine (a medication used for peptic ulcer disease [PUD - painful sores in the stomach] prophylaxis [prevention,]) hydrochlorothiazide (a medication used for high blood pressure,) losartan (a medication used for high blood pressure,) and buspirone (a medication used for anxiety) at a different time than ordered by Resident 81's physician.These failures had the potential for Residents 81 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have,) and health complications such as stomach pain, uncontrolled blood pressure and anxiety, resulting in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors (the observed or identified preparation or administration of medications or biologicals which are not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards):1. For one of one sampled resident (Resident 35) reviewed for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin administration sites.2. For one of five sampled residents (Resident 25) reviewed for unnecessary medications by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq - beneath the skin) insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) administration sites.The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to label:1. one (1) budesonide (a medication used to treat and prevent shortness of breath) inhalation solution foil pouch (package made of foil protecting the inhalation solution from light and degradation) for Resident 55 at room temperature in accordance with the manufacturer's requirements in one (1) of one (1) inspected medication carts (Medication Cart Station 1.)2. one (1) budesonide and formoterol (a combination medication used to treat Chronic Obstructive Pulmonary Disease [COPD]- a disease that blocks air flow and makes breathing difficult]) inhalation aerosol (form of medication that is inhaled) for Resident 57 with an open date, in accordance with facility requirements and manufacturer's requirements in one (1) of one (1) inspected medication carts (Medication Cart Station 1.)These deficient practices increased the risk that Residents 55 and 57 could have received medication that had become ineffective or toxic due to improper…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility's menu and nutritional adequacy by failing to ensure residents with No Added Salt (NAS, leaves out all salt in preparing and cooking foods) diet were not provided with an extra packet of salt on their meal tray. The deficient practice had the potential for residents to consume more than allowable sodium intake that can affect their medical condition.Findings: During a review of Resident 79’s admission Record, the admission Record indicated the facility admitted the resident on 6/21/2024, and readmitted the resident on 3/25/2025, with diagnoses including chest pain, essential hypertension (occurs when you have abnormally high blood pressure that is not the result of a medical condition), and cardiomegaly (an enlarged heart). During a review of Resident 79’s History and Physical (H&P), dated 3/27/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 79’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 maintain a complete and accurate medical records in accordance with accepted professional standards for three of eight sampled residents (Residents 22, 32, and 60) reviewed for informed consents (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) and infection control by:1. Failing to document the method used for verification that the physician discussed the risk and benefits of the proposed treatment to Resident 22 and resident representative.2. Failing to ensure Resident 32's informed consent form was completed and accurate prior to signing and acknowledging the form.3. Failing to ensure Augmentin (medication used to treat infection) was documented as administered on 6/5/2025, at 4 p.m. in Resident 60's medical record.These failures had the potential for failing to ensure the residents or representative consented to the proposed treatment and their right to…

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

Based on observation, interview and record review, the facility failed to implement infection control practices for one of three sampled staff (Laundry Staff 1 [LS 1]) reviewed for Infection Control by failing to ensure laundry area was kept clean and sanitary. On 7/1/2025 personal belongings (two bags, one sweater, one cellphone and one pair of sunglasses) were noted inside the clean laundry room.This failure had the potential for cross contamination (unintentional transfer of bacteria or germs or other contaminant from one surface to another) and spread infections and illnesses to residents, and staff.Findings: During a concurrent observation, and interview on 7/1/2025, at 7:30 a.m., with the Housekeeping Manager (HSKM), inside the clean laundry room. Observed one black bag, one white printed bag and one black sweater hanging by the door and observed one cellphone and a pair of sunglasses under the air-conditioning unit just beside the table with the folded clean linens. The HSKM stated the personal belongings belong to LS 1. During an interview on 7/1/2025, at 8:02 a.m., 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 implement policy for antibiotic (medication used to treat infection) stewardship (efforts in doctors' offices, hospitals, long-term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate, means prescribing the right drug at the right dose at the right time for the right duration) for two of three sampled residents (Residents 60 and 78) by:1. Failing to monitor Resident 60 for the adverse effect (undesired or harmful effects) of Augmentin (medication used to treat infection) on the following dates and times:a. 7 a.m. to 3 p.m. on 6/6/2025, 6/7/2025, 6/9/2025, and 6/12/2025.b. 3 p.m., to 11 p.m. on 6/11/2025, and 6/12/2025.c. 11 p.m. to 7 a.m. on 6/5/2025, 6/6/2025, 6/7/2025, 6/8/2025, 6/10/2025, 6/11/2025. and 6/12/2025.2. Failing to monitor Resident 78 for the adverse effect of Cephalexin (medication used to treat infection) on 6/17/2025. at 3 p.m. - 11 p.m., and 11 p.m. - 7 a.m., 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 maintain the electrical and patient care equipment in safe operating condition for five of five sampled residents (Residents 19, 64, 44, 57, and 34) reviewed under environmental task by failing to ensure:1. Resident 19's fall mat/floor mat (a cushioned floor pad designed to help prevent injury should a person fall) did not have peeling covers.2. Residents 64, 44, 57, and 34's bed remote control did not have frayed/exposed wires. The deficient practices had the potential for residents to sustain accidents such as electrical shock and falls.Findings: 1. During a review of Resident 19’s admission Record, the admission Record indicated the facility admitted the resident on 5/4/2022, and readmitted the resident on 8/26/2022, with diagnoses including age-related osteoporosis (is a condition where this natural bone thinning becomes severe, making bones weak and brittle, and much more likely to break, often from a minor fall or even a cough or…

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

Based on observation, interview, and record review, the facility failed to honor the resident's right to a dignified existence for one of two sampled residents (Resident 22), reviewed for dignity care area by failing to prevent a confused resident from undressing and removing her top clothing and was vulnerable for visitors and staff's view when passing by the resident's bed. This deficient practice had the potential to cause emotional distress and affect their self-esteem and cause a loss of dignity and decline in psychosocial wellbeing. Findings: During a review of Resident 22's admission Record, the admission Record indicated the facility admitted the resident on 12/11/2024, with diagnoses including mood disorder (a mental health condition characterized by significant disturbances in a person's emotional state, leading to prolonged periods of extreme happiness, sadness, or both), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and psychotic disorder (severe mental disorders that cause abnormal thinking and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to honor the resident's right to be informed in advance by the physician or other practitioner or professional, of the risks and benefits of proposed care, treatment and treatment alternative or option for two of two sampled residents (Residents 25 and 1) reviewed for informed consents (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) by failing to ensure:1. Resident 25's Zyprexa (treatment for mental health conditions such as schizophrenia and bipolar I disorder) had the correct dosage on the consent form.2. Resident 1's Depakote (it helps manage manic or mixed episodes [periods of high energy, irritability, or both] in adults with bipolar disorder) indicated the dosage on the consent form. This deficient practice violated the residents' right to make an informed decision regarding the use of psychoactive medications (substances that, when taken in or administered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (1) of five (5) sampled residents (Resident 25) was free from unnecessary use of psychotropic drug (any medication capable of affecting the mind, emotions, and behavior) in accordance with facility policy and procedures by failing to ensure:1. Resident 25 had specific, measurable target behaviors monitored related to the use of valproic acid (a psychotropic medication used for bipolar disorder [mental health conditions characterized by periodic, intense emotional states affecting a person's mood, energy, and ability to function]) to ensure resident's drug regimen was free from unnecessary medications (any medication in excessive dose, excessive duration, without adequate indication for its use and monitoring).This deficient practice had the potential to place Resident 25 at risk for significant adverse consequence (unwanted, uncomfortable, or dangerous effects that a drug may have) from the use of unnecessary psychotropic drug, which could…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injury (also called pressure ulcer, localized damage to the skin and/or underlying tissue usually over a bony prominence) for two of two sampled residents (Resident 6 and 10) investigated under pressure injury by:1. Failing to ensure Resident 6's bilateral heel protectors (protective cushions or coverings for the heels) were applied on the resident as ordered by the physician.2. Failing to ensure Resident 10's low air loss mattress (LALM - a mattress that helps prevent and treat pressure injuries by circulating air and relieving pressure on the body) was set according to resident's weight or comfort.These deficient practices had the potential for the development and worsening of pressure injuries to residents. Findings: a. During a review of Resident 6’s admission Record, the admission Record indicated the facility originally admitted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure physician visited one of three sampled residents (Resident 29) by:1. Failing to ensure the Attending Physician (AP) made an initial face-to-face visit within 30 days for the first 90 days following Resident 29's admission.2. Failing to ensure Resident 29 was seen the Psychiatrist Doctor (Psych MD- a medical doctor specializing in mental health, who can diagnose and treat mental, emotional and behavioral disorders) as per physician order.These failures had the potential to result in an undetected decline in medical, health or psychosocial condition and could lead to a delay in necessary care, treatment and services.Findings: During a review of Resident 29’s admission Record, the admission Record indicated the facility initially admitted Resident 29 on 9/18/2024, and readmitted on [DATE], with diagnoses including cerebral ischemia (a condition where the brain doesn't receive enough blood flow, leading to a lack of oxygen and nutrients, unspecified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 respect the rights and dignity for one of three sampled residents, Resident 1. During lunch, a facility staff was witnessed yelling at Resident 1. This deficient practice prevents the facility ' s residents who are dependent on staff from maintaining and/or enhancing their mental health and social interactions. Findings: A review of Resident 1 ' s admission Record indicated an admission date of 2/8/2023 with the following diagnoses of unspecified dementia (a decline in memory, thinking, and language skills), schizoaffective disorder bipolar type (encountering hallucinations and delusions alongside mood changes of extreme highs and lows), and other specified persistent mood disorders. A review of Resident 1 ' s Minimum Data Set (MDS- a resident screening tool) dated 5/9/2025 indicated Resident 1 was severely impaired with thought process and judgement. During an interview on 6/11/2025 at 2:08 p.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated on 5/25/2025, approximately during lunch time as 12 p.m. to 1 p.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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a call light device (also known as a call bell or nurse call button, is a device typically found near a patient's bed or within reach. consists of a button that, when pressed, sends a signal to the nursing station or a centralized system, alerting healthcare providers that assistance is required in the room) was within reach for two of three sampled residents (Resident 2 and 3). This failure had the potential to result in a delay in care and not receiving assistance timely. Findings: During a review of Resident 2 ' s admission Record, the admission Record indicated the facility admitted Resident 2 on 2/2/2017 with diagnoses that included unspecified (unconfirmed) Alzheimer ' s Disease (a disease characterized by a progressive decline in mental abilities), essential hypertension (HTN-high blood pressure) and cognitive communication deficit (difficulty communicating due to a disruption in cognitive processes like attention, memory,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review, and interview, the facility failed to notify Medical Doctor (MD) 1 when two of three sampled residents (Resident 1 and Resident 2) had a change of skin condition and itchiness. This deficient practice had the potential to result in delayed medical intervention to Residents 1 and 2. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure), angina pectoris (type of chest pain caused by reduced blood flow to the heart), and dysphagia (difficulty in swallowing). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 1/6/2025, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. During a review of Resident 1's SBAR (Situation, Background, Assessment and Recommendation - a communication 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 provide the necessary care and services for two of three sampled residents (Resident 1 and Resident 2) when: 1. Resident 1 had a skin rash and itchiness on bilateral (both) upper and lower extremities (refers to the hands and feet, or parts of the body farthest from the center, like the arms and legs). Medical Doctor (MD) 1 was not informed of the change of Resident 1's skin condition. This deficient practice placed Resident 1 at risk for more skin irritation and delay in provision of care. 2. The facility failed to effectively manage Resident 2's discomfort by not identifying the cause of Resident 2's skin itchiness. Resident 2 stated the itchiness keeps her awake at night because she cannot sleep at night. This deficient practice had the potential for Resident 2 to experience unnecessary discomfort. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on…

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

Based on interview and record review, the facility failed to implement and maintain an infection control program by failing to ensure the Nursing Station 1 and Nursing Station 2 high touch areas (surfaces that are frequently touched by healthcare providers and clients such as computers, telephones, and work surfaces) were routinely disinfected during an invasive group A streptococcus (IGAS, a severe and sometimes life-threatening infection in which the bacteria have invaded parts of the body where bacteria are not usually found, such as the blood, deep muscle and fat tissue) outbreak (OB, the occurrence of cases of disease in excess of what would normally be expected in a defined community, geographical area or season). This deficient practice had the potential to spread microorganisms, including IGAS, to facility residents, visitors, and staff. Findings: During a review of the Nursing Station 1 (NS 1) and Nursing Station 2 (NS 2) Disinfection Logs for High Touch Areas for 9/2024, the logs indicated in order to prevent an outbreak, it is critical that staff thoroughly clean 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 STAT (immediate or urgent) X-ray (a medical procedure that creates pictures of the structures of the inside of the body) was implemented timely for one of three sampled residents (Resident 1). This deficient practice resulted to a delay in obtaining results and delay in the necessary medical care impacting Resident 1. Findings: During a review of Resident 1's admission Record, it indicated the facility admitted the resident on 3/21/2018, with diagnoses including Alzheimer's Disease (a brain disorder that gradually destroys memory and thinking skills) and dementia (the loss of cognitive [ relating to the brain's mental processes, such as thinking, learning, and remembering] functioning - thinking, remembering, and reasoning). During a review of Resident 1's History & Physical (H&P), dated 11/12/2022, it indicated the resident had displaced left proximal humerus fracture (a break in the upper arm bone, or humerus, near the shoulder joint) with mild angulation. During a review of Resident 1's Minimum Data Set (MDS, a…

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

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: a. Walk-in refrigerator shelves were chipped and cracked. b. Freezer one (1) and two (2) bottom shelves had dried up pink liquid, and dust buildup. c. One (1) dented can was stored with non-dented cans. d. Knife container had dust and sticky residue. e. One scoop had sticky and dirt debris was stored with the clean scoops. f. Scoop handles storage was not in one direction. g. Clean storage area for pots and pans had dust, crumbs, food residues and dried up food. h. Mixer had dirt and food buildup. i. Food carts used for lunch service had dried up milk spill and tape residues. j. Resident's food from home in the resident's refrigerator had no label and no received date. These failures had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (transfer of bacteria from one object to another) in 78 of 78…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 have a policy regarding the use and storage of food brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption when the policy did not include the facility's responsibility for storing food brought in by family and other visitors beyond one (1) mealtime. This deficient practice had the potential to cause a decrease food intake resulting to unintentional (without trying) weight loss, frustrations, and psychosocial harm to 78 of 78 facility residents. Findings: During a review of the facility's Policies and Procedures (P&P) titled Food from Outside Sources dated 1/10/2024, the P&P indicated Policy: Food from outside sources is discouraged due to concerns with food safety and infection control and maintaining control of therapeutic diet orders. Procedure: 1. While it is preferred that families and/or friends do not bring foods or beverages into the facility, it is within resident's rights to allow the resident to eat outside food, especially if an individual…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dispose garbage and refuse properly by not maintaining the trash area free from trash, plastic utensils, other dirt debris and liquid drippings from the garbage bin. This deficient practice had a potential to attract birds, flies, insects, pest and possibly spread infection to 78 of 78 facility residents. Findings: During a concurrent observation of the dumpster (a large metal trash container designed to be emptied into a truck) area outside of the facility and interview with the Dietary Supervisor (DS) on 7/24/2024 at 8:20 a.m., the bottom of the blue dumpster had soiled plastic spoon and fork, trash, and liquid drippings from dumpster. The DS stated the trash surroundings was not clean. During a concurrent observation of the trash area and interview with the Maintenance Supervisor (MS) on 7/24/2024 at 8:22 a.m., the MS stated he was the one cleaning the trash area and brought the blower last Saturday to blow away the leaves. The MS stated they do not use water pressure to clean. The MS stated it 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 maintain sanitary conditions in the food services department when one (1) fly (a type of insect) was observed flying in the kitchen and landing on surfaces and yellow cake. This deficient practice had a potential to result in 78 of 78 residents, who received food from the kitchen, to acquire food borne illnesses (illness caused by consuming contaminated foods or beverages) by consuming potentially contaminated food. Findings: During a concurrent observation of the kitchen and interview with the Registered Dietitian (RD) and the Dietary Supervisor (DS) on 7/23/2024 at 10:53 a.m., an insect landed on the can opener. The RD stated the insect was a fly. The DS stated the fly could be coming from the breakroom or office when staff opened the door. The DS stated they did not want the fly on the food because it could transmit germs and residents could get sick and an infection. During concurrent observation in the trayline (area where food was assembled) area and interview with the RD and the DS on 7/23/2024 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 observation, interview, and record review the facility failed to provide reasonable accommodation of resident needs and preferences to five out of twelve residents (Resident 25, 52, 61, 7, and 135) investigated during review of environment facility task by failing to ensure: 1. The call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was available for Resident 25. 2. The call light was within reach for Resident 52, 31, 57, and 35. These deficient practices had the potential to result in the resident not being able to call for facility staff assistance and delay in the provision of necessary care and services that can negatively affect resident's comfort and well-being. Findings: 1. During a review of Resident 25's admission Record, it indicated the facility admitted the resident on 4/28/2017, with diagnoses including but not limited to dementia (loss of memory, language, and other thinking abilities that interfere with daily life and gets worse over…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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' medical records were updated to show documented evidence that advance directives (AD, written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were discussed with the residents and that the facility maintained a current copy of the resident's AD in the clinical record for three of four sampled residents (Resident 21, 52, and 57) reviewed under the Advance Directives care area. These deficient practices violated the resident's rights and/or representative's right to be fully informed of the option to formulate an AD and had the potential to cause conflict with a resident's wishes regarding health care. Findings: a. During a review of Resident 21's admission Record, it indicated the facility admitted the resident on 5/4/2022 and readmitted the resident on 8/26/2022 with diagnoses that included Alzheimer's disease (a brain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to notify the primary physician and responsible party of a significant change in condition (major decline or improvement in a resident's status that will not resolve itself without intervention) for one of five residents with limited range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) concerns (Resident 68) and one of six sampled residents reviewed under the Infection Control task (Resident 76) by failing to: 1. Report Resident 68's refusal to participate in ROM exercises, especially to the right arm. 2. Report Resident 68's new onset pain and increased swelling in the right arm on 6/20/2024 to the primary physician and responsible party in accordance with Resident 68's care plan and the facility's policy. These failures had the potential for Resident 68 to have an undetected injury in the right arm. (Cross reference to F689 and F849.) 3. Ensure Licensed Vocational Nurse 3 (LVN 3)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents were free from any physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the patient's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for one out of one sampled resident (Resident 46) investigated during a random observation by: 1. Failing to obtain an appropriate physician order for the use of bed pad alarm (a pressure-sensitive pad placed under the mattress or seat cushion that trigger an alarm or warning light when they detect a change in pressure). 2. Failing to assess Resident 46 quarterly for continued use of the bed pad alarm per facility policy and procedure. These deficient practices Resident 46 at risk for unnecessary prolonged use of restraints, restriction from freedom of movement which can lead to a decline in functioning. Findings: During a review of Resident 46's admission…

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

Based on interview and record review the facility failed to develop and implement a person-centered care plan with measurable objectives and timeframes to one out of three sampled residents (Resident 70) investigated during review of behavioral/emotional care area by failing to develop a care plan that addressed the resident's behavior of disrobing (the act of removing clothing). The deficient practice had violated Resident 70's right to maintain their highest practicable psychosocial well-being. Cross reference to F550. Findings: During a review of Resident 70's admission Record, it indicated the facility admitted Resident 70 on 9/8/2023 with diagnoses including, but not limited to, dementia (loss of memory, language, and other thinking abilities that interfere with daily life and gets worse over time), Alzheimer's Disease (a common type of dementia), major depressive disorder (a persistent feeling of sadness and loss of interest), and anxiety disorder (excessive worry and feelings of fear and uneasiness). During a review of Resident 70's History and Physical (H&P), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide care in accordance with professional standards of quality by: 1. Failing to ensure the nurses were rotating (a method to ensure repeated injections are not administered in the same area) the insulin (a medication that regulates sugar in the blood) injection sites for one of two sampled residents, (Resident 10) investigated during review of insulin care area. 2. Administering insulin when the blood sugar (BS - the amount of sugar measured in the blood stream) was below the physician ordered parameters (a set of limits determining if a medication can be given) for one of two sampled residents (Resident 38) investigated during review of insulin care area. These deficient practices had the potential to result in bruising, pain, and/or lipohypertrophy (lump or accumulation of fatty tissue under skin) to Resident 10 and placed Resident 38 at risk for hypoglycemia (a condition when the blood sugar is dangerously low). Cross-reference to F760.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 services to four of five sampled residents (Resident 52, 68, 21, and 69) with limited range of motion ([ROM] full movement potential of a joint where two bones meet]) and mobility (ability to move) concerns by failing to: 1. Ensure Resident 52's left (L) thumb spica wrist brace (a device to decrease movement and provide support and comfort through immobilization after an injury) was applied per physician orders. 2. Monitor the placement of Resident 52's left thumb spica wrist brace. 3. Notify Resident 52's physician regarding Resident 52's refusal to wear the left thumb spica wrist brace at all times. 4. Provide Resident 68 with ambulation (the act of walking) using a front-wheeled walker (FWW, an assistive device with two front wheels used for stability when walking), five times per week, in accordance with the physician orders, dated 11/25/2022, from 11/2022 to 12/2022. 5. Ensure Resident 68's Joint Mobility Screening (brief…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 environment free from accidents and hazards, ensure residents received adequate supervision, and implement interventions to prevent accidents for five out of five sampled residents (Residents 2, 22, 46, 62, and 68) investigated under the Accidents care area by: 1. Failing to ensure two tubes of hydrocortisone (a type of medicine used for treating dermatitis [inflammation of the skin with dry skin, redness, and itchiness] and other skin conditions that cause itching) 1 percent (% - a unit of measurement) cream were not left unattended and easily accessible on top of Resident 2's overbed table. This deficient practice placed other residents at risk for obtaining topical medication without staff knowledge resulting in accidental ingestion causing harm to residents. 2. Failing to ensure Residents 22, 46, and 62's wheelchair were not placed on top of floor mat while the residents were up on the wheelchair. This deficient practice had…

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

Based on interview and record review, the facility failed to complete a performance evaluation (PE - a formal and productive procedure to measure an employee's work and results based on their job responsibilities) every twelve months for three Restorative Nursing Aides (RNA - Certified Nursing Assistants [CNA] with specialized training to help residents regain their physical function and quality of life after illness or injury) reviewed under the sufficient and competent nurse staffing task. This deficient practice prevented the identified RNA's from receiving individualized training and education based on the outcome of their PE that could impact resident safety and satisfaction. Findings: During a review of the facility's RNA job description, last reviewed on 1/10/2024, it indicated the RNA performs restorative nursing approaches on residents to assist the resident in reaching their maximum potential mobility. The RNA duties and responsibilities included range of motion, daily and weekly documentation for residents in the program, assistance with walking and transfers, activities…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 control and accountability of Controlled Substance (CS- medications which have a potential for abuse and may also lead to physical or psychological dependence, also known an Controlled Medication [Drug]) awaiting final disposition (process of returning and/or destroying unused medications) when the facility's Antibiotic or Controlled Drug Record accountability logs did not include the verifying signatures of either the Director of Nursing (DON) or a Registered Nurse (RN) along with the Licensed Vocational Nurse (LVN) for seven of seven sampled logs. This deficient practice increased the opportunity for CS diversion (the transfer of a controlled substance or other medication from a lawful to an unlawful channel of distribution or use) and accidental exposure of residents to harmful medications, potentially negatively impacting their health and wellbeing. Findings: During a review of Antibiotic or Controlled Drug Record accountability logs on 7/24/2024 at 1:13 PM, with the DON, 7 Antibiotic or Controlled Drug Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were free of any significant medication errors for three of ten sampled residents (Resident 10, 38, and 76) by: 1. Failing to ensure nurses were rotating (a method to ensure repeated injections are not administered in the same area) the insulin (a medication that regulates sugar in the blood) injection sites for Resident 10 during review of insulin care area. 2. Administering insulin to Resident 38 when the blood sugar (BS - the amount of sugar measured in the blood stream) was below the physician ordered parameters (a set of limits determining if a medication can be given) during review of insulin care area. 3. Failing to ensure Treatment Nurse 1 (TN 1) administered the first dose of Keflex (an antibiotic [medication that fights infections caused by bacteria delivered directly into the bloodstream]) immediately or within four hours of receiving a verbal order from the Wound Care Consultant (WCC) for Resident 76 with 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 prepare food by methods that conserved flavor and appearance when the broccoli was mushy, overcooked and did not have a garlic flavor. This deficient practice placed 21 of 78 facility residents on regular consistency texture (texture with no restriction) at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen. Findings: A review of the facility's summer menu spreadsheets (a list containing types and amount of foods of what each diet type would receive) dated 7/23/2024, indicated regular texture diet included the following food items on the tray: -Roast Turkey 3 ounces (oz, unit of measurement) -Gravy 1 oz -Bread stuffing 2.7 oz -Broccoli with garlic ½ cup (c, household measurement) -Wheat roll 1 piece -Glazed apple square 1 pc, except for the following diets: consistent carbohydrate diet (CCHO, diet that had the same amount of carbohydrates per meal). During a trayline (an area where food was assembled) observation on 7/23/2024 at 12:20 p.m., the broccoli in the…

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

Based on observation, interview and record review, the facility failed to prepare foods in a form designed to meet individual needs when: 1. Resident (Resident 33) on vegan (a diet containing plant and plant products only), lactose free diet (diet that consist of food with no lactose, a type of sugar in milk, found in milk, cheese and dairy products) received grilled cheese and bread stuffing containing eggs, poultry seasoning, low sodium chicken stock and lactose on her lunch tray. 2. Fifteen (15) of 78 residents on puree diet (food with smooth, pudding like consistency) had parsley flakes on top of puree foods as garnish. These deficient practices had the potential to cause weight loss and frustrations (Resident 33), coughing, choking (to keep from breathing the normal way) and death for residents on puree diets. Findings: 1. During a review of Resident 33's admission Record, it indicated the facility admitted the resident on 2/23/2020 with diagnoses including unspecified dementia (a form of mild or mixed dementia characterized with a mild cognitive impairment), iron deficiency…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents were treated with respect and dignity in a manner that promotes maintenance or enhancement of his or her quality of life for two of two sampled residents (Residents 55 and 70) investigated under the dignity care area by: 1. Failing to ensure Certified Nursing Assistant 11 (CNA 11) was at eye level with Resident 55 while providing feeding assistance for Resident 55. 2. Failing to ensure Resident 70 did not disrobe (removing clothing) within public view. These deficient practices had the potential to result in a decrease in the residents' psychosocial well-being and loss of dignity. Findings: 1. During a review of Resident 55's admission Record, it indicated the facility admitted the resident on 8/29/2020 with diagnoses including dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), 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 implement policies and procedures (P&P) related to screening (sometimes called background check - a process a person or company uses to verify that an individual is who they claim to be and do not possess a criminal record) procedures by failing to conduct a background check screening prior to employment of one of seven staff members (Restorative Nursing Assistant 1, [RNA 1] ) investigated under the sufficient and competent nurse staffing facility task. This failure placed the residents at risk for abuse, neglect, and exploitation, and misappropriation of resident property for approximately nine months. Findings: During a concurrent interview and record review on 7/25/2024 at 3:30 p.m. with the Director of Staff Development (DSD), reviewed Restorative Nursing Aides (RNA - Certified Nursing Assistants [CNA] with specialized training to help residents regain their physical function and quality of life after illness or injury) 1's employee file. The DSD stated RNA 1 was hired on 4/9/2019 and did not have a background check…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 received treatment and care in accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial needs for one of one sampled resident (Resident 2) investigated during a random observation by: 1. Failing to ensure Certified Nursing Assistant 4 (CNA 4) did not apply the hydrocortisone (a type of medicine used for treating dermatitis [inflammation of the skin with dry skin, redness, and itchiness] and other skin conditions that cause itching) 1 percent (% - a unit of measurement) cream on the resident's abdomen, bilateral lower extremities (BLE), and bilateral breast folds. This deficient practice placed the resident at risk for adverse reactions due to CNA 4's application of the medication without physician's orders and not within the scope of CNA 4's practice. 2. Failing to ensure there was a physician's order prior to administering hydrocortisone 1% cream. These deficient practices placed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents received care consistent with professional standards of practice to prevent pressure injuries (PI/PU, injuries to the skin and underlying tissue resulting from prolonged pressure) by failing to set the Low Air Loss Mattress (LALM, a mattress designed to prevent and treat PIs) in accordance with manufacturer's instructions for one randomly sampled resident (Resident 68) observed during the screening process. This deficient practice had the potential for the worsening of or development of PIs. Findings: During a review of Resident 68's admission Record, it indicated the facility admitted the resident on 6/30/2022 and readmitted the resident on 1/13/2023 with diagnoses that included encounter for palliative care (hospice, a type of medical care for residents who are in the last stages of life), unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), pressure ulcer of sacral region (at the bottom of the spine lying between the…

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

Based on observation, interview and record review, the facility failed to provide individualized care approaches to meet the emotional and psychosocial needs of residents with mental disorder diagnosis for one of three sampled residents (Resident 70) residents investigated during review of behavioral-emotional care area by failing to address Resident 70's behavior of disrobing. This deficient practice had the potential to prevent Resident 70 from receiving appropriate treatment, approaches, and the ability to attain the highest practicable mental and psychosocial well-being. Cross reference F550 and F656 Findings: During a review of Resident 70's admission Record, it indicated the facility admitted Resident 70 on 9/8/2023 with diagnoses including, but not limited to, dementia (loss of memory, language, and other thinking abilities that interfere with daily life and gets worse over time), Alzheimer's Disease (a common type of dementia), major depressive disorder (a persistent feeling of sadness and loss of interest), and anxiety disorder (excessive worry and feelings of fear and…

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

Based on interview and record review, the facility failed to ensure the consultant pharmacist's (CP) recommendation for June 2024 Medication Regimen Review (MRR) (a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) note was carried out as per facility policy and procedure for one of four sampled residents (Resident 70). The deficient practice increased the risk of receiving medication that was not optimal for Resident 70's medical condition, that would not maintain the resident's highest level of physical, mental, and psychosocial well-being and/or increase the risk of adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) from the medication therapy. Cross reference to F758. Findings: During a review of Resident 70's admission Record (a document containing demographic and diagnostic information,) dated 7/26/2024, the admission Record indicated the facility originally admitted Resident 70 on 9/8/2023 and re-admitted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 70) drug regimen was free from the use of unnecessary (any medication in excessive dose, excessive duration, without adequate monitoring) psychotropic (any medication capable of affecting the mind, emotions, and behavior) medications in accordance with the facility policy and procedure by failing to identify specific, measurable target behaviors related to the use of Ativan (a psychotropic medication used to treat anxiety) for Resident 70. These deficient practices had the potential to place Resident 70 at risk for significant adverse consequences (unwanted, uncomfortable, or dangerous effects that a drug may have) from the use of unnecessary psychotropic medications, which could result to impairment or decline in the residents' mental, physical condition, functional, and psychosocial status. Cross reference to F756 Findings: During a review of Resident 70's admission Record (a document containing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that its medication error rate was less than five percent (%). Two medication errors out of twenty-five (25) total opportunities contributed to an overall medication error rate of eight % affecting one of seven residents observed for medication administration (Resident 14.) The medication errors were as follows: 1. Resident 14 did not receive a dose of Tylenol (a medication used for pain) as ordered by Resident 14's physician, and 2. Resident 14 received Keflex (a medication used to treat an infection) in a form that was not ordered by Resident 14's physician. These failures had the potential to result in Resident 14 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) and the potential to result in Residents 14's health and well-being to be negatively impacted. Findings: During an observation on 7/23/2024 at 12:15 PM, in Medication Cart Station 1, Licensed Vocational…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 appropriate hospice services (specialized care designed to give supportive care to people in the final phase of a terminal illness with a focus on comfort, quality of life rather than cure, and free of pain to live each day as fully as possible) to one of three sampled residents (Resident 68) receiving hospice care by failing to officially designate the facility's staff member responsible for coordinating hospice services in the facility's policy and ensure the facility's licensed staff were aware of the facility's designated coordinator for hospice care. These failures that the potential to prevent Resident 68 from receiving well-coordinated and comprehensive hospice services. Cross reference to F580. Findings: During a review of the facility's policy and procedure (P&P) titled, Hospice Program, revised 7/2017, the P&P did not indicate the name and title of the staff to coordinate care provided to the resident by the facility staff and hospice staff. During an interview on 7/25/2024 at 8:25 a.m. with Licensed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement and maintain an infection control program for two of six sampled residents (Resident 76 and Resident 2) reviewed under the Infection Control task by failing to: 1. Ensure Licensed Vocational Nurse 3 (LVN 3) monitored, identified, and reported Resident 76's open wounds (a break in the skin) with signs and symptoms (s/s) of invasive group A streptococcus (IGAS - a severe and sometimes life-threatening infection that is spread from person to person through respiratory droplets or touching other surfaces contaminated with bacteria that may invade parts of the body where bacteria are not usually found) on the left wrist. 2. Ensure Treatment Nurse 1 (TN 1) identified and reported Resident 76's open wounds with s/s of IGAS on the left wrist. 3. Ensure Resident 76's open wound was immediately tested for IGAS and the resident was placed in contact /droplet isolation (used to help prevent the spread of infectious agents that spread by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain mechanical, electrical, and patient care equipment in safe operating condition for one of one sampled resident (Resident 46) investigated during a random observation when Resident 46's bed controller (device used to change the height and angle of the bed) cable was observed with exposed wires. This deficient practice had the potential to place Resident 46 at risk for injury. Findings: During a review of Resident 46's admission Record, it indicated the facility admitted the resident on 8/26/2019 and readmitted on [DATE] with diagnoses including dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), schizoaffective disorder (a mental disorder characterized by abnormal thought processes and an unstable mood, and history of…

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

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program regarding Invasive Group A Streptococcal disease (iGAS - occurs when GAS bacteria get into parts of the body where these bacteria were not usually found and cause severe infection) for one of five sampled residents (Resident 5) by failing to: a. Ensure facility staff's personal protective equipment (PPE - equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) was worn inside the facility. Housekeeping 1's (HKP 1) face mask was not covering the nose while talking to Resident 5. Resident 5 was not wearing a face mask. Kitchen [NAME] (KC) was not wearing a face mask while inside the facility kitchen. b. Ensure the facility staff performed hand hygiene (hand washing with soap and water and use of alcohol-based hand sanitizer) before and after touching the used face mask. These deficient practices placed the residents and staff at risk for exposure and contracting iGAS. Findings: A review of Resident 5's admission…

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

Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 2) was provided privacy while talking on the phone. On 3/12/2024, observed Resident 2 talking on the phone while standing outside of Station 2. This deficient practice violated Resident 2's right to have a private conversation. Findings: A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 3/1/2024 with diagnoses that included unspecified (unconfirmed) Alzheimer ' s disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment. Alzheimer's disease involves parts of the brain that control thought, memory, and language), dementia (not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), major depressive disorder (causes a persistently low or depressed mood and a loss of interest in activities that you used to enjoy), 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 observation, interview, and record review, the facility failed to follow its abuse policy by failing to report an allegation of family to resident abuse no later than two hours after the allegation was made, to the State Survey Agency (responsible for surveying/licensing the facility) for one of four sampled residents (Resident 2). This deficient practice placed Resident 2 at risk for further abuse. Findings: A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 3/1/2024 with diagnoses that included unspecified (unconfirmed) Alzheimer ' s disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment. Alzheimer's disease involves parts of the brain that control thought, memory, and language), dementia (not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), major depressive disorder (causes a persistently low or depressed mood 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 observation, interview and record review, the facility failed to report allegation of family to resident abuse no later than two hours after the allegation was made, to the State Survey Agency (responsible for surveying/licensing the facility) for one of four sampled residents (Resident 2). This deficient practice placed Resident 2 at risk for further abuse. Findings: A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 3/1/2024 with diagnoses that included unspecified (unconfirmed) Alzheimer ' s disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment. Alzheimer's disease involves parts of the brain that control thought, memory, and language), dementia (not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), major depressive disorder (causes a persistently low or depressed mood and a loss of interest in activities that you…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 follow its facility ' s policy and procedure on fall and accidents and failed to provide necessary care and services to ensure the safety of one of four sampled resident (Resident 1) when Certified Nursing Assistant 1 (CNA 1) witnessed Resident 1 slide down to the floor unassisted on 3/6/2024 by: 1. Failing to update the fall care plan after the fall. 2. Failing to complete a Rehab Post Fall Assessment. 3. Failing to complete a Post Fall Risk Assessment. 3. Failing to conduct an interdisciplinary team (IDT- a coordinated group of experts from several different fields who work together) meeting. These deficient practices had the potential to place Resident 1 at risk for injury from falls. Findings: A review of Resident 1 ' s admission Record, indicated the facility admitted the resident on 9/8/2023, with diagnoses that included unspecified (unconfirmed) dementia (not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain complete and accurate medical records in accordance with accepted professional standards for one of three sampled residents (Resident 1) by failing to document administration of enalapril maleate (medication used to treat high blood pressure) accurately and per physician order. This deficient practice had the potential to result in inadequate management of Resident 1 ' s high blood pressure and the medical records containing inaccurate documentation can result in the delay of delivery of care. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 3/21/2022 with diagnoses that included periprosthetic fracture (a broken bone that occurs around the implants of a total hip replacement) around the internal prosthetic (implant- is an artificial device that replaces a missing body part) right hip joint, history of fall, unspecified dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily…

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

Based on observation, interview, and record review the facility failed to implement infection control practices for one out of nine sampled residents (Resident 6) by failing to ensure: 1. The suction canister (a temporary storage container for secretions or fluids removed from the body) and Yankauer suction tip (an oral suctioning tool used in medical procedures)of Resident 6 was dated and labeled with the name of the resident. 2. The Yankauer suction tip (an oral suctioning tool used in medical procedures) of Resident 6 was not touching the floor. These deficient practices had to potential for pathogens (an organism causing disease to the host) to grow in the canisters and tubing that could cause residents to get sick. Findings: A review of Resident 6 ' s admission Record indicated the facility admitted Resident 6 on 10/28/2022 and the facility readmitted Resident 6 on 5/23/2023, with diagnoses including chronic obstructive pulmonary disease (a common lung disease causing restricted airflow and breathing problems), allergic rhinitis (inflammation of the inside of the nose caused by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure three Certified Nurse Assistants (CNA 1, 2, and 3) were not standing while assisting residents with feeding, for three out of nine sample residents (Residents 68, 48, and 80) investigated for dining observation. This deficient practice had the potential to affect the residents' sense of self-worth and self-esteem. Findings: a. A review of the admission Record indicated Resident 68 was admitted to the facility, on 09/09/2020 and was readmitted on [DATE], with diagnoses that included sepsis (body's extreme response to an infection) unspecified organism, other idiopathic peripheral autonomic neuropathy (nerves that control involuntary bodily functions are damaged), and unspecified dementia (group of conditions that affect memory, thinking and behavior) with behavioral disturbance. A review of the Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/16/2021, indicated Resident 68 had severely impaired…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 informed consent (permission granted in the knowledge of possible health risks) by the physician before administering an antipsychotic (mind altering medication to treat mental health conditions) medication from the resident's responsible party (RP), for two of 41 sampled residents (Residents 44 and 67). This deficient practice had the potential to affect the residents' right to make decisions on medication therapy. Findings: A review of the admission Record indicated Resident 44 was admitted to the facility, on 10/19/2021, with diagnoses including dementia (chronic brain disorder marked by memory disorders, personality changes, and impaired reasoning), and depression (feelings of sadness). A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 10/23/2021, indicated Resident 44 was severely impaired in cognition (process of acquiring knowledge and understanding through thought, experience, and the senses) in skills required for daily decision making. The MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). A total three medication errors were observed out of a total of 25 opportunities affecting one out of four residents (Resident 34) observed for medication administration resulting in an overall medication error rate of 12 %. The deficient practice of administering medications contrary to physician's orders, manufacturer's specifications, or accepted professional standards increased the risk that Resident 34's health and well-being may be negatively affected. Findings: On 12/29/2021 at 08:32 a.m., observed Licensed Vocational Nurse 1 (LVN 1) administering the following medications to Resident 34: 1. Ferrous Gluconate 240 milligram (mg., a unit of measure) tablet. 2. Vitamin B-12 500 micrograms (mcg., a unit of measure) tablet. 3. Vitamin D 25 mcg. tablet. On 12/29/2021 at 10 a.m., during a record review, reviewed Resident 34's admission Record indicated Resident 34 was…

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

Based on interview and record review, the facility failed to ensure Licensed Vocational Nurse 3 (LVN 3) accurately documented on the medication administration record (MAR) for seven (Residents 18, 26, 46, 52, 64, 69 and 84) of seven sample residents. This deficient practice had the potential not to receive accurate information in the medical records with blank entries for medications that were administered. Findings: a A review of admission Record indicated Resident 18 was admitted to the facility, on 3/25/2021, with diagnoses that included diabetes mellitus (high blood sugar) and hypertension (high blood pressure). A review of Resident 18's MAR, for the month of 12/2021, indicated blank entries on 12/25/2021, for Lisinopril (blood pressure medication) at 8 a.m., Humalog solution (medication to lower blood sugar) at 11:45 a.m., and Humalog solution at 11:30 a.m. b. A review of the admission Record indicated Resident 26 was admitted to the facility, on 12/30/2020, with diagnoses that included dementia (chronic brain disorder marked by memory disorders, personality changes, 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.