Burbank Healthcare & Rehab

Based on interview and record review, the facility failed to develop and implement a person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for one of five sampled residents (Resident 5) regarding skin scraping (a quick, minor medical procedure where a doctor uses a dull blade to gently rub or scrape the top layer of skin to collect a small sample).This failure had the potential for delays in the delivery of necessary care and services and could place Resident 5 at risk for scabies (a contagious skin infestation caused by tiny, eight-legged mites called Sarcoptes scabiei).Findings:During a review of Resident 5's admission Record, the admission Record indicated the facility admitted Resident 5 on 4/17/2026, with diagnoses that included metabolic encephalopathy (a brain dysfunction caused by chemical imbalances in the body), unspecified (unconfirmed) pruritus (an uncomfortable, irritating sensation that makes you want to scratch your skin) and history of fall.During a review of Resident 5's…

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

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of five sampled residents (Residents 5) by failing to administer clobetasol (medication used to treat severe skin conditions by reducing itching, redness, and swelling) on 4/23/2026, as per physician order.This failure had the potential to result in medication errors and could worsen Resident 5's dermatitis (common condition that causes swelling and irritation of the skin).Findings:During a review of Resident 5's admission Record, the admission Record indicated the facility admitted Resident 5 on 4/17/2026, with diagnoses that included metabolic encephalopathy (a brain dysfunction caused by chemical imbalances in the body), unspecified (unconfirmed) pruritus (an uncomfortable, irritating sensation that makes you want to scratch your skin) and history of fall.During a review of Resident 5's History and Physical (H&P-a medical examination that involves 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 interview and record review, the facility failed to maintain accurate and complete medical record for one of three sampled residents (Resident 3) by failing to document contact isolation (a safety measure used in hospitals to prevent the spread of germs that are transferred by touching a patient or items in their room) monitoring on 4/22/2026, during night shift.This failure had the potential to cause confusion in Resident 3's care and the medical records containing inaccurate documentation.Findings:During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 8/15/2024, with diagnoses that included unspecified (unconfirmed) emphysema (a long-term lung condition that causes shortness of breath), unspecified dermatitis (a common condition that causes swelling and irritation of the skin) and history of fall.During a review of Resident 3's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 12/5/2025,…

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

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of three sampled residents (Residents 1) by failing to: 1. Ensure administration of cephalexin (medication used to treat infection) and clindamycin (medication used to treat infection) on 3/14/2026, at 9 p.m., as ordered by the physician.2. Ensure administration of cephalexin and clindamycin on 3/21/2026, at 9 p.m. to complete the seven days course of the antibiotic (medication used to treat infection) as ordered by the physician.These failures had the potential to result in medication errors and could worsen Resident 1's cellulitis (a skin infection that causes swelling and redness).Findings:a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 5/13/2024, with diagnoses that included unspecified (unconfirmed) multiple sclerosis (MS-a chronic, progressive disease involving damage to the nerve…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who tested negative for skin scraping (a diagnostic procedure where a healthcare provider uses a scalpel blade to gently scrape the top layer of skin, usually over a burrow [hole], to collect samples) for scabies (a parasitic infestation caused by tiny mites that burrow into the skin and lay eggs, causing intense itching and a rash) was not given permethrin (medication used to treat scabies and lice) and ivermectin (medications used to treat scabies).This failure had the potential to result in Resident 1 receiving unnecessary medications (any medicine or treatment that a person is taking but does not need, does not benefit from, or that causes more harm than good) and could potentially place Resident 1 at risk for adverse (are harmful, unintended, and undesirable effects that can occur at normal or excessive doses)/side effects (secondary, usually predictable, and often mild effects of a medication…

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

Based on interview and record review, the facility failed to implement its policy for antibiotic (medication used to treat infection) stewardship (efforts in doctor's 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) by failing to monitor Resident 1 for the adverse effects (undesired or harmful effects) of clindamycin (medication used to treat infection) on 3/8/2026.This failure had the potential to increase antibiotic resistance (do not respond to a drug) and had the potential for Residents 1 to experience an adverse reaction.Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 5/13/2024, with diagnoses that included unspecified (unconfirmed) multiple sclerosis (MS-a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), acute panmyelosis (a very rare, aggressive form of acute…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the comprehensive care plan (a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs) was revised for two of three sampled residents (Resident 1 and 2) when: 1. On 3/15/2026, Resident 1 was transferred to the general acute care hospital (GACH) for altered level of consciousness (a state of reduced alertness or inability to arouse due to low awareness of the environment) and was diagnosed with opioid intoxication [a class of medication that produce powerful pain-relieving effects and have the potential to cause drowsiness, constipation, and respiratory depression] that overwhelms the body's tolerance). 2. On 3/12/2026, Resident 2 was transferred to the GACH for psychiatric (relating to mental illness) evaluation. This deficient practice had the potential to delay provision of care for Resident 1 and 2.Findings: a. During a review of Resident 1's admission Record, the…

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

Based on observation, interview, and record review, the facility failed to ensure the resident has the right to be free from physical restraint for one of four sampled residents (Resident 2). The facility failed to ensure Resident 2's bed was not placed against the wall to restrain the resident's movements. This deficient practice violated Resident 2's right to be free from physical restraints.Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident on 9/20/2013 with diagnoses including unspecified dementia (a mental decline such as memory loss or confusion, that interferes with daily life, but the exact cause cannot be determined), age-related osteoporosis (a disease where bones become weak, brittle, and porous making them fragile and prone to breaking [fractures]), and hypotension (low blood pressure). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 1/23/2026, the MDS indicated Resident 2's cognitive (conscious mental activities including thinking, reasoning,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Certified Nursing Assistants (CNA 1 and CNA 2) performed proper hand hygiene after providing Activities of Daily Living (ADLs) (e.g., bathing, dressing, and toileting) for one of four sampled residents (Resident 4).This deficient practice had the potential to result in the transmission of infectious organisms and cross-contamination to other residents, staff, and visitors. Findings: During a review of Resident 4's admission Record (AR), the AR indicated the facility admitted Resident 4 on 3/18/2025 and re-admitted the resident on 1/7/2025 with diagnoses including generalized muscle weakness, difficulty walking, and dementia (a progressive decline in cognitive function). During a review of Resident 4's Care Plan (CP), initiated on 4/2/2025, the CP indicated Resident 4 had self-care deficits and required assistance with ADLs as needed, including incontinent care. During a review of Resident 4's Minimum Data Set (MDS), dated [DATE],…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 their quality of life by failing to ensure Certified Nurse Assistants (CNA) did not provide feeding assistance while for three of ten residents (Resident 18, 107, and 67) observed during the Dining task. This deficient practice had the potential to result in a decrease in psychosocial well-being for the residents leading to an overall decline and malnutrition (a serious condition that happens when your diet does not contain the right amount of nutrients). Findings: a. During a review of Resident 18's admission Record (AR), the AR indicated the facility admitted the resident on 10/13/2024, with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident medication self-administration was clinically appropriate and failed to honor the resident's right to self-administer medications for one of ten sampled residents (Resident 55) reviewed under the Accidents care area by failing to perform a medication self-administration assessment when staff had knowledge that the resident kept medication at the bed side for self-administration. This deficient practice violated the residents' right to self-administer medications and had potential for the residents to experience adverse effects (an undesired effect of a drug or other type of treatment) of the medication. Cross-reference F689. Findings: During a review of Resident 55's admission Record (AR), the AR indicated Resident 55 was originally admitted to the facility on [DATE], and was most recently readmitted on [DATE], with diagnoses that included dementia (a general term for loss of memory, language, problem-solving and other…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for four of five sampled residents (Resident 104, 62, 187, and 78) reviewed for physical restraints, by failing to: 1. Ensure Resident 104 did not have pillows and a rolled towel tucked under the resident's fitted sheet bilaterally (both sides) on 3/9/2026 and 3/11/2026. 2. Ensure a restraint assessment was completed prior to the use of bed placed against the wall for Resident 62. 3. Ensure Resident 62 did not have a pad alarm (a pad with sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff) in use when the resident with capacity verbalized she did not want…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 screened using the Preadmission Screening and Resident Review (PASRR - a federal requirement to help ensure that individuals are not appropriately placed in nursing homes for long-term care) for a mental disorder (MD) or intellectual disability (ID) prior to admission and that individuals identified with serious mental illness (SMI) and/or ID/developmental disability (DD)/related conditions (RC) receive the care and services in maintaining his/her highest practicable level in the most appropriate setting for three of three sampled residents (Residents 3, 62, and 17), by: 1. Failing to submit a new Level I PASRR for Residents 3 and 62 who had discrepancy in the previous PASRR Level I Screening. 2. Failing to submit a new Level 1 PASRR screening when Resident 17 was readmitted from the hospital on 4/3/2025 with a new diagnosis of serious mental illness/disorder. These deficient practices had the potential to result in inappropriate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for four of 34 sampled residents (Residents 66, 179, 142, and 97) by failing to ensure: 1. Resident 66 had a care plan on the use of psychotropic medication (prescription drugs that change brain chemistry to alter mood, thoughts, behavior, or perception) Divalproex sodium (a prescription medication used to calm overactive nerves in the brain) and anticoagulant (a type of medicine that prevents blood from clotting (or clumping) too easily) enoxaparin sodium (a prescription medication used to prevent and treat harmful blood clots). 2. Resident 179 had a care plan on the use of anticoagulant heparin (a medication commonly known as a blood thinner or an anticoagulant with primary purpose to stop blood clots from forming, or to prevent existing clots from getting bigger). 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 environment was free of accident hazards for twelve of 14 sampled residents (Residents 180, 72, 179, 12, 1, 104, 55, 9, 21, 183, 22, and 78) reviewed for accidents by failing to ensure: 1. Residents 180, 72, 179, and 12 did not have a furniture or equipment on top of the floor mat (specially designed mats provide cushioning and support to patients who are at risk of falling, helping to prevent serious injuries). 2. Residents 180, 1, 72, 104, and 55 did not have medications or biologicals (medicines derived from living organisms-such as humans, animals, or microorganisms-rather than being created from chemicals) left at the bedside. 3. Residents 1, 9, and 78's tab/pad alarm (a type of fall-management monitor used in hospitals, nursing homes, and home care settings to alert caregivers when a person at risk of falling is attempting to get out of bed or a chair without assistance) was connected to the alarm console and was working…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 respiratory care provided to residents was consistent with professional standards of practice for three (3) of 3 sampled residents (Resident 128, Resident 1, and Resident 66) reviewed for respiratory care by failing to ensure: 1. Resident 128's oxygen (O2) via nasal cannula (NC - a simple, two-pronged device that delivers extra oxygen to the nose) tubing was not touching the floor. 2. Resident 1's nebulizer (device that transforms liquid medicine into a fine, breathable mist) mask and tubing, dated 2/22/2026, was discarded and replaced with a new nebulizer mask and tubing. 3. Resident 66's nebulizer tubing and mouthpiece, dated 2/23/2026, was discarded and replaced with a new nebulizer tubing and mouthpiece. These deficient practices placed the residents at risk for acquiring infections due to contaminated tubing and develop complications such as shortness of breath and desaturation (low levels of oxygen in the blood). Findings: 1.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: 1. Have Trelegy (a medication used to treat chronic obstructive pulmonary disease [COPD - a disease causing shortness of breath and chest congestion) oral inhalation for Resident 33 available in the facility between 8/1/2025 and 3/9/2026, observed during Medication Administration Task. 2. Reconcile (the process of comparing transactions and activity to supporting documentation) six (6) medication emergency kits (eKIT - storage container for emergency use medications) containing Controlled Substances (CS- medications which have a potential for abuse and may also lead to physical or psychological dependence, also known as Controlled Medications [CM]) and document on the CS accountability log for March 2026, in two (2) of 2 inspected Medication Rooms (Medication room [ROOM NUMBER] and 2). As a result, control and accountability of CSs did not follow state and federal regulations and facility policy and procedures (P&P). These deficient…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (%). Three (3) medication errors out of 32 total opportunities contributed to an overall medication error rate of 9.38% affecting two (2) of four (4) residents observed for medication administration (Resident 33 and 184). The medication errors were as follows: 1. Resident 33 did not receive brimonidine (a medication used for glaucoma [a condition of increased pressure in the eyeball]) drops and Trelegy (a medication used to treat chronic obstructive pulmonary disease [COPD - a disease causing shortness of breath and chest congestion due to mucus) oral inhalation as ordered by Resident 33's physician. 2. Resident 184 did not receive Systane (a medication used for dry eyes) drops as ordered by Resident 184's physician. These failures had the potential to result in Resident 33 and 184 to experience adverse effects (unwanted, uncomfortable, or dangerous effects) and health…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) by not: 1. Administering Trelegy (a medication used to treat chronic obstructive pulmonary disease [COPD - a disease causing shortness of breath and chest congestion]) to Resident 33 between 8/1/2025 and 3/9/2026. This deficient practice resulted in Resident 33 to not receive Trelegy daily between 8/1/2025 and 3/9/2026 in accordance with the physician's orders and standards of practice and had the potential to cause Resident 33 to experience adverse effects (unwanted, unintended results) and serious health complications such as exacerbation of COPD, difficulty breathing resulting in physical and psychosocial harm, hospitalization and/or death. 2. Administering…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 store medications in accordance with manufacturer specifications, professional principles and facility policy and procedures (P&P) by failing to: 1. Remove and discard from use one (1) open Aplisol (also known as Tubersol - medication used to diagnose tuberculosis [infection in the lungs]) vial for facility stock, in accordance with manufacturer's requirements and facility policy and procedures in 1 of two (2) inspected Medication Rooms (Medication room [ROOM NUMBER]). 2. Store one lorazepam (a medication used to treat anxiety and restlessness) oral concentrate (a solution with increased strength) bottle in the refrigerator for Resident 128 in accordance with the manufacturer's requirements in one of three inspected medication carts (Medication Cart 1 Station 1.) 3. Ensure orally administered medications were stored separately from injectable medications, in 1 of six (6) inspected medication carts (Medication Cart 2 Station 1.) 4. Label…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reviewed during the Kitchen task by failing to: 1. Ensure perishable items, hotdogs, were disposed of by the best by date of 2/3/2026. 2. Ensure six (6) plates of salad were labeled with a prepared date. 3. Ensure 10 prepared bowls of ice cream were labeled with a prepared date. These deficient practices had the potential to result in harmful bacterial growth and cross- contamination (the process by which bacteria, chemicals, or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs). Findings: During a concurrent observation and interview on 3/9/2026 at 7:50 a.m. with the Dietary Supervisor Assistant (DSA), inside the walk-in refrigerator, one (1) opened container of hotdogs, opened date 1/27/2026 and best by date 2/3/2026. The DSA stated he will dispose…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medication administration record (MAR - a record of all active physician orders and medications administered to a resident) was not falsified by documenting Trelegy (a medication used to treat chronic obstructive pulmonary disease [COPD - a disease causing shortness of breath and chest congestion due to mucus]) was administered once a day between 8/1/2025 to 3/9/2026 when it was unavailable in the facility for one (1) of four (4) residents observed for medications administration (Resident 33). This deficient practice increased the risk that Resident 33 could have experience worsening COPD, causing difficulty in breathing and possibly resulting in hospitalization and/or death. Cross-reference F755, F759, and F760. Findings: During a review of Resident 33's admission Record (a document containing demographic and diagnostic information), dated 3/9/2026, the admission Record indicated Resident 33 was originally admitted to the…

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

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to ensure: 1. Resident 182's call light (a button, cord, or remote device in a hospital or nursing home room that allows a resident to electronically alert nurses or staff that they need assistance) was not inside the trash can and was sanitized before handing it off to the resident for use during random resident screening. 2. The mobile linen carts on the units were not covered with a permeable (material that allows liquid to pass through)/mesh material observed during infection control task. These deficient practices had the potential to cause cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect a mechanical device used by caregivers to safely move people with limited…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 essential equipment was maintained in a safe and working condition when: 1. One (1) of 1 sampled walk-in freezer reviewed during the Kitchen task had ice build-up inside the freezer. This deficient practice had the potential to result in an injury among staff and cross-contamination (the process by which bacteria, chemicals, or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) of food items. 2. 1 of 1 sampled resident (Resident 33) Resident 33's call light (a button or device a resident uses to get help from staff) was not properly connected to the wall panel during an observation on 3/9/2026. Findings: a. During a concurrent observation and interview on 3/9/2026 at 7:52 a.m. with the Dietary Service Assistant (DSA), inside the walk-in freezer, the walk-in freezer temperature reading indicated negative one (1) degree Fahrenheit ( F – a unit of measurement). The…

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

Based on interview and record review, the facility failed to 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 one of one sampled resident (Resident 66) 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 Resident 66's informed consent on the use of psychotropic medication (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) (Buspirone, a prescription medication used to treat chronic anxiety and manage daily anxiety symptoms, such as irritability and restlessness) matches the physician's order. This deficient practice violated the residents' right to make an informed decision regarding the use of psychotropic medications. Findings: During a review of Resident 66's Face Sheet (FS), the FS indicated the facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 keep the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) and bed remote control within reach of the resident for two of six sampled residents (Residents 182 and 140) reviewed under environment task. This deficient practice had the potential for Residents 182 and 140 unable to summon health care worker for help and to adjust the bed for comfort as needed. Findings: 1. During a review of Resident 182's Face Sheet (FS), the FS indicated the facility admitted the resident on 1/13/2026, and readmitted the resident on 3/2/2026, with diagnoses including muscle weakness, difficulty in walking, and history of traumatic fracture (a broken bone caused by a sudden, high-energy impact or injury). During a review of Resident 182's History and Physical (H&P), dated 3/4/2026, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 182's Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete the Advanced Directive Acknowledgement Form (a form that shows a person was given information about their medical wishes and rights) was complete for one of three sampled residents (Resident 14). This deficient practice had the potential to result in Resident 14's healthcare wishes not being known or followed, placing the resident at risk of receiving unwanted or inappropriate treatment. Findings: During a review of Resident 14's Face Sheet (FS), the FS indicated Resident 14 was originally admitted on [DATE] and re-admitted on [DATE] to the facility with a diagnosis of fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing(the upper part of the thigh bone is broken but didn't go through the skin and is healing normally without complications ); encephalopathy, unspecified ( a disease affecting how the brain works); type 2 diabetes mellitus without complications (a disorder…

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

Based on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic medication (medications that affect the mind, emotions, and behavior) and the use of chemical restraints (any drug that is used for discipline or staff convenience and not required to treat medical symptoms) for one of five sampled residents (Resident 9) reviewed for unnecessary medications by failing to ensure quetiapine fumarate (an atypical antipsychotic drug [treats symptoms of psychosis-such as hallucinations, delusions, and severe agitation]) was prescribed and monitored for specific, measurable behavioral manifestations. This deficient practice had the potential to result in the administration of unnecessary psychotropic medication and placed Resident 9 at increased risk for adverse effects related to psychotropic medication therapy, such as drowsiness, dizziness, or increased risk of fall, possibly leading to impairment or decline in their mental or physical condition or functional or psychosocial status. Findings: During a review of Resident 9's admission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure timely submission of a completed Minimum Data Set (MDS - a resident assessment tool) for two of three sampled residents (Residents 21 and 50) reviewed for Resident Assessment task, by failing to: 1. Transmit (electronic submission of MDS to the Centers of Medicare & Medicaid Services [CMS - a federal agency that administers major healthcare programs]) the Quarterly MDS Assessment timely for Resident 21. 2. Transmit the admission MDS Assessment timely for Resident 50. These deficient practices had the potential to negatively affect the provision of necessary care and services needed by Residents 21 and 50. Findings: a. During a review of Resident 21's admission Record (AR), the AR indicated that the facility admitted the resident on 6/13/2025 with diagnoses including bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), anemia (a condition where…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS-a resident assessment tool) by failing to ensure the MDS assessment of one of three sampled residents (Resident 189) was transmitted accurately when a discharge assessment was submitted on 2/20/2026 and remained discharged from the facility. Resident 189 returned to the facility at 1:30 p.m. on 2/21/2026. This deficient practice had the potential to cause confusion and delay in the delivery of necessary care and services to Resident 189. Findings: During a review of Resident 189's admission Record (AR), the AR indicated Resident 189 was originally admitted in the facility on 9/11/2024 and readmitted in the facility on 11/12/2025 with diagnoses including malignant neoplasm (a tumor [abnormal growth of tissue] that can invade surrounding normal tissue and/or spread to other parts of the body) of left kidney, bone, and left lung, moderate protein-calorie malnutrition (a condition that occurs when there is a lack…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 injury (also called pressure ulcer, the breakdown of skin integrity due to pressure) for one of one sampled resident (Resident 128) reviewed under pressure injury by failing to ensure Resident 128's low air loss mattress (LALM, a special type of air mattress that uses a constant, gentle flow of air through microscopic holes to keep the skin dry and prevent pressure wounds) was replaced timely when the LALM was beeping indicating low pressure with an orange light and the resident appeared sunken into the bed. This deficient practice placed Resident 128 at risk for the development and worsening of pressure injuries. Findings: During a review of Resident 128's admission Record, the admission Record indicated the facility admitted Resident 128 on 2/10/2026, with diagnoses including pressure ulcer of sacral (bottom of the spine) region and right heel, malignant neoplasm (a tumor [abnormal growth of tissue] that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received services and assistance for two of four sampled residents (Resident 38 and Resident 180) reviewed for urinary tract infection (UTI, a common infection that occurs when bacteria enters and multiplies in the urinary system, which includes the kidneys, bladder, and urethra) by failing: 1. To ensure Resident 90's urinal bottle (a handheld container designed for collecting urine) was not hanging on the side of the trash can. 2. To ensure Resident 180's urinal bottle was labeled. These deficient practices had the potential for the residents' urinal bottle to be contaminated which may lead to development of urinary tract infection. Findings: 1. During a review of Resident 38's admission Record (AR), the AR indicated the facility admitted the resident on 1/15/2026, with diagnoses including history of falling, generalized muscle weakness, and difficulty in walking. During a review of…

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

Based on observation, interview, and record review, the facility failed to ensure the staff providing care and services to the resident who has a feeding tube (soft plastic tubes through which liquid nutrition travels through the gastrointestinal tract [the series of organs that food and liquids pass through as they are digested, absorbed, and leave the body as feces]) are aware of, competent in, and utilize facility protocols regarding feeding tube nutrition and care for one of ten sampled residents (Resident 1) observed during Dining Observation by failing to ensure Licensed Vocational Nurse (LVN) 1 checked the gastrostomy tube (g-tube - a small tube placed through the skin directly into the stomach to deliver nutrition, fluids, and medications) placement prior to administering Jevity 1.5 (a high-calorie, liquid nutrition formula designed for people who cannot eat enough food by mouth, typically used through a feeding tube) bolus feeding (a method of delivering liquid nutrition (formula) directly into the stomach through a feeding tube, usually using a large syringe, 3-6 times 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 parenteral fluids (liquids, such as medication or nutrition, that are administered to the body by bypassing the digestive system) were administered consistent with professional standards of practice to one of one sampled resident (Resident 179) reviewed for hydration by failing to ensure the Resident 179's peripheral intravenous (IV - within a vein) line (a small, flexible plastic tube (catheter) inserted through the skin into a small vein-usually in the hand, arm, or foot-to deliver fluids and medications directly into the bloodstream) had the date and initials of the licensed nurse who inserted the IV line or changed the IV dressing. This deficient practice had the potential for complications associated with intravenous therapy (a medical technique that delivers fluids, medication, or nutrients directly into a person's bloodstream through a vein) and catheter-related infections. Findings: During a review of Resident 179's Face Sheet (FS), the FS indicated the facility admitted the resident on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide pain management consistent with professional standards of practice and the residents' goals and preferences for two of two sampled residents (Resident 62 and 142) reviewed for Pain care area, by failing to: 1. Follow the physician order for pain consult referral for Resident 62. This deficient practice had the potential to result in mismanagement of resident pain resulting in limited resident participation in activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily) and mobility. 2. Ensure Licensed Vocational Nurse (LVN) 4 assessed Resident 142's pain level prior to administrating the pain medication and to accurately document Resident 142's pain in the Medication Administration Record (MAR). This deficient practice has the potential to result in ineffective pain management, which may negatively impact Resident 142's comfort, safety, and overall well-being. Findings: a. During a review of…

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

Based on interview and record review, the facility failed to ensure residents who received hemodialysis (HD - also known as dialysis, process of removing waste products and excess fluid from the body) received treatment consistent with professional standards of practice for one of one sampled resident (Resident 59) reviewed under the Dialysis care area by failing to ensure communication with the HD Center (a specialized outpatient facility that provides HD) when Licensed Vocational Nurse (LVN) 4 failed to follow-up with the HD Center when the Dialysis Communication Record form was not completed on 3/6/2026 and 3/9/2026. This deficient practice placed the resident at risk for a delay in care and services related to HD. Findings: During a review of Resident 59's admission Record (AR), the AR indicated the facility originally admitted the resident on 4/5/2016 and most recently admitted the resident on 12/3/2024 with diagnoses that included End Stage Renal Disease (ESRD - irreversible kidney failure), dependence on renal (kidney) dialysis, hypertensive heart and chronic Kidney 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 interview and record review, the facility failed to ensure a resident receive treatment and care in accordance with professional standards of practice for one of one sampled resident (Resident 153), by failing to arrange Resident 153's transportation to their Oncology (the specialized branch of medicine dedicated to the diagnosis, treatment, and prevention of cancer [a group of diseases characterized by the uncontrolled proliferation of cells]) appointment. This deficient practice resulted in a missed Oncology visit on 3/10/2026 for Resident 153. Findings: During a review of Resident 153's admission Record (AR), the AR indicated that the facility admitted the resident on 12/15/2025 with diagnoses including acute kidney failure (also known as acute kidney injury, condition in which the kidneys suddenly cannot filter waste from the blood), elevated white blood cell count, and disorder of bone. The AR indicated Resident153 as the primary decision maker. During a review of Resident 153's History and Physical (H&P), dated 12/17/2025, the H&P indicated the resident had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide adaptive feeding equipment (specialized tools and utensils designed to assist individuals with limited motor skills, strength, or coordination in eating independently and safely) or one (1) out of 1 sampled resident (Resident 160) observed during dining observation facility task on 3/9/2026, lunch time. This deficient practice had the potential for Resident160 to have a decline in function and loss of independence. Findings: During a review of Resident 160's Face Sheet (FS), the FS indicated Resident 160 was admitted on [DATE] to the facility with diagnoses including type 2 diabetes mellitus without complications (a disorder characterized by difficulty in blood sugar control and poor wound healing); hydrocephalus, unspecified (too much fluid builds up in the brain); presence of cerebrospinal fluid drainage device (a small tube is placed in the body to remove extra fluid from the brain). During a review of Resident 160's History…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its antibiotic stewardship program (a coherent set of actions which promote using antimicrobials responsibly) that includes antibiotic (ATB, a medicine that fights bacterial infections by killing bacteria or stopping them from multiplying) use protocols and a system to monitor antibiotic use for two of two sampled residents (Residents 179 and 1) reviewed for antibiotic use by failing to ensure: 1. Resident 19's use of antibiotic Ertapenem Sodium had monitoring for adverse effects (a harmful, undesired, or unexpected symptom that happens after taking a medication, having a medical procedure, or being exposed to a substance). 2. Resident 2's Linezolid (a type of medication that is used to treat different types of infection) was started timely. 3. Resident 2 was monitored for adverse side effects for Resident 2 while receiving the Linezolid. These deficient practices had the potential to increase antibiotic resistance (when bacteria develop the…

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

Based on observation, interview, and record review, the facility failed to ensure there were safe and sanitary food preparation practices in the kitchen when kitchen staff failed to:1. Calibrate thermometers on 3/3/2026 and 3/4/2026.2. Monitor and document Refrigerator 1, Refrigerator 2, Freezer 1, and Freezer 2 temperatures on 3/3/2026 p.m. shift and 3/4/2026 a.m. shift.These deficient practices had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in medically compromised residents who received food from the kitchen.Findings:During a concurrent interview and record review of the facility-provided document titled, Thermometer Calibration Log, and Refrigerator & Freezer Temperature Log, on 3/4/2026 at 9:15 a.m. with the Dietary Service Supervisor (DSS), the DSS stated temperatures for the freezers and refrigerators are kept in a binder. The DSS stated per the Thermometer…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interventions to prevent falls were in place for one of three sampled residents (Resident 3) by failing to implement floor mats (a thick, soft foam pad placed on the floor next to a bed or chair) as ordered by the doctor when on 3/4/2026 during an observation no floor mat where noted in Resident 3's room, who was identified as a fall risk (how likely a person is to lose their balance and fall causing potentially injury). This deficient practice placed Resident 1 at increased risk of having a serious injury after a fall. Findings:During a review of Resident 3's admission Record (AR), the AR indicated the facility admitted Resident 3 on 2/24/2026 with diagnoses including muscle weakness, history of falling, and cerebral infarction (a type of ischemic stroke where a blockage, such as a blood clot, cuts off blood flow to a part of the brain, causing that brain tissue to die from lack of oxygen).During a review of Resident 3's Order Summary Report (OSR) dated 2/24/2026, the OSR indicated:- Floor mat bed 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 interview and record review, the facility failed to report an allegation of a misappropriation of resident property (the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent) of one of four sampled residents (Resident 4) to the State Survey Agency (SSA) when Family Member (FM) 1 allegedly took Resident 4's wallet and charged $500 on Resident 1's credit card. This deficient practice had the potential to place Resident 1 at increased risk for further abuse which could have led to additional unreported incidents and delay the SSA's ability to promptly investigate the allegation of a misappropriation of resident property.Findings: During a review of Resident 4's admission Record (AR), the AR indicated the facility originally admitted Resident 4 on 1/10/2026 with diagnoses including muscle weakness and sepsis (a life-threatening medical emergency caused by the body's extreme response to infection). During a review of Resident 1's History and Physical (H&P), dated 1/11/2026, the H&P…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a person-centered Care Plan (a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs) for one of three sampled residents (Resident 2) to address that Resident 2 was immunocompromised (having a weakened immune system that cannot fight infections and diseases as effectively as a healthy one) and had high risk for infection. This failure had the potential to delay provision of necessary care for Resident 2 and placed Resident 2 at risk of developing an infection. Findings:During a review of Resident 2's Face Sheet, undated, the Face Sheet indicated the facility originally admitted Resident 2 on 6/20/2026 and readmitted on [DATE], with diagnoses including diffuse large B-cell lymphoma (is a fast-growing, aggressive type of non-Hodgkin lymphoma [blood cancer] that develops when abnormal B-cell lymphocytes [a type of white blood cell] multiply uncontrollably and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that the comprehensive care plan (a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs) was revised for two of three sampled residents (Resident 2 and 3) when facility staff cohorted (grouping residents together based on their infection status to prevent the spread of illness to healthy residents) Residents 2 and 3 with Resident 1 who was suspected with Clostridium Difficile infection (CDI or C. difficile - bacteria that causes severe, diarrhea [loose, watery stools], and inflammation of the colon) on 1/18/2026 and tested positive for CDI on 1/20/2026. This deficient practice had the potential to delay provision of care for Resident 2 and Resident 3. The delay in provision of care to Resident 2 and Resident 3 could result in severe infection, sepsis (a life-threatening medical emergency caused by the body's extreme, overreaction to an infection), hospitalization, or death.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 its policy for the 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) program for one of three sampled residents (Resident 1) by failing to monitor Resident 1 for the adverse effects (undesired or harmful effects) of levofloxacin (antibiotic medication used to treat infection) from 12/23/2025 to 12/29/2025.These failures had the potential to increase antibiotic resistance (don't respond to a drug) from unnecessary or inappropriate antibiotic use and had the potential to result in Resident 1 to experience an adverse reaction.During a review of Resident1's admission Record, the admission Record indicated the facility admitted Resident 1 on 11/21/2025, with diagnoses that included unspecified (unconfirmed) acute kidney failure (when the…

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

Based on interview, and record review, the facility failed to develop and implement a person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for one of three sampled residents (Resident 1) to address Resident 1's refusal of Restorative Nursing Assistance (RNA- provide specialized rehabilitative care, helping residents regain independence with daily activities like walking, bathing, and eating, under the supervision of licensed nurses and therapists) services.This failure had the potential to result in a delay in the delivery of necessary care and services.Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 11/21/2025, with diagnoses that included unspecified (unconfirmed) acute kidney failure (when the kidneys suddenly cannot filter waste products from the blood), and difficulty in walking and generalized weakness.During a review of Resident 1's History and Physical (H&P-a medical examination that involves a doctor taking…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents with or without limited range of motion (ROM - movement of the joints) received appropriate treatment and services to increase, prevent, or maintain the ROM mobility for one of three sampled residents (Resident 1) who had a physician's orders for Restorative Nursing Assistance (RNA) ambulation five times a week.This failure resulted in Resident 1 not receiving RNA ambulation and placed Resident 1 at risk for decline in physical function.During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 11/21/2025, with diagnoses that included unspecified (unconfirmed) acute kidney failure (when the kidneys suddenly cannot filter waste products from the blood), difficulty in walking and generalized weakness.During a review of Resident 1's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 11/25/2025, the H&P indicated Resident 1 had the…

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

Based on interview and record review, the facility failed to maintain an accurate and complete medical record for one of three sampled residents (Resident 1) by failing to document the time of the Physician notification and the Physicians' response after the facility's notification of Resident 1's abnormal (result that falls outside the reference range) blood test result on 12/26/2025.This failure had the potential to result in medication errors, cause confusion in care and the medical records containing inaccurate documentation.Findings:During a review of Resident1's admission Record, the admission Record indicated the facility admitted Resident 1 on 11/21/2025, with diagnoses that included unspecified (unconfirmed) acute kidney failure (when the kidneys suddenly cannot filter waste products from the blood), difficulty in walking and generalized weakness. During a review of Resident 1's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 11/25/2025, the H&P…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 notify the resident and the resident's representative (RR - a person authorized by State or Federal law including but not limited to agents under power of attorney [POA - a legal document that allows someone else to act on your behalf]) of the transfer or discharge and the reasons for the move in writing for two of three sampled residents (Residents 1 and 2).These failures had the potential for incomplete information conveyed to Residents 1 and 2 or their RR and could have violated residents and RR's rights to appeal (the process in which cases are reviewed by a higher authority) transfer or discharge.Findings: a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 4/29/2025, with diagnoses that included unspecified (unconfirmed) psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), unspecified dementia (a progressive state…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the residents received care consistent with professional standards of practice for one of three sampled residents (Resident 1) by failing to notify the physician on 9/1/2025, when Resident 1 had a 20 millimeter of mercury (mmHg - unit of pressure commonly used for blood pressure readings) decrease in systolic blood pressure (sbp - top number of the blood pressure that represents the pressure in your arteries when your heart pumps blood out to the rest of your body).This failure had the potential to place Resident 1 at risk of orthostatic hypotension (a condition where blood pressure drops significantly when a person stands up from a lying or sitting position) and could negatively impact residents' well-being.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 4/29/2025, with diagnoses that included unspecified (unconfirmed) psychosis (a severe mental condition in which…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical records were complete and accurately documented for two of three sampled residents (Residents 1 and 2), when Resident 1 and Resident 2's Inventory Lists, on the Discharge portion, were left blank.This failure had the potential for Resident 1 and Resident 2's personal belongings to be lost.Findings: a. During a review of Resident 1's admission Record, the admission Records indicated the facility admitted Resident 1 on 4/29/2025, with diagnoses that included unspecified (unconfirmed) psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), unspecified dementia (a progressive state of decline in mental abilities) and essential hypertension (high blood pressure with no single, identifiable cause).During a review of Resident 1's Inventory List (a detailed and organized list of everything a person owns), dated 8/28/2025, the Inventory List indicated the Discharge portion of 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 ensure one of two sampled residents (Resident 1) were free of significant medication error when Licensed Vocational Nurse (LVN) 1 failed to follow the doctor's ordered parameters (specific instructions from a doctor on exactly how and when to give a medication) for administering valsartan (a medication used to treat high blood pressure and heart failure [a condition in which the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen]) to Resident 1. This failure resulted in LVN 1 administering valsartan to Resident 1 without first assessing Resident 1's blood pressure and heart rate per the doctor's order.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. The admission Record indicated Resident 1's diagnoses included essential hypertension (high blood pressure that is not caused by another medical condition),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement their infection control policy for one of three sampled residents (Resident 1) when Licensed Vocational Nurse (LVN) 1: 1. Did not wear gown and gloves prior to entering Resident 1's room, which was placed on contact isolation precautions (a facility procedure to stop the spread of germs by requiring hand hygiene and the use of gown and gloves before entering a resident's room, followed by its removal when exiting a resident's room). 2. Placed a medicine cup, containing crushed medications mixed with applesauce, inside a medication cart next to a glucometer (an electronic device used for multiple residents that measures the amount of sugar in the blood). These deficient practices had the potential to spread infection to Resident 1 and to other residents within the facility. Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. 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.

Based on 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 biologicals) for one of three sampled residents (Resident 1) by failing to follow Resident 1's physician order to administer valsartan (medication used to treat high blood pressure) for systolic blood pressure (sbp- the top number in a blood pressure reading, indicating the pressure in your arteries when your heart beats) above 100 millimeters of mercury (mmHg-a standard unit of pressure).This failure had the potential to result in medication error and could cause Resident 1's uncontrolled hypertension (HTN-high blood pressure).Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 10/15/2025, with diagnoses that included paroxysmal atrial fibrillation (irregular heartbeat in the upper heart chambers that starts and stops on its own), generalized muscle weakness and essential hypertension (occurs when 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 observation, interview, and record review, the facility failed to follow professional standards of practice for one of three sampled residents (Resident 3) by failing to: 1. Ensure Resident 3 had physician orders for the resident's indwelling urinary catheter (a flexible plastic tube inserted into the bladder that helps provide continuous urinary drainage) care and monitoring. 2. Ensure Resident 3's indwelling urinary catheter was monitored for signs and symptoms of urinary tract infection (UTI - an infection in any part of the urinary system [kidneys, bladder, or urethra]). 3. Ensure Licensed Vocational Nurse (LVN) 2 and LVN 3 did not perform indwelling urinary catheter treatments on Resident 3 without a physician orders. 4. Ensure Resident 3's Care Plan on obstructive uropathy (a condition in which the flow of urine was blocked and the urine flow backward to the kidney) was implemented. 5. Ensure Resident 3's change of condition (COC) was reported timely to the resident's Attending Physician (MD). These deficient practices had the potential to place Resident 3 at risk for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 3 and Resident 5) with indwelling urinary catheter (a flexible plastic tube inserted into the bladder that helps provide continuous urinary drainage) received proper care and services by failing to: 1. Ensure Resident 3's urine output was monitored for presence of hematuria (blood in the urine). 2. Ensure Resident 3's indwelling urinary catheter tubing was anchored (secured) to the resident's thigh. These deficient practices resulted to Resident 3's urinary catheter tubing and drainage bag with dark yellow to dark red, cloudy urine with visible sediments and hematuria during an observation on 4/10/2025 at 10:40 a.m. On 4/11/2025 at 1:17 a.m., Resident 3's Laboratory Results Report, dated 4/11/2025, the resident's urinalysis (urine test) indicated a white blood count (measures the number of white blood cells [WBCs - a part of the immune system that protects the body from infection] 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 interview and record review, the facility failed to ensure a comprehensive, person-centered care plan with measurable objectives and interventions for one of seven sampled residents (Resident 3) was created and implemented that addressed Resident 3's indwelling urinary catheter (a flexible plastic tube inserted into the bladder that helps provide continuous urinary drainage). This deficient practice had placed Resident 3 at risk for not receiving the necessary services and assistance that can result in resident injury or serious condition. Findings: During a record review of Resident 3's admission Record, the admission Record indicated the facility admitted the resident on 7/14/2020 with diagnoses including acute kidney failure (condition in which the kidneys suddenly cannot filter waste from the blood), benign prostatic hyperplasia (BPH - a condition that occurs when the prostate gland enlarges, potentially slowing or blocking the urine stream), and obstructive and reflux uropathy (a condition in which the flow of urine was blocked and the urine flow backward to the…

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

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 3) received care consistent with professional standards of practice to prevent pressure ulcers (PU, a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) by failing to ensure Resident 3's low air-loss mattress (LALM - a mattress composed of inflatable air cushions that is used to relieve pressure on body parts) was set to appropriate setting per manufacturer's guidelines. This deficient practice had placed Resident 3 at risk for the development of pressure ulcers. Findings: During a record review of Resident 3's admission Record, the admission Record indicated the facility admitted the resident on 7/14/2020 with diagnoses including acute kidney failure (condition in which the kidneys suddenly cannot filter waste from the blood), benign prostatic hyperplasia (BPH - a condition that occurs when the prostate gland enlarges, potentially slowing or blocking the urine…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical records of one of seven sampled residents (Resident 1) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to ensure Certified Nursing Assistant (CNA) 2 documented Resident 3's percentage of food eaten on the correct time. This deficient practice resulted in inaccurate information on Resident 1's medical records and had the potential for delayed and inaccurate medical interventions. Findings: During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 3/24/2025 with diagnoses including unspecified displaced fracture (a piece of broken bone that shifted out of alignment with each other) of the second cervical vertebra (the bone on the neck that allows a person to rotate the head from side to side), epilepsy (a condition that affects the brain and causes frequent seizures [sudden uncontrolled body movements and changes in behavior that occurs because of abnormal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for six of eight sampled residents (Residents 31, 5, 30, 63, 33, and 151) investigated during review of physical restraints care area by failing to ensure: 1. Residents 31 and 5's pad alarm (when connected to a fall prevention monitor, the pressure pad will trigger the fall alarm when weight is removed from the pad) had a physician's order, restraint assessment, informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered), and a care plan on its use. 2. Resident 30 and 33's use of the restraint bed placed against the wall had a physician's order, restraint assessment,…

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

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 to four (4) out of 4 sampled residents (Residents 49, 159, 73, and 100) investigated under insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin administration sites. These deficient practices had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as 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 49's admission Record, the admission Record indicated the facility originally admitted Resident 49 on 9/11/2024 and readmitted the resident on 10/26/2024, with diagnoses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, the breakdown of skin integrity due to pressure) for four of five sampled residents (Residents 124, 30, 110, and 100) investigated under pressure injury by failing to ensure: 1. Resident 124 and 100's Low Air Loss Mattress (LALM, a mattress that helps prevent and treat pressure wounds by circulating air and relieving pressure on the body) machine was labeled accurately. 2. Residents 30's LALM was set according to resident's weight. 3. Resident 110's LALM had a physician's order. 4. Resident 110's LALM was set to the correct weight. These deficient practices had the potential for development and worsening of pressure ulcers/injuries to residents. Findings: 1. During a review of Resident 124's admission Record (AR), the AR indicated the facility admitted the resident on 4/20/2022, and readmitted 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 ensure the resident environment was free of accident hazards for four of eight sampled residents (Residents 124, 2, 174, and 334) investigated under accidents, and for one of eight sampled residents (Resident 129) reviewed under physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) care area by failing to: 1. Ensure Resident 124, 2, and 174's fall mat (a cushioned floor pad designed to help prevent injury should a person fall) did not have a furniture or equipment on top of them. 2. Ensure Resident 334's bed pad alarm (a device that triggers an audible alarm when a patient attempts to rise off the pad) was functioning when the cord was observed unplugged from the bed pad alarm unit or box. 3. Identify, evaluate, and analyze hazards and risks 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: 1. Ensure to dispose of medications in a manner that was not retrievable (able to get back), in one (1) of two (2) inspected Medication Rooms (Medication Room Station 1). 2. Not dispose aerosolized (having tiny particles of matter and gas or liquid that turn into a fine mist to be inhaled) inhaler (a device containing a pressurized canister that is inhaled and delivers medication to the lungs) in the pharmaceutical (any medication/drug or dietary supplement for use by humans) waste bin (specialized container for disposing pharmaceutical waste) in one (1) of two (2) inspected Medication Rooms (Medication Room Station 1). As a result, control and accountability of discontinued medications and medications awaiting final disposition (process of returning and/or destroying unused medications) did not follow state and federal regulations and facility policy and procedures (P&P). These deficient practices increased the opportunity for medication diversion (the transfer of a medication from a lawful to an unlawful…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 132) drug regimen was free from unnecessary medications (any medication in excessive dose, excessive duration, without adequate monitoring) in accordance with the facility policy and procedures (P&P) by failing to ensure Resident 132 had a specific, measurable target behavior related to the use of quetiapine (an antipsychotic [medication capable of affecting the mind, emotions, and behavior] used to treat mental illness). This deficient practice had the potential to place Resident 132 at risk for significant adverse effects (unwanted, unintended results) from the use of unnecessary antipsychotic drugs, which could result to impairment or decline in the resident's mental, physical condition, functional, and psychosocial status. Findings: During a review of Resident 132's admission Record (a document containing demographic and diagnostic information,) dated 12/19/2024, the admission Record indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a medication error rate below 5 percent (%) by having two (2) medication errors out of 29 opportunities contributing to an overall error rate of 6.9% for two (2) out of three (3) sampled residents (Resident 28 and 39) observed during the Medication Administration facility task. The medication errors were as follows: 1. Resident 28 did not receive a dose of oyster shell calcium (a medication used as a dietary supplement to provide support to bones) as ordered by Resident 28's physician, and 2. Resident 39 did not receive a dose of docusate (a medication used to treat symptoms of gas such as painful pressure, fullness, and bloating) at the scheduled time as ordered by Resident 39's physician. These failures had the potential to cause Resident 28 and 39 to experience health complications leading to fragile bones, breakage of bones, and constipation resulting in the health and well-being of Resident 28's and 39's being negatively…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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: 1. For one (1) of three (3) sampled residents (Resident 28) investigated under medication administration by failing to administer epoetin alfa (a medication used to treat anemia [a blood disorder when the body doesn't produce enough red blood cells,]) as prescribed by Resident 28's physician. As a result, Resident 28 received two (2) doses of epoetin alfa, against the physician orders. 2. For four (4) out of four (4) sampled residents (Residents 49, 73, 100 and 159) investigated under insulin (a hormone that lowers the level of sugar in the blood) care area by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (the tissue layer between the skin and the muscle) insulin administration sites These deficient practices had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Remove and discard from use one expired anastrazole (a medication used for breast cancer) medication bottle for Resident 173, in accordance with facility and manufacturer's requirements in one of two inspected medication rooms (Medication room [ROOM NUMBER].) 2. Label one 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 94 with an open date, in accordance with facility requirements and manufacturer's requirements in one of four inspected medication carts (Medication Cart 1). 3. Remove and discard from use two expired loperamide (a medication used to treat diarrhea) medication boxes for facility stock, in accordance with facility and manufacturer's requirements in two of four inspected medication carts (Medication Carts 2 and 3.) 4. Store one…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the menu and did not meet nutritional needs of 123 of 168 residents on regular texture diets (diet with no restriction) when staff did not level off the scoop when scooping rice and carrots from the steamtable to the resident's plates. This failure had the potential to result in increased food and nutrient intake resulting to unintended (not done on purpose) weight gain and increased in blood sugar levels for residents on consistent carbohydrate diet ([CCHO] diet with the same amount of carbohydrates per meal). Findings: During a review of the facility's daily spreadsheet titled Winter Menus, dated 12/16/2024, the spreadsheet indicated residents on regular texture and soft mechanical (foods that are chopped) diet would get the following food items on their tray: Fish Filled with tarragon sauce 3 ounces ([oz] a unit of measurement)/ 1 oz. Tartar sauce 1 tablespoon ([Tbsp.], a household measurement) Cajun Country [NAME] 1/3 cup ([c], a household measurement) Creamed spinach ½ c Parsley Sprig 1 Sweet corn…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents on puree diet/level four (4) (food that are soft and pudding-like consistency) received puree spinach that was too sticky and did not fall from the spoon during a spoon tilt test (a method used to determine the stickiness of food and ability of the food to hold together). This deficient practice had the potential to cause coughing, choking (to keep from breathing the normal way) and death for 24 of 168 residents on puree/level 4 diet. Findings: During a review of the facility's daily spreadsheet titled Winter Menus, dated 12/16/2024, the spreadsheet indicated residents on puree/level 4 diet would include the following foods on the tray: Puree fish filled 3 ounces (oz, a unit of measurement) with tarragon sauce (1 oz) on the fish. Puree tartar sauce 1 oz Puree Cajun country rice 3 oz Puree creamed spinach 3oz. Parsley flakes Puree sweet corn 3 oz Puree fruit Bavarian cream 3 oz During an observation on 12/16/2024 at 11:08 a.m. of puree…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 meet three (3) of 3 sampled resident's (Resident 34, Resident 1, and Resident 20) food preferences when: a. Resident 34 disliked green beans and was given green beans for lunch. b. Resident 1 was restricted lactose (a sugar present in milk) and lactose containing product (yogurt, ice cream, cream, cheese, sour cream, salad dressing) by indicating Resident 1 was allergic (affected with an immune reaction that occurs when the body mistakenly identifies a certain food as harmful, and reaction could lead to various symptoms ranging to mild and life-threatening) to lactose when Resident 1 was not allergic to lactose and liked lactose and lactose-containing product except milk to drink. c. Resident 20 disliked milk products and was given milk shakes for lunch. These deficient practices had the potential to cause frustrations and decrease food intake resulting to unintended (not done on purpose) weight loss. Findings: a. During a review of Resident…

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

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: a. Three (3) of five (5) green racks had chips in the walk-in refrigerator. b. Food preparation surfaces and kitchen equipment were not cleaned and sanitized. 1. Two (2) green racks had dust buildup in the walk-in refrigerator. 2. Walk-in freezer's roof and right-side wall had ice crystal buildup. 3. Bottom shelves of the reach-in refrigerator had dust and dirt debris. 4. Dry storage room floor had food debris. 5. Juice machine filter had dust buildup and racks are sticky and dusty to touch. 6. Scoops and paper drawer had food debris. 7. Ice container had white residue buildup. 8. Coffee machine hot waterspout (a tube or lip projecting from a container, through which liquid can be poured) had dried up mineral water buildup. c. Ten (10) dented cans were stored with non-dented cans. d. Two of two trayline (an area where foods were assembled on the trays) staff's (Dietary Aide 1's [DA 1] and [NAME] 1's) hairs were not fully…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 through their submitted application to the State Agency 1 (SA 1) for the change of medical director to comply with the State and Federal requirement for 12 months of 12 months (12/20/2023 to 12/20/2024). This deficient practice had the potential to result in delay in the medical director's ability to implement necessary changes or improvements in care practices, negatively affecting the quality-of-care residents receive. Findings: During an interview on 12/18/2024 at 11:12 a.m., with the Administrator (ADM), the ADM stated the medical director application was sent to SA 1 last 3/2023. The ADM stated she will provide a copy. The ADM stated they just found the copy last night. During a concurrent interview and review of the facility's mail receipt information, on 12/18/2024 at 11:35 a.m., the ADM stated the original application was last sent on 6/30/2022 and was delivered to SA 1 on 7/7/2022. The ADM stated the facility mailed the revised application on 3/20/2023. The ADM stated she assumed the position on 3/21/2024.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by: 1. Failing to ensure the oxygen (O2) nasal cannula (NC) tubing (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) was kept off the floor for one (1) of 1 sampled resident (Resident 159) investigated during a random observation. 2. Failing to ensure the staff washed or sanitized their hands prior to distributing trays and assisting residents to eat in the Dining Room Area for Station 2 and failed to offer hand hygiene to the residents prior to eating during Dining Observation Task. 3. Failing to ensure the water temperature in the building especially the areas where the identified water stagnation happens were above 113 degrees Fahrenheit (F, a scale for measuring temperature), to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy and procedure (P&P) related to a resident's decision-making process for informed consent (IC-voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for one of six sample residents (Resident 37) by obtaining a consent for an antipsychotic medication from the resident without capacity to make medical decisions. This failure had the potential for Resident 37 to not understand his treatment. Findings: During a review of Resident 37's admission Record (not dated), the admission Record indicated Resident 37 was admitted on [DATE] with the following diagnoses, but not limited to, dementia (a progressive state of decline in mental abilities), bipolar disorder (a mental disorder with mood swings that range from the lows of depression to elevated periods of emotional highs), degeneration of nervous system due to alcohol, attention-deficit hyperactivity…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm by one resident towards another) for one of three sampled residents (Resident 85) when on 12/10/2024 at 1:30 p.m., Certified Nursing Assistant 3 (CNA 3) and Resident 999 witnessed Resident 73 pull Resident 85's right arm (while he was on his wheelchair going to the bathroom accompanied by CNA 3) while passing Resident 73's bed (who was sitting at the edge of his bed) leading to both residents landing on the floor. This deficient practice resulted in Resident 85 being subjected to physical abuse by Resident 73 while under the care of the facility. Resident 85 sustained a superficial scratch on his right cheek. Based on the Reasonable Person Concept (the usual behavior of an average person under the same circumstances), due to Residents 73's aggression and unstable psychological condition, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to thoroughly investigate a physical abuse (deliberately aggressive or violent behavior with the intention to cause harm by one resident towards another) allegation for one of three sampled residents (Resident 85) by failing to include in their final investigation report the precipitating factors (a specific event or trigger to the onset of the current problem) that led to Resident 73 pulling Resident 85's right arm on 12/10/2024 at 1:30 p.m. while passing Resident 73 who was sitting at the edge of the bed. Resident 185 was on his wheelchair on the way to the bathroom accompanied by Certified Nursing Assistant 3 (CNA 3). The incident led to both residents landing on the floor with Resident 85 sustaining a superficial scratch on his right cheek. This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect residents from abuse. Cross Reference F600 Findings: During a review of Resident 85's…

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

Based on interview and record review, the facility failed to ensure that the discharge information is documented in the resident's medical record and is communicated to the resident for two of two sampled residents (Resident 54 and 75) investigated under Discharge care area by: 1. Failing to take and document the resident's vital signs prior to discharge for Residents 54 and 75. 2. Failing to provide special instructions for Resident 54 including follow-up with the gastrointestinal (GI - relating to your stomach and intestines physician and list of medications. 3. Failing to accurately document Resident 54's exact discharge location address and contact information. These deficient practices had the potential to result in discontinuity of the residents' care and an unsafe transition of care. Cross Reference F661 Findings: a. During a review of Resident 54's admission Record, the admission Record indicated the facility admitted the resident on 8/14/2024 with diagnoses including traumatic subdural hemorrhage (a dangerous bleeding that occurs between the skull and the brain) without…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 are screened using the Preadmission Screening and Resident Review (PASRR, a federal requirement to help ensure that individuals are not appropriately placed in nursing homes for long-term care) for a mental disorder (MD) or intellectual disability (ID) prior to admission and that individuals identified with serious mental illness (SMI) and/or ID/developmental disability (DD)/related conditions (RC) receive the care and services in maintaining his/her highest practicable level in the most appropriate setting for two of three sampled residents (Resident 124 and 11) investigated under PASRR care area, by: 1. Failing to follow through with Resident 124's PASRR recommendations to obtain a PASRR Level II (a person-centered evaluation that is completed for anyone identified by Level I Screening as having, or suspected of having, a PASSR condition, i.e., SMI, ID, DD, or RC) evaluation for Resident 124. 2. Failing to submit a new Level I…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 there was documented evidence that discharge planning arrangements regarding follow-up gastrointestinal (GI - relating to your stomach and intestines consultation was made and provided to the resident upon discharge for one of three sampled resident (Resident 54) investigated under closed records review. This deficient practice had the potential to result in an unsafe discharge, incomplete documentation, and communication of Resident 54's stay in the facility. Cross Reference F622 Findings: During a review of Resident 54's admission Record, the admission Record indicated the facility admitted the resident on 8/14/2024 with diagnoses including traumatic subdural hemorrhage (a dangerous bleeding that occurs between the skull and the brain) without loss of consciousness, schizoaffective disorder (a mental illness that can affect your thoughts, mood and behavior), epilepsy ( happens as a result of abnormal electrical brain activity), and alcoholic cirrhosis of the liver (when healthy liver tissue is replaced by scar…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 replace the prescription eyeglasses for one of two sampled residents (Resident 20). This failure had the potential to result in a decline of Resident 20's activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) due to poor vision. Findings: During a review of Resident 20's admission Record (not dated), the admission Record indicated Resident 20 was admitted on [DATE] with the following diagnoses, but not limited to, glaucoma (an eye disease caused by increased pressure inside the eye that may lead to vision loss), cerebral palsy (a condition that affects a person's ability to move, maintain balance, and posture). During a review of Resident 20's Care Plan, dated 10/8/24, the care plan indicated Resident 20 had impaired visual functioning related to aging and glaucoma. The care plan goal indicated Resident 20 will minimize the risk of injury related to visual…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an ulnar splint (a device that helps correct and manage a hand deformity that causes fingers to drift away from the thumb) was provided for one of two sampled residents (Resident 2. This failure had the potential to affect Resident 20's range of motion and cause contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion) in her hand. Findings: During a review of Resident 20's admission Record (not dated), the admission Record indicated Resident 20 was admitted on [DATE] with the following diagnoses, but not limited to, cerebral palsy (a conditions that affects ability to move, maintain balance, and posture), contracture of left hand, generalized muscle weakness, unspecified osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Minimum Data Set (MDS- a resident assessment tool), dated 10/2/24, the MDS indicated Resident 20's cognitive function (a 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 ensure residents with a urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) received appropriate care and services to prevent urinary tract infections (UTI, an infection in the bladder/urinary tract) for three (3) of 3 sampled residents (Residents 49, 153, and 1) investigated under the urinary catheter or UTI care area when the facility failed to ensure Residents 49, 153, and 1's urinary catheter tubing did not have loops while hanging on the side the bed. This deficient practice had the potential for the residents' urine not to flow freely which may lead to development of UTI. Findings: a. During a review of Resident 49's admission Record, the admission Record indicated the facility originally admitted Resident 49 on 9/11/2024 and readmitted the resident on 10/26/2024, with diagnoses including obstructive and reflux uropathy (a condition in which the flow of urine is blocked, causing the urine to back up…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 b. During a review of Resident 141's admission Record (AR), the AR indicated the facility admitted the resident on 7/6/2023, and readmitted the resident on 10/7/2024, with diagnoses including gastrointestinal hemorrhage (a bleeding disorder in the digestive tract), gastrostomy, and dysphagia (difficulty swallowing). During a review of Resident 141's H&P, dated 10/9/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 141's MDS dated [DATE], the MDS indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident had a feeding tube while a resident in the facility. During a review of Resident 141's Order Summary Report, the Order Summary Report indicated the following physician orders: -10/7/2024 Enteral Feed Order. Turn pump on at 12 p.m. and turn off at 8 a.m. (or until dose is completed). -11/7/2024 Enteral Feed Order. Glucerna 1.5 (a brand of nutritionally complete liquid formula) at 60…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Nurse Practitioner (NP) obtained an informed consent (IC-voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for one of six sample residents (Resident 37) for an antipsychotic medication (a substance that can change how a person's brain works and can affect awareness, thoughts, mood, and behavior) from a resident without the capacity to make medical decisions. This failure had the potential for Resident 37 to not understand the risks and benefits of the treatment. Findings: During a review of Resident 37's admission Record (not dated), the admission Record indicated, Resident 37 was admitted on [DATE] with the following diagnoses, but not limited to, dementia (a progressive state of decline in mental abilities), bipolar disorder (a mental illness that causes mood swings that range from the lows of depression to elevated periods of emotional highs),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that Licensed Vocational Nurse 4 (LVN 4) was competent in implementing the facility's policy and procedure for transfers and discharges for two of three sampled residents (Resident 54 and 75). This deficient practice had the potential to result in a delay of the provision of necessary care and services. Cross-reference: F622 and F661 Findings: a. During a review of Resident 54's admission Record, the admission Record indicated the facility admitted the resident on 8/14/2024 with diagnoses including traumatic subdural hemorrhage (a dangerous bleeding that occurs between the skull and the brain) without loss of consciousness, schizoaffective disorder (a mental illness that can affect your thoughts, mood and behavior), epilepsy ( happens as a result of abnormal electrical brain activity), and alcoholic cirrhosis of the liver (when healthy liver tissue is replaced by scar tissue, which prevents the liver from functioning normally) without ascites (where fluid builds up in the abdomen, or belly, and can cause swelling).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 three of six sampled residents' (Resident 1, 2 and 4) environment remains as free of accident hazards as is possible by failing to: a. Ensure Resident 2's wound cleanser was not left unattended on the resident's bedside table. b. Conduct an inventory of Resident 4's belongings thoroughly on admission to ensure the resident did not have access to a bottle of chlorhexidine gluconate (an antiseptic agent that had been shown to decrease microbial flora on the skin and prevent infection risks). Licensed Vocational Nurse 2 (LVN 2) observed Resident 4 holding a bottle of chlorhexidine gluconate against the resident's mouth. c. Ensure Resident 1's medications (two tablets of Tylenol [an analgesic for mild pain but not for inflammation], one tablet of docusate sodium [a medication utilized for managing and treating constipation], one tablet of Apixaban [a medication to prevent serious blood clots from forming due to a certain irregular heartbeat], one tablet of gabapentin [a medication for nerve pain] and one…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 clinical records were complete and accurately documented for one of six sampled residents (Resident 4) by failing to ensure Resident 4 ' s clinical history and diagnosis were accurately documented in the resident ' s clinical records. This deficient practice had the potential for delayed and inappropriate medical interventions for Resident 4. Findings: During a review of Resident 4 ' s admission Record, it indicated the facility admitted the resident on 7/23/2024 with diagnoses including acute respiratory failure (occurs when the lungs cannot release enough oxygen into the blood), metabolic encephalopathy (an alteration in consciousness due to brain dysfunction), and gastro-esophageal reflux disease (a condition in which the stomach acid repeatedly flows back up into the esophagus [tube connecting the mouth and stomach]). During a review of Resident 4 ' s Change of Condition (COC) Form, dated 7/24/2024, it indicated that on 7/24/2024 at 8:03 p.m., LVN 2 observed the resident holding a small white bottle 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.

Based on interview and record review, the facility failed to develop and implement comprehensive care plans for one of three sampled residents (Resident 2) by: 1. Failing to implement an intervention in Resident 2 ' s care plan titled Residents ' preference to exercise unsupervised in the patio and parking, dated 9/29/2022, indicating the Physical Therapist (PT) to assess Resident 2 quarterly (every three months) and as needed for safety of gait, transfer, sitting, balance and need for safety device. 2. Failing to implement an intervention in Resident 2 ' s care plan titled, At risk for fall risk for fall related to episode of going unsupervised to the front patio, dated 10/3/2022, indicating Receptionist 1 (RCP 1) will oversee Resident 2 when the resident goes to the front patio unsupervised. 3. Failing to ensure a care plan was developed for Resident 2 ' s unsupervised out on pass (a temporary permission of a resident to leave the facility or hospital in a specified time) order on 5/2/2024. 4. Failing to implement an intervention in Resident 2 ' s care plan titled, Out on pass,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 measures for five of ten staff (Receptionist 1 [RCP1], Laundry Staff 1 [LS 1, LS 2, Housekeeper 1 [HSK 1] HSK 2 during a Coronavirus Disease 2019 (COVID-19, a very contagious disease that affects the lungs) outbreak (a sudden rise in the incidence of a disease) by: 1. Failing to ensure RCP 1 wore a face mask while assisting visitors in the reception area. 2. Failing to ensure RCP 1 inform visitors of COVID-19 outbreak and the use of N95 mask during outbreak. 3. Failing to ensure HSK 1 and HSK 2 wore a face mask while talking to each other inside the laundry room. 4. Failing to ensure LS 1 and LS 2 wore a face mask covering their nose and mouth while inside the laundry room with HSK 1 and HSK 2. These deficient practices had the potential to expose and spread COVID-19 to other residents, staff, and visitors. Findings: During an observation on 6/20/2024 at 8:40 a.m. in the reception area, RCP 1 was observed not wearing a mask while assisting other staff and visitors within six feet 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 ensure one of three sampled residents (Resident 2) was provided adequate supervision by failing ensure Receptionist 1 (RCP 1) call for staff assistance when RCP 1 did not visually see Resident 2 in the front patio. Resident 2 was observed walking in the facility parking lot alone and unsupervised on 6/17/2024. This deficient practice placed Resident 2 at risk for fall and injury. Findings: A review of Resident 2 ' s admission Record indicated the facility admitted Resident 2 on 7/27/2015 with diagnoses that included syncope (loss of consciousness for a short period of time) and collapse (fall down), hemiplegia (loss of strength in the arm, leg, and sometimes face on one side of the body) and hemiparesis (partial weakness) following cerebral infarction (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off) affecting right dominant side and essential hypertension (occurs when you have abnormally high blood pressure that's not the…

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

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free of any significant medication errors (one which causes the resident discomfort or jeopardizes his or her health and safety) by: 1. Failing to provide documented evidence that lispro (medication used to lower glucose [sugar] level in the blood) four units was given to Resident 1 on 4/16/2024 and 4/18/2024 at 5:15 p.m. 2. Failing to provide documented evidence that Lantus (a long-acting [slowly absorbed after being administered, and maintains its effects over a long period of time] man-made-insulin used to control high blood sugar) 21 units was given to Resident 1 on 4/16/2024, 4/18/2024, and 4/19/2024 at 9 p.m. 3. Failing to ensure lispro was not given for blood sugar below 100 on 5/14/2024 at 7:15 a.m., when Resident 1's blood sugar level was 93. 4. Failing to provide documented evidence that Lantus 21 units was given to Resident 1 on 5/16/2024 at 9 p.m. These deficient practices placed Resident 1 at risk of inadequate blood sugar management, which can cause…

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

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who was receiving apixaban (blood thinner or anticoagulant-a medication used to treat and prevent blood clot [a sticky lump that forms when blood dries up or becomes thick]) was monitored for signs of bleeding. This deficient practice placed Resident 1 at risk for adverse reactions including bleeding easily and bruising. Findings: A review of Resident 1's Administration Record indicated the facility admitted Resident 1 on 1/20/2023 with diagnoses that included type 2 diabetes mellitus (the most common type of diabetes, is a disease that occurs when your blood glucose, also called blood sugar, is too high) without complications, unspecific (unconfirmed) atrial fibrillation (the heart's upper chambers beat chaotically and irregularly), long term use of insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) and long term use of anticoagulant (a group of medications that decrease your blood's ability to clot [a sticky lump that forms when blood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a baseline individualized care plan for one of three sampled residents (Resident 1). Resident 1 had no care plan to address safety and supervision related to history of leaving against medical advice. On 4/29/2024 facility admitted Resident 1 from General Acute Care Hospital 1 (GACH 1) with two history of leaving against medical advice and on 4/30/2024, Resident 1 eloped from the facility. This deficient practice had the potential for Resident 1 to not receive appropriate care and treatment specific to their needs. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 4/29/2024 with diagnoses that included unspecified (unconfirmed) complete intestinal obstruction (a blockage that keeps food or liquid from passing through your small intestine or large intestine), gastrointestinal stromal tumor of stomach (a type of cancer [a disease in which some of the body's cells grow uncontrollably and spread to other parts of the body] that begins in the digestive system [breaks…

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

Based on observation, interview, and record review, the facility failed to ensure a resident was provided supervision to prevent leaving without a physician's order for one of three sampled residents (Resident 1). On 4/30/2024 Activity Coordinator (AC) entered the pin code to open the elevator going down and left Resident 1 and Family Member 1 (FM 1) unsupervised. This deficient practice resulted to Resident 1's leaving the facility without a physician's order and can potentially place Resident 1 at risk for injury, bleeding, infection, and dislodgement (to remove or force out of a particular place) of Jackson Pratt (JP-a surgical suction drain that gently draws fluid from a wound to help you recover after surgery) drain. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 4/29/2024 with diagnoses that included unspecified (unconfirmed) complete intestinal obstruction (a blockage that keeps food or liquid from passing through your small intestine or large intestine), gastrointestinal stromal tumor of stomach (a type of cancer [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 interview and record review, the facility failed to maintain a complete and accurate medical records in accordance with accepted professional standards for one of three sampled residents (Resident 1) who eloped on 4/30/2024. This deficient practice had the potential to result in confusion in the care and services rendered to Resident 1 and resulted in inaccurate information entered into Resident 1's clinical record. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 4/29/2024 with diagnoses that included unspecified (unconfirmed) complete intestinal obstruction (a blockage that keeps food or liquid from passing through your small intestine or large intestine), gastrointestinal stromal tumor of stomach (a type of cancer [a disease in which some of the body's cells grow uncontrollably and spread to other parts of the body] that begins in the digestive system [breaks down the food we eat into tiny parts to give us fuel and the nutrients we need to live]), other abnormalities of gait (person's manner of walking) and homelessness.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 employ a qualified social worker (an individual with a minimum of a bachelor ' s degree in social work or a bachelor ' s degree in a human services field including, but not limited to, sociology [study of social life, social change, and the social causes and consequences of human behavior], gerontology [study of the biological, psychological, and social aspects of aging], special education, rehabilitation counseling, and psychology [scientific study of the mind and behavior]; and one year of supervised social work experience in a health care setting working directly with individuals) on a full-time basis. This deficient practice placed all residents in the facility at risk of not receiving their needed medically related social services. Cross reference F660. Finding: On 3/15/2024 at 10:25 a.m., during an interview, the Director of Nursing (DON) stated the facility had 188 beds and the census of residents was 174. On 3/20/2024 at 12:50 p.m., during an interview, Social Services Assistant 1 (SSA 1) stated the Social Worker…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safety of one of three sampled residents (Resident 1) who was identified as high fall risk. On 1/14/2024 at 9 a.m., Resident 1 ' s Responsible Party 1 (RP 1) informed the facility that the resident had a witnessed fall at 4 a.m. on 1/14/2024. Resident 2, who was alert and awake witnessed Resident 1 on the floor. Resident 1 sustained a skin tear on the right shin. The facility: 1. Failed to assess and monitor Resident 1 after her fall. 2. Failed to report and conduct a thorough investigation of Resident 1 ' s fall. These deficient practices had the potential for exposure to and delayed identification of serious injuries or harm to the resident. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 7/28/2019. Resident 1 ' s diagnoses included epilepsy (a common condition that affects the brain and causes frequent seizures [a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident-to-resident abuse within two hours from the initial report of the incident for two of three sampled residents (Resident 1 and Resident 2). On 12/29/2023 at 2:15 p.m., Resident 1 reported to Certified Nursing Assistant 1 (CNA 1) that Resident 2 hit her. The allegation was not reported until 12/30/2023. This deficient practice had the potential to result in unidentified abuse in the facility and had the potential to place Resident 1 at risk for further abuse. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 2/3/2023 with diagnoses that included unspecified (unconfirmed) atrial fibrillation (abnormal Heartbeat), essential hypertension (occurs when you have abnormally high blood pressure that is not the result of a medical condition), and dysphagia (difficulty swallowing). A review of Resident 1 ' s History and Physical (H&P), dated 9/28/2023, indicated the resident did…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 report the allegation of visitor to resident abuse to the State Survey Agency (SSA) for one of three sampled residents (Resident 1). This deficient practice had the potential to result in unidentified abuse and failure to protect other residents from abuse. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 9/6/2021 with diagnoses including encephalopathy (damage or disease that affects the brain), Alzheimer ' s disease (a brain disorder that slowly destroys memory, thinking skills, and the ability to carry out the simplest tasks), and essential hypertension (abnormally high blood pressure that was not the result of a medical condition). A review of the Incident Report Burbank Police Department, dated 3/4/2023, indicated that police department officers went to the facility to investigate a facility reported allegation of abuse of Resident 1. The report indicated that the police officers interviewed the social service designee 2 (SSD 2) and the Director of Staff Development…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 submit the results of the facility investigation on the allegation of abuse within five (5) working days to the State Survey Agency (SSA) for one of three sampled residents (Resident 1). The allegation of abuse happened on 3/4/2023. The facility failed to submit the 5-day investigation report on 3/10/2023. This deficient practice had the potential to delay the investigations and result in failure to protect other residents from abuse. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 9/6/2021 with diagnoses including encephalopathy (damage or disease that affects the brain), Alzheimer ' s disease (a brain disorder that slowly destroys memory, thinking skills, and the ability to carry out the simplest tasks), and essential hypertension (abnormally high blood pressure that was not the result of a medical condition). A review of the Incident Report Burbank Police Department, dated 3/4/2023, indicated that police department officers went to the facility to investigate 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 provide care in a manner that maintained a resident ' s dignity for one of four sampled residents (Resident 4) by failing to ensure Resident 4 ' s urinary collection bag was covered with a privacy bag. This deficient practice had the potential to affect the self-esteem and self-worth of Resident 4. Findings: A review of Resident 4 ' s admission Record indicated the facility admitted the resident on 12/27/2023 with diagnoses that included fracture (broken bone) of neck of left femur (thigh bone), dementia (a decline in memory, language, problem-solving and other thinking skills that affect a person's ability to perform everyday activities), hypertension (uncontrolled elevated blood pressure), and retention of urine (a condition in which you cannot empty all the urine from your bladder). During a concurrent observation and interview on 12/28/2023 at 9:11 a.m., with Certified Nursing Assistant 1 (CNA 1) inside Resident 4 ' s room, Resident 4 ' s urinary drainage bag was observed with no privacy cover. CNA 1…

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

Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 4) urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) was secured to resident ' s thigh. This deficient practice placed the resident at risk to have a potential dislodgement (forced out of position) of the catheter that may result with a trauma to the urethra (a tube that connects the urinary bladder to the urinary meatus [opening] for the removal of urine from the body of both females and males). Findings: A review of Resident 4 ' s admission Record indicated the facility admitted the resident on 12/27/2023 with diagnoses that included fracture (broken bone) of neck of left femur (thigh bone), dementia (a decline in memory, language, problem-solving and other thinking skills that affect a person's ability to perform everyday activities), hypertension (uncontrolled elevated blood pressure), and retention of urine (a condition in which you cannot empty all the urine from your bladder). During a concurrent observation…

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

Based on observation, interview, and record review, the facility failed to implement infection control measures for one of four sampled residents (Resident 4) by failing to ensure residents urinary catheter tubing (a flexible tube used to empty the bladder and collect urine in a drainage bag) was not touching the floor. This deficient practice had the potential for cross contamination (unintentional transfer of bacteria/germs or other contaminant from one surface to another) of infection. Findings: A review of Resident 4 ' s admission Record indicated the facility admitted the resident on 12/27/2023 with diagnoses that included fracture (broken bone) of neck of left femur (thigh bone), dementia (a decline in memory, language, problem-solving and other thinking skills that affect a person's ability to perform everyday activities), hypertension (uncontrolled elevated blood pressure), and retention of urine (a condition in which you cannot empty all the urine from your bladder). During a concurrent observation and interview on 12/28/2023 at 9:11 a.m., with Certified Nursing Assistant 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to keep the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) within reach of the resident for five out of 11 sampled residents (Resident 26, 16, 137, 21, and 152). The deficient practice had the potential for residents not being able to summon healthcare workers for help as needed. Findings: a.1 A review of Resident 26's admission Record indicated the facility admitted the resident on 9/20/2013 and readmitted the resident on 12/16/2019, with diagnoses including dementia (a general term for impaired ability to remember, think, or make decisions that interferes with doing everyday activities), age-related osteoporosis (occurs when the body loses too much bone, makes too little bone, or both), and long-term use of anticoagulants (a group of medications that decrease the blood's ability to clot). A review of Resident 26's Minimum Data Set (MDS, a standardized assessment and care screening…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the residents' medical records were updated regarding advance directive (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) for seven of 30 sampled residents (Resident 21, 22, 58, 27, 36, 46, and 109) when: 1. Resident 21's Advance Directive Acknowledgement form was not placed in the resident's medical record. 2. Resident 22's Advance Directive Acknowledgement form about the resident's medical wishes was left blank. 3. Resident 58 or his responsible party was not provided information about advance directives. 4. Resident 27's, 36's, 46's, and 109's medical records did not contain a completed Preferred Intensity of Care Surrogate Decision Maker form (document that indicates the facility provided the resident information about their rights to formulate an advance directive) or Advance Directive Acknowledgement form. These deficient…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 to two out of 11 sampled residents (Residents 146 and 137) by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin (a hormone that lowers the level of sugar in the blood) administration sites. The deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat). Findings: 1. A review of Resident 146's admission Record indicated the facility admitted the resident on 3/9/2023, with a diagnosis of type 2 diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel). A review of Resident 146's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/15/2023, indicated the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide care consistent with professional standards of practice to prevent pressure ulcer/injury (ulcers that happen on areas of the skin that are under pressure from lying in bed, sitting in a wheelchair, or wearing a cast for a long period) to three out of 11 sampled residents (Residents 110, 153, and 148) by failing to ensure the residents' low air-loss mattresses (LALM, an air mattress covered with tiny holes) were set according to the residents' weights. The deficient practice had the potential for development and worsening of pressure ulcers to the residents. Findings: a. 1. A review of Resident 110's admission Record indicated the facility admitted the resident on 8/21/2020 and readmitted the resident on 5/17/2023, with diagnoses including type 2 diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as fuel), muscle weakness, and difficulty walking. A review of Resident 110's…

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

Based on observation, interview, and record review, the facility failed to: 1. Include the verifying signatures of either the Director of Nursing (DON) or a Registered Nurse (RN) along with Licensed Vocational Nurse (LVN) on the Antibiotic or Controlled Drug (also known as Controlled Medication or Controlled Substance [CM, CS]- medications which have a potential for abuse and may also lead to physical or psychological dependence) or Controlled Drug Record or Controlled Drug Administration Record accountability logs for three sampled month records (October 2023, November 2023, and December 2023). As a result, control and accountability of controlled substances awaiting final disposition (process of returning and/or destroying unused medications) did not follow the facility policy and procedures. 2. Account for eight doses of controlled substances for Residents 53, 71, 113 and 127 in one of three inspected medication carts (Medication Cart Station 2 Cart 3.) These deficient practices increased the opportunity for controlled substance diversion (the transfer of a controlled substance…

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

Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than 5 percent (%) due to 11 errors observed out of 31 total opportunities (error rate of 35.48%). The medication errors were as follows: 1. Resident 1 received seven medications in a form that was not ordered by Resident 1's physician. 2. Resident 1 did not receive fish oil (a medication used as a dietary supplement to provide support to the heart and brain and may lower blood cholesterol [fat] levels) and vitamin C (a medication used for the growth and repair of tissues in all parts of the body, including skin healing) as ordered by Resident 1's physician. 3. Resident 83 received a dose of docusate (a medication used for bowel [intestine] management) and a form and dose of aspirin (a medication used to prevent blood clots) that was different than the one ordered by Resident 83's physician. These failures had the potential to result in Residents 1 and 83 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 17 licensed vocational nurses (LVNs) did not administer expired insulin (a medication used to regular blood sugar levels) to three of ten residents (Resident 22, 73, and 148) observed for medication availability. As a result, Residents 22, 73, and 148 received a total of 61 doses of expired insulin. These practices had the potential to cause Residents 22, 73, and 148 to experience serious health complications due to uncontrolled blood sugar levels, possibly resulting in hospitalization or death. Findings: a. During an observation, interview, and record review, on [DATE] at 11:50 a.m., in Medication Cart 1 Station 1, in the presence of LVN 4, the following medications were found either stored in a manner contrary to their respective manufacturer's requirements, not labeled with an open date as required by their respective manufacturer's specifications, or stored and labeled contrary to facility policies: 1. One open insulin glargine…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Remove and discard from use one expired insulin (medication used to regulate blood sugar levels) glargine (long-acting insulin) prefilled pen (an injection device containing insulin) for Resident 22, and one insulin Lispro (fast-acting insulin) Kwikpen (type of injection device) for Resident 148, in accordance with manufacturer's requirements in one of three inspected medication carts (Medication Cart 1 Station 1.) 2. Label one lorazepam (a medication used to treat anxiety [state of excessive worry or fear] and restlessness) oral concentrate (a solution with increased strength) bottle with an open date and store in the refrigerator for Resident 165 in accordance with the manufacturer's requirements in one of three inspected medication carts (Medication Cart 1 Station 1.) 3. Label one inhalation treatment with an open date for Residents 471 in accordance with the manufacturer's requirements in one of three inspected medication carts…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 proper sanitation and food handling practices by failing to ensure: 1. A white plastic cup was not used as a scooper and left inside the bin of white flour. 2. Lays Classic (food service package) potato chips wrapped on a thin, clingy plastic wrap was labeled with a date opened and was not left in the dry pantry. 3. Two bananas on a bin dated 12/7/2023 with blackened peel were discarded. These deficient practices had the potential to cause foodborne illnesses (any illness of a toxic or infectious nature contracted through consumption of contaminated water or food). Findings: During an observation and interview on 12/11/2023, at 8:02 a.m., observed with Dietary Aide 1 (DA 1) a white plastic cup used as a scooper for white flour left inside the bin, a bag of Lays Classic potato chips wrapped on a thin, clingy plastic wrap without a label of when it was opened, and two bananas with blackened peels in a bin labeled 12/7/2023 inside the dry goods pantry. DA 1 stated the white plastic cup should not be used…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 for one of 30 residents (Resident 48) when Certified Nursing Assistant (CNA) 6 was observed standing over Resident 48 while assisting the resident with feeding. This deficient practice had the potential for Resident 48 to feel disrespected. Findings: A review of Resident 48's admission Record indicated the facility originally admitted the resident on 8/10/2023 and readmitted the resident on 9/22/2023 with diagnoses including metabolic encephalopathy (an alteration in consciousness caused due to brain dysfunction), dysphagia (difficulty in swallowing), and generalized muscle weakness. A review of Resident 48's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/15/2023, indicated Resident 48 was rarely or never understood and required supervision or touching assistance with eating. A review of Resident 48's Care Plans, revised 11/23/2023, indicated Resident 48 has alteration in nutritional status related poor oral intake…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident who experienced a significant change in status was comprehensively assessed using the Centers for Medicare & Medicaid Services (CMS) Resident Assessment Instrument (RAI) process for one of 30 sampled residents (Resident 28) when the facility did not conduct a significant change assessment on Resident 28's Minimum Data Set (MDS - a standardized assessment and care screening tool) after Resident 28 was discharged from hospice (type of care that focuses on the care, comfort, and quality of life of a person with a serious illness who is approaching the end of life). This deficient practice had the potential to delay care for Resident 28. Findings: A review of Resident 28's admission Record indicated the facility admitted the resident on 5/3/2023 with diagnoses including cerebellar ataxia (inability to coordinate muscle movement due to disease or injury to the cerebellum [part of the brain responsible for coordinating movement and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for two of 22 residents (Resident 71 and 141) by failing to: a. Develop and implement Resident 71's care plan on the use of antidepressant (Lexapro, a type of medicine used to treat clinical depression [mood disorder that causes a persistent feeling of sadness and loss of interest]). b. Develop and implement Resident 141's care plan on the use of insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood). c. Develop and implement Resident 141's care plan on the use of Eliquis (Apixaban, an anticoagulant [decrease your blood's ability to clot] medication used to treat and prevent blood clots). These deficient practices had the potential to result in inconsistent implementation of the care plan that may lead to a delay in or lack of delivery of care and services as well as subjecting residents to adverse effects (a harmful or abnormal result) 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 develop a written Discharge Summary, which included a recapitulation (summary) of the resident's stay at the facility for one of three sampled residents (Resident 168) in accordance with the facility policy. This deficient practice had the potential to result in Resident 168 not receiving the necessary information for provision of care when discharged and to ensure safe transition to another setting such as in resident's home. Findings: A closed record review of Resident 168's admission Record indicated the facility readmitted the resident on 8/30/2023 with diagnoses including difficulty walking, dementia (decline in mental ability severe enough to interfere with daily functioning/life), moderate protein-calorie malnutrition (lack of proper nutrition), and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 168's Minimum Data Set (MDS-a standardized assessment and care screening tool), dated 9/1/2023, indicated the resident was…

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

Based on observation, interview, and record review the facility failed to provide an environment that is free from accident hazard to one out of 11 sampled residents (Resident 137) by failing to ensure the bed of Resident 137, who was known to be at high risk for fall with injury, was placed on the lowest position as indicated in the care plan. This deficient practice had the potential for repeated accidents and falls that could lead to fractures (a partial or complete break in bone) and even death. Findings: A review of Resident 137's admission Record indicated the facility admitted the resident on 1/20/2023 and readmitted the resident on 5/2/2023, with diagnoses of long-term use of anticoagulants (a group of medications that decrease the blood's ability to clot), neuralgia (pain felt in one or more nerves), neuritis (inflammation of a nerve), and personal history of traumatic fracture (a serious injury that occurs when extreme force is applied to the bone, such as during a car accident or life-threatening fall, or as a result of a direct blow). A review of Resident 137's Minimum…

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

Based on observation, intervention, and record review, the licensed nursing staff failed to ensure one of four sampled residents (Resident 68) receiving enteral water flushes (a way to deliver fluids directly into the stomach or small intestine) received proper care and services consistent with professional standard of care by failing to ensure that Resident 68's hanging water flush bag was labeled with the resident's initials, date, and time hung or administered. This deficient practice had the potential to cause possible complications and risk factors like infection, aspiration (food or fluids entering the lungs), weight loss, and dehydration (a harmful reduction in the amount of water in the body) for Residents 68. Findings: A review of Resident 68's admission indicated the facility initially admitted the resident on 4/18/2023 and readmitted the resident on 10/28/2023 with diagnoses including gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), adult failure to thrive (FTT-syndrome of weight loss, decreased appetite 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 resident receive treatment and care in accordance with professional standards of practice to one out of 11 sampled residents (Resident 53) by: 1. Failing to reassess the resident's pain level prior to administering a narcotic (a drug that causes unfeelingness or feeling almost unconscious with inability to act or think normally) pain medication. 2. Not accurately documenting the resident's pain level. These deficient practices resulted in Resident 53 receiving a narcotic pain medication intended and ordered for severe pain (7-10, [0 representing no pain and 10 very much pain]), and had a potential for uncontrolled pain and suffering on the resident. Findings: A review of Resident 53's admission Record indicated the facility admitted the resident on 1/14/2016 and readmitted the resident on 10/31/2022, with diagnoses including depression (constant feeling of sadness and loss of interest), chronic pain, and osteoarthritis of left shoulder (occurs when the cartilage starts wearing down on the ball and/or socket side…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 keep the resident's bed in functional condition for one out of 11 sampled residents (Resident 71) by failing to ensure Resident 71's bed was plugged in for the resident to adjust the bed according to her needs. The deficient practice had the potential for delay in the delivery of necessary care and services and discomfort to the residents. Findings: A review of Resident 71's admission Record indicated the facility admitted the resident on 1/13/2017 and readmitted the resident on 10/12/2021, with diagnoses including polyneuropathy (any condition that affects the nerves outside the brain or spinal cord), bilateral primary osteoarthritis (condition that causes the joints to become very painful and stiff) of the knee, and spondylosis (age-related degeneration or breakdown of the spine). A review of Resident 71's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 10/10/2023, indicated the resident had the ability to make self-understood and understand others. During an interview on…

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

Based on interview and record review, the facility failed to provide the requested medical records to the responsible party of one of three sampled residents (Resident 1). The facility received the request to release Resident 1 ' s medical records on 9/19/2023. This deficient practice violated the resident ' s rights to secure personal medical records. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 11/29/2022 with diagnoses including right femur fracture (broken thighbone), type two diabetes mellitus (a disease that occurs when the blood sugar is too high), and essential hypertension (abnormal high blood pressure that was not a result of a medical condition). A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/6/2022, indicated the resident ' s cognition (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was moderately impaired. A review of Resident 1 ' s Authorization for Use or Disclosure of Protected Health…

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

Based on interview and record review, the facility failed to provide the requested medical records to the legal representative of one of three sampled residents (Resident 3). The facility received the request to release Resident 3 ' s medical records on 9/19/2023. This deficient practice violated the resident ' s rights to secure personal medical records. Findings: A review of Resident 3 ' s admission Record indicated the facility admitted the resident on 9/13/2022 with diagnoses including diverticulitis of the intestine (inflammation or infection of the small, bulging sacs or pouches that form on the inner lining of the intestine), chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), and atherosclerotic heart disease (thickening or hardening of the arteries in the heart). A review of Resident 3 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/15/2022, indicated the resident ' s cognition (conscious mental activities including thinking, reasoning, understanding, learning, 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 with a Coronavirus Disease 2019 (COVID-19- highly contagious respiratory disease is thought to spread from person to person through droplets released when an infected person coughs, sneezes or talks) outbreak (sudden increase in number of cases), failed to implement infection control practices for three of five sampled staff by: 1. Failing to ensure Certified Nursing Assistant 1 (CNA 1) tied the back of his protective gown before going inside Resident 1 and Resident 2' s room who was positive for COVID-19. 2. Failing to ensure Social Service Designee 1 (SSD 1) wore protective mask covering her nose and mouth while speaking to the admission Director (AD). 3. Failing to ensure AD wore protective mask while speaking to SSD 1. These deficient practices had the potential to result in the spread of infection placing the residents, staff, and visitors at risk for COVID-19. Findings: a. A review of Resident 1's admission Record indicated the facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 six of seven sampled licensed vocational nurses (LVNs 1, 3, 4, 5, 6, and 7) worked within their scope of practice. LVNs were performing resident assessments without reporting to a registered nurse (RN) to conduct a complete assessment. This deficient practice placed the residents at risk for not receiving the appropriate care and services necessary to meet their medical, physical, mental, and psychosocial needs. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 2/3/2023 with diagnoses including atrial fibrillation (an abnormal heartbeat caused by extremely fast and irregular beats from the upper chambers of the heart), depression (a constant feeling of sadness and loss of interest which stops a person from doing normal activities), and essential hypertension (abnormal blood pressure that was not a result of a medical condition). A review of Resident 1 ' s undated History and Physical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide supervision for two of three sampled residents (Resident 1 and Resident 2), who were both assessed with agitation and aggressive behavior, had a physical altercation in the TV room in the presence of five facility staff. None of the five facility staff present in the TV room responded to stop the physical altercation between Resident 1 and Resident 2. As a result, on 9/12/2023 at 5:35 p.m., Resident 1 and Resident 2 both sustained skin tears (wounds caused by shear [cut], friction, and/or blunt force resulting in separation of skin layers) from the physical altercation. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 2/3/2023 with diagnoses including atrial fibrillation (an abnormal heartbeat caused by extremely fast and irregular beats from the upper chambers of the heart), depression (a constant feeling of sadness and loss of interest which stops a person from doing normal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 infection control procedures for one of three sampled residents (Resident 1) by failing to: a. Ensure facility staff performs hand hygiene (hand washing with soap and water and use of alcohol-based hand sanitizer) before wearing gloves and rendering wound care. b. Ensure facility staff ' s protective equipment (PPE - equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) was worn inside the facility. The face mask was not covering Licensed Vocational Nurse 1 (LVN 1) ' s nose and mouth while rendering wound care and talking to the resident. These deficient practices placed Resident 1 at risk for exposure and contracting infections. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 2/3/2023 with diagnoses including atrial fibrillation (an abnormal heartbeat caused by extremely fast and irregular beats from the upper chambers of the heart), depression (a constant feeling of sadness and loss of interest which stops a person…

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