Topanga Terrace

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 by failing to ensure that providers signed telephone orders within five (5) days for two of four sampled residents (Resident 27 and Resident 92). This deficient practice resulted in a deviation from the facility's own policy and had the potential to cause delays in necessary services and continuity of care.Findings: a. During a review of Resident 27's admission Record, the admission Record indicated the facility originally admitted Resident 27 on 11/12/2016 and re-admitted the resident on 10/5/2025, with diagnoses including type two (2) diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]), and hyperlipidemia (abnormally high concentration of fats in the blood). During a review of Resident 27's Minimum Data Set (MDS - a resident assessment tool) dated 10/11/2025,…

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 observation, interview and record review, the facility failed to ensure nurse staffing information was posted daily (on 11/17/2025).As a result, the resident census and the actual hours worked by licensed and unlicensed nurses were not readily accessible to residents and visitors.Findings: During an observation on 11/17/2025 at 1:45 p.m., observed in front of nursing station 2, a facility document titled, Nursing Staff Per Shift and Hours, dated 11/15/2025 was posted. During an interview on 11/19/2025 at 2:14 p.m., with the Director of Staff Development (DSD) and Assistant Director of Staff Development (ADSD), the DSD and ADSD stated that they (DSD and ADSD) should update the Nursing Staff Per shift and Hours daily indicating the current resident census and nursing hours at the beginning of each shift and before their shift ends and post the staffing information in the nursing stations. The DSD stated that staff responsible for posting the staffing information on the weekends forgot to update the posting in the morning of 11/17/2025. During an interview on 11/20/2025 at…

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

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 when licensed nurses failed to ensure bumex (medication used to get rid of extra water and salt through the urine) and/or carvedilol (blood pressure [BP] and heart rate lowering medication) were readily available on three different days in September 2025 for one of five residents (Resident 6) during a an unnecessary medication investigation. This deficient practice resulted in Resident 6 not receiving bumex and/or carvedilol on three different days in 09/2025. Findings: During a review of Resident 6's admission Record, the admission Record indicated the facility initially admitted Resident 6 on 2/17/2015 and readmitted on [DATE] with diagnoses including congestive heart failure (CHF - when the heart muscle can't pump enough blood to meet the body's needs), dysphagia (difficulty swallowing), and dementia (a progressive state of decline in mental abilities). During a review of Resident 6's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain medical records that were complete and accurately documented for two of 25 sampled residents (Residents 11 and 74) by: Failing to document Resident 11's blood pressure (the force your heart uses to send blood pumping through your body) prior to giving the resident metoprolol (a blood pressure lowering medication) on 9/9/2025 during medication review. This deficient practice resulted in inaccurate documentation in Resident 11's medical record and placed Resident 11 at risk for hypotension (low blood pressure). 2. Failing to ensure Resident 74's diagnosis of depression was reflected in the resident's list of diagnoses in the medical record. This failure resulted in Resident 74's medical record containing incomplete information which increased the potential of Resident 74 not receiving care for his diagnosis of depression. Findings: 1. During a review of Resident 11's admission Record, the admission Record indicated the facility initially…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 appropriate infection control practices for two of two sampled residents (Resident 2 and 34) when a work computer laptop was observed placed on top of a soiled linen hamper (a large, lidded container designated for dirty linen). This deficient practice had the potential to cause cross contamination (transfer of bacteria or other microorganisms from one place to another) and the spread of infection for residents, staff and visitors. Findings: a. During a review of Resident 2's admission Record, the admission Record indicated the facility originally admitted the resident on 5/22/2019 and re-admitted the resident on 11/12/2025, with diagnosis that included acute (sudden onset) and chronic (long term) respiratory failure (a condition where the lungs cannot release enough oxygen into the blood), end stage renal disease (ESRD, irreversible kidney failure) and dependence on renal dialysis (a medical treatment that removes waste 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 offer an updated Coronavirus Disease (COVID-19, a severe respiratory illness caused by virus and transmitted from person to person) vaccination to one of five sampled residents (Resident 2). This deficient practice placed Resident 2 at a higher risk of acquiring (to get) and transmitting (pass on) the COVID-19 virus to other residents in the facility. Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility originally admitted the resident on 5/22/2019 and readmitted the resident on 11/12/2025 with diagnoses including, but not limited to, acute (sudden onset) and chronic (long term) respiratory failure (a condition where the lungs cannot release enough oxygen into the blood) with hypoxia (an insufficient amount of oxygen in your body tissues), end stage renal disease (ESRD, irreversible kidney failure), and type two diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control 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 licensed nurses provided non-pharmacological interventions (any type of healthcare intervention which is not primarily based on medication) prior to administering as needed (prn) opioid pain medication (treats moderate to severe pain) to a resident for two of 30 sampled residents (Resident 204 and 26). This deficient practice had the potential to place the resident at increased risk of experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention). Findings: a. During a review of Resident 204's admission Record, the admission Record indicated the facility admitted the resident on 10/14/2024 with diagnoses including atrial fibrillation (a heart condition that causes an irregular heartbeat) and pneumonitis (inflammation of the lung tissue). During a review of Resident 204's History and Physical (H&P - a comprehensive assessment of a resident that includes taking a detailed medical history from 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 that two of 30 sampled residents (Residents 24 and 70) were administered medications as prescribed by the physician when: 1. Lorazepam (anti-anxiety medication) was not administered to Resident 24 in accordance with physician's orders. 2. Three doses of metoprolol (a medication that treats high blood pressure, chest pain, and heart failure) were not held as ordered when Resident 70 received dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). These deficient practices had the potential to place Resident 24 at increased risk of being given extra doses of lorazepam and Resident 70 to experience low blood pressure. Findings: 1. During a review of Resident 24's admission Record, the admission Record indicated the facility admitted the resident on 8/16/2024 with diagnoses including acute and chronic respiratory failure (inadequate gas exchange by the respiratory system). During a review of Resident 24's Minimum Data Set (MDS - a standardized…

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

Based on interview and record review, the facility failed to ensure licensed nurses attempted non-pharmacological interventions (any type of healthcare intervention which is not primarily based on medication) prior to administering as needed (prn) lorazepam (medication used to treat anxiety disorder [intense, excessive, and persistent worry and fear about everyday situations]) to a resident for one of 30 sampled residents (Resident 24). This deficient practice had the potential to place the resident at increased risk of experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention) from lorazepam. Findings: During a review of Resident 24's admission Record, the admission Record indicated the facility admitted the resident on 8/16/2024 with diagnoses including acute (sudden) and chronic (persisting for a long time or constantly recurring) respiratory failure (inadequate gas exchange by the respiratory system). During a review of Resident 24's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 10/7/2024, the…

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

Based on interview and record review, the facility failed to: 1. Develop a comprehensive person-centered care plan (a plan for an individual's specific health needs and desired health outcomes) addressing the resident`s vision impairment (occurs when an eye condition affects the visual system and its vision functions) for one of one sampled resident (Resident 93). 2. Develop individualized person-centered care plan for insulin (a medication used in the treatment and management of diabetes mellitus[DM- a disease that occurs when the sugar level is high in the blood]) use for one of ten sampled residents (Resident 67). These deficient practices had the potential to result in failure to deliver the necessary care and services for Resident 93 and had the potential to lead to the inadequate care of Resident 67. Findings: a. During a review of Resident 93's admission Record, the admission Record indicated the facility admitted the resident on 8/26/2024 with diagnoses that included depression (characterized by a prolonged low mood and loss of interest in activities that used to be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provided a communication device or board (a tool that includes pictures that help residents communicate their healthcare and every-day needs to facility staff) at their bedsides in the language that the residents were able to understand for two of four sampled residents (Resident 22 and Resident 350). These deficient practices prevented the residents from communicating with the staff and had the potential to delay receiving care/treatment the residents needed. Findings: a. During a review of Resident 22's admission Record, the admission Record indicated the facility originally admitted the resident on 02/13/2023, and readmitted on [DATE], with diagnoses including dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and dysphagia (difficulty swallowing). During a review of the Minimum Data Set (MDS - a standardized…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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`s Interdisciplinary Care Team (a group of professionals from different disciplines who work together to treat a patient's condition) failed to collaborate and communicate with the care team members the resident`s concern about her vision loss for one of one sampled resident (Resident 93). This deficient practice resulted in nurses` not being aware of the resident`s visual function status which has the potential for the resident to fall and suffer serious injury due to inability to see. Findings: During a review of Resident 93's admission Record, the admission Record indicated the facility admitted the resident on 8/26/2024 with diagnoses that included depression (characterized by a prolonged low mood and loss of interest in activities that used to be enjoyable) and chronic respiratory failure (shortness of breath or feeling like you can't get enough air, extreme tiredness, an inability to exercise as you did before, and sleepiness). During a review of Resident 93's Minimum Data Set (MDS - a standardized assessment and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of two sampled residents Resident 65 was free from significant medication error by failing to ensure metoprolol (medication to treat high blood pressure [the force of the blood pushing on the blood vessel walls is too high]) was administered in accordance with the physician's order with parameter to hold (do not give) the medication if Resident 65's heart rate is less than 60 beats per minute (bpm-a normal resting heart rate for adults ranges from 60 to 100 beats per minute). This deficient practice placed Resident 65 at risk for bradycardia (low heart rate- can be life threatening if the heart is unable to maintain a rate that pumps enough oxygen-rich blood throughout the bod) which could lead to shortness of breath, chest pain, fatigues, and dizziness. Findings: During a review of Resident 65's admission Record, the admission Record indicated the facility originally admitted the resident on 6/11/2021 and readmitted on [DATE], with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure leftover food brought from outside was stored in the refrigerator or discarded per facility policy for one of one sampled resident (Resident 43) investigated under Food Safety Requirement. This deficient practice had the potential to result in foodborne illness (also called food poisoning, illness caused by eating contaminated food) for Resident 43. Findings: During a review of Resident 43's admission Record, the document indicated the resident was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included depression (a serious mood disorder that can affect a person's thoughts, feelings, behavior, and sense of well-being) and type 2 diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel). During a review of Resident 43`s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 10/04/2024, the MDS…

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

Based on observation, interview, and record review, the facility failed to: 1. Ensure Licensed Vocational Nurse 3 (LVN 3) donned (put on) a gown prior to administering medications to a resident via gastrostomy tube (GT - a small tube that is surgically inserted into the stomach through the abdomen to provide nutrition, fluids, and medication) who was on enhanced barrier precautions (EBP - a set of infection control practices that use personal protective equipment [PPE - equipment worn to reduce exposure to hazards in the workplace] to reduce the spread of multidrug-resistant organisms [MDROs - bacteria that are resistant to three or more classes of antimicrobial drugs] in nursing homes) for one of 30 sampled residents (Resident 77). 2. Ensure a resident's nasal cannula (device used to deliver supplemental oxygen placed directly on a resident's nostrils) oxygen tubing was kept off the floor for one of 30 sampled residents (Resident 204). These deficient practices placed the residents at increased risk of developing an infection. Findings: 1. During a review of Resident 77's admission…

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

Based on interview and record review, the facility failed to implement its policies and procedures related to the influenza (a high contagious viral infection of the respiratory passages) vaccine for one of five sampled residents (Resident 93). This deficient practice placed Resident 93 at an increased risk of acquiring (to get) and transmitting (pass on) the influenza virus to other residents in the facility. Findings: During a review of Resident 93`s admission Record, the admission Record indicated the facility admitted the resident on 8/26/2024, with diagnoses including encephalopathy (a change in your brain function due to injury or disease), abnormal posture (when the position of the body is not normal), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily activities of living). During a review of Resident 93's Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 9/1/2024, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 offer the Coronavirus Disease (COVID-19, a severe respiratory illness caused by virus and transmitted from person to person) vaccination to one of five sampled residents (Resident 43). This deficient practice placed Resident 43 at a higher risk of acquiring (to get) and transmitting (pass on) the COVID-19 virus to other residents in the facility. Findings: During a review of Resident 43`s admission Record, the admission Record indicated that the facility originally admitted the resident on 2/3/2017, and readmitted on [DATE], with diagnoses including chronic respiratory failure (a condition in which your lungs have a hard time loading your blood with oxygen or removing carbon dioxide), encounter for attention to tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe [trachea] to help you breathe), and dependence on respirator ( cannot breathe without a machine). During a review of Resident 43's Minimum Data…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and procedures (P&P) for ensuring the reporting of a reasonable suspicion of a crime in accordance with Section 1150B of the Act by failing to report to the State Survey Agency (SSA) an injury of unknown source within two (2) hours for one of three sampled residents (Resident 1). This deficient practice resulted in a delay of an onsite inspection by the SSA to ensure the safety of the other residents and had the potential to result in unidentified abuse. Findings: A review of Resident 1 ' s admission Record indicated the facility originally admitted Resident 1 on 5/13/2021 and readmitted the resident on 4/11/2024 with diagnoses that included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), dementia (the loss of cognitive functioning such as thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents' room temperatures at a range between 71 and 81 degrees Fahrenheit (° F, a measurement of temperature) for four of four sampled residents (Resident 354, 59, 105, and 104). This deficient practice resulted in increased levels of discomfort for the residents and had the potential to negatively impact the resident's quality of life. Findings: a. A review of Resident 354's admission Record indicated the facility admitted the resident on 9/18/2023 with diagnoses that included hemiplegia (inability to move one side of the body) and hemiparesis (mild to severe loss of strength or paralysis on one side of the body) following cerebral infarction (stroke, when blood flow to the brain is blocked or there is sudden bleeding in the brain) affecting the right dominant (strong) side and aphasia (difficulty speaking). A review of Resident 354's Minimum Data Set (MDS - an assessment and screening tool) dated 9/24/2023, indicated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the State Long-Term Care (LTC) Ombudsman (advocates for residents of nursing homes, board and care homes, and assisted living facilities) of the transfers and discharges from the facility for 12 of 12 sampled residents (Resident 102, 304, 306, 307, 308, 309, 310, 311, 312, 313, 76, and 91) investigated addressing the care area of discharge. These deficient practices had the potential to deny residents protection from being inappropriately discharged . Findings: a. A review of Resident 102's admission Record indicated the facility admitted the resident on 8/10/2023 with diagnoses including aftercare following joint replacement surgery (surgical procedure in which part of the damaged joint are removed and replaced with a metal, plastic or ceramic device), anemia (blood has a lower than normal number of red blood cells), and hypertension (high blood pressure). A review of Resident 102's Minimum Data Set (MDS-standardized assessment and 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 meet professional standards of quality for two of two sampled residents (Resident 81 and 32) by: 1. Failing to ensure nurses rotated injection sites when administering Lovenox (enoxaparin - medication that decreases the ability of blood to clot) for Resident 81. 2. Failing to ensure nurses rotated injection sites when administering insulin (hormone that lowers the level of glucose [sugar] in the blood) NPH Isophane (intermediate-acting insulin) and Regular suspension (short-acting insulin) 70-30 (combination of 70% NPH insulin and 30% regular insulin) for Resident 32. These deficient practices had the potential to result in Residents 81 and 32 experiencing lipohypertrophy (a lump of fatty tissue under the skin caused by repeated injections in the same place) and ineffective management of diabetes mellitus (DM- a chronic condition that affects the way the body processes blood sugar) for Resident 32. Findings: 1.a. A review of Resident 81'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 observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%-unit of measure). Five (5) medication errors out of 36 opportunities contributed to an overall medication error rate of 13.8% affecting three of 10 sampled residents (Resident 11,35, and 46) observed for medication administration. The deficient practice of failing to administer medications in accordance with the attending physician's orders increased the risk that Residents 11, 35, and 46 may have experienced health complications related to incorrect medication administration which could have negatively impacted their health and well-being. Findings: a. A review of the Resident 11`s admission Record indicated that the resident was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included Type 2 Diabetes Mellitus (DM-a serious condition where your blood glucose [sugar] level is too high) and dysphagia (difficulty swallowing). A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that six of six sampled residents (Resident 54, 36, 52, 49, 47, and 2) were free from significant medication errors by: a) Failing to ensure that Amlodipine besylate (medication to treat high blood pressure [the force of the blood pushing on the blood vessel walls is too high]) was administered in accordance with the physician's order with a parameter to hold (do not give) the medication if Resident 54's systolic blood pressure (SBP, measures the pressure in your arteries [pathway that carries blood away from the heart] when your heart beats) was less than 110 millimeters of mercury (mmHg-a unit of measure). b) Failing to ensure that Carvedilol (medication to treat high blood pressure) was administered in accordance with the physician's order with a parameter to hold if Resident 36's SBP was less than 120 mmHg. c) Failing to ensure that Metoprolol Tartrate (medication used to treat high blood pressure) was administered in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to: 1. Ensure one of six medication carts (Med Cart 5) was locked and secure and was under direct observation of authorized staff in an area where residents could access it. 2. Ensure one of five sampled residents' (Resident 314) fluticasone-salmeterol (medications to help relieve shortness of breath) and budesonide-formoterol fumarate dihydrate (medication that helps with breathing by decreasing the inflammation in the lungs) inhalers were labeled with an open date according to manufacture guidelines. 3. Ensure two of five sampled residents' (Resident 71 and 25) levetiracetam (medication to control seizures [burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements]) oral (by mouth) solution was labeled with an open date according to manufacture guidelines. 4. Ensure two of five sampled residents' (Resident 8 and 20) opened bottle of potassium chloride 10% liquid was labeled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 infection control practices by failing to: 1. Ensure hand hygiene (cleaning one's hands that substantially reduces potential pathogens [harmful microorganisms] on the hands) was done for two of two sampled residents (Resident 44 and 34). Hand hygiene was not performed after giving pain medication to Resident 44 and before preparing Resident 34's gastrostomy (GT-tube inserted through the belly that brings nutrition directly to the stomach) feeding. 2. Ensure hand hygiene was done for two of two sampled residents (Resident 17 and 40). Hand hygiene was not performed after turning off Resident 17's GT feeding pump and before preparing Resident 40's medications. 3. Ensure Family Member (FM 1) was wearing a disposable gown and gloves before entering the room for one of one sampled residents (Resident 6), who was on contact isolation (used when a resident has an infectious disease that may be spread by touching either the resident or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its antibiotic stewardship (actions designed to use antibiotic [medications that fight bacterial infections] medications effectively while reducing the possibility of being prescribed an unnecessary medication) program by failing to conduct infection surveillance and complete the infection control reporting form once signs and symptoms of infection were identified and antibiotics were initiated for four of five sampled residents (Residents 43, 47, 76, 87). This deficient practice had the potential for Residents 43, 47, 76 and 87 to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use for future infections. Findings: a. A review of Resident 43's admission Record indicated the facility admitted the resident on 2/3/2017 with diagnoses including chronic respiratory failure (condition in which not enough oxygen passes from your lungs into your blood), tracheostomy (surgically created…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Certified Nursing Assistant 2 (CNA 2) was seated and at eye level while assisting a resident with feeding for one of one sampled residents (Resident 32) investigated for dignity. This deficient practice had the potential to affect Resident 32's sense of self-worth and self-esteem. Findings: A review of Resident 32's admission Record indicated the facility originally admitted the resident on 8/14/2014 and readmitted the resident on 8/4/2016 with diagnoses including personal history of transient ischemic attack (temporary blockage of blood flow to the brain) and cerebral infarction (refers to damage to tissues in the brain due to loss of oxygen to the area), and dysphagia (difficulty swallowing). A review of Resident 32's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 7/13/2023, indicated the resident had severely impaired cognitive (relating to or involving the process of thinking and reasoning) skills of daily decision making and was totally dependent (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 low air loss mattress (LALM, a pressure-relieving mattress used to prevent and treat pressure ulcers [a wound that occurs as a result of prolonged pressure on a specific area of the body]) was set according to the resident's weight and comfort for one of two sampled residents (Resident 94). This deficient practice placed the resident at risk of discomfort and development of new pressure ulcers. Findings: A review of Resident 94's admission Record indicated the facility admitted the resident on 05/08/2023, with diagnoses including end stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and morbid obesity (is when you weigh 100 pounds over your recommended weight). A review of Resident 94's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 08/12/2023, indicated the resident had the ability to make self-understood 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 only medications that were administered were documented in the Medication Administration Record (MAR-report that serves as a legal record of the drugs administered to a patient at a facility by a health care professional) for two of ten sampled residents (Residents 11 and 35) observed for medication administration. This deficient practice resulted in residents' medical records that were not accurate and not in accordance with professional standards of practice. Findings: a. A review of Resident 11's admission Record indicated the facility originally admitted the resident to the facility on 4/8/2008 and readmitted on [DATE], with diagnoses that included type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), other disorders of phosphorous (type of mineral) metabolism, and dysphagia (difficulty swallowing). A review of Resident 11's Minimum Data Set (MDS - a comprehensive 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 there was documented evidence that the pneumococcal vaccine (prevents infection from pneumonia [infection that infects one of both lungs]) was offered to one of five sampled residents (Resident 34). This deficient practice placed Resident 34 at a higher risk of acquiring and transmitting pneumonia to other residents in the facility. Findings: A review of Resident 34's admission Record indicated the facility originally admitted the resident on 1/7/2015 and readmitted on [DATE] with diagnoses including atrial fibrillation (irregular heart rate), gastrostomy (GT-tube inserted through the belly that brings nutrition directly to the stomach) and type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar). A review of Resident 34's Minimum Data Set (MDS-standardized assessment and screening tool) dated 9/6/2023, indicated resident had severely impaired cognition (ability to think and make decisions). 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.