West Hills Health And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure prompt attempts were made to resolve the grievance for one of three sampled residents (Resident 1). This deficient practice violated Resident 1's' right to have his grievance addressed. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted Resident 1 on 7/24/2018 and readmitted Resident 1 to the facility on 4/1/2025, with diagnoses including nontraumatic intracerebral hemorrhage (refers to any form of bleeding within the skull), other forms of scoliosis (a side-to-side curve of your spine), kyphosis (excessive forward rounding of the upper back), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) and chronic mastoiditis (a long term infection of the mastoid bone behind the ear) of the left ear. During a review of Resident 1's MDS dated [DATE], the MDS indicated Resident 1's cognition (refers to conscious mental activities including…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one of three sampled residents (Resident 1) received services and treatment for pain management by failing to obtain pain medication orders appropriate for Resident 1's pain level. This deficient practice had the potential to result in inadequate management of Resident 1's pain. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted Resident 1 on 7/24/2018 and readmitted Resident 1 to the facility on 4/1/2025, with diagnoses including nontraumatic intracerebral hemorrhage (refers to any form of bleeding within the skull), other forms of scoliosis (a side-to-side curve of your spine), kyphosis (excessive forward rounding of the upper back), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) and chronic mastoiditis (a long term infection of the mastoid bone behind the ear) of the left ear. During a review of Resident 1's Order Summary Report, the Order Summary Report indicated an order dated 3/31/2025…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to submit a new corrected and accurate Level 1 Preadmission Screening and Resident Review (PASARR- an assessment to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) for one of four sampled residents (Resident 2).This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 2.Findings:During a review of Resident 2's admission Record, the admission Record indicated the facility originally admitted the resident on 8/15/2025 and readmitted the resident on 9/19/2025 with diagnoses that included cerebral palsy (a group of disorders that affect movement, muscle tone, and coordination caused by the damage to the developing brain before or during birth), [NAME] -Chiari Syndrome (structural abnormality in the skull that causes part of the brain to move into the spinal canal) without spina bifida…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff were not standing over a resident while assisting with feeding for one of three sampled residents (Resident 3).This deficient practice had the potential to affect the resident's self-esteem, self-worth, and sense of independence. During a review of Resident 3's admission Record, the admission Record indicated the facility readmitted the resident on 7/25/2024 with diagnoses including anoxic brain damage (when the brain is deprived of oxygen entirely, leading to the death of brain cells and potential permanent damage after just a few minutes), epileptic seizure (a sudden, abnormal surge of electrical activity in the brain that can cause temporary changes in movement, behavior, sensations, or awareness), and dysphagia, oral phase (difficulty swallowing that originates in the mouth).During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool) dated 5/27/2025, the MDS indicated Resident 3's cognition (the process of acquiring knowledge and understanding through thought,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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) received care and services in accordance with professional standards of practice by:1.Failing to administer Resident 1's doxycycline monohydrate (antibiotic used to treat a wide range of bacterial infections), mirtazapine (medication used to treat depression [a mood disorder characterized by a persistent feeling of sadness and loss of interest in activities, which significantly impacts daily life]), atorvastatin (lowers cholesterol and triglyceride [fats] levels in the blood), and omeprazole (medication used to reduce the amount of acid produced by the stomach) as prescribed by the physician.This deficient practice resulted in the omission of medications which could have resulted in severe health complications.2. Failing to ensure licensed nurses informed Resident 1's physician of Resident 1's medications not being available and not administering Resident 1's doxycycline monohydrate, mirtazapine, atorvastatin on 8/2/2025 and omeprazole on 8/3/2025.This deficient practice…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 plan of care that summarizes a resident's health conditions, specific care and service facility staff need to provide a resident to promote healing and prevent a worsening of a condition, and current treatments) by failing to:1. Address which medications Resident 15 is to take when she is out on pass and what kind of monitoring is conducted before taking them for one of five residents investigated for receiving unnecessary medications. This had the potential for Resident 15 to not receive the due medications or to have side effects such as dizziness and fainting from not monitoring blood pressure before administering. 2. Address Resident 86`s oxygen use.This deficient practice had the potential to result in Resident 86`s inadequate carefor one of three residents investigated under the oxygen care area.Findings: 1. During a review of Resident 15’s admission Record, the admission Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 1. Ensure a resident`s representative or responsible party (RP) was included during the Interdisciplinary (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of the residents' care plan) care plan (a document that summarizes a resident's needs, goals, and care/treatment) meeting for two of two residents (Resident 5 and 12) reviewed under the care area Care Planning. This deficient practice had the potential to result in failure to deliver the necessary care and services. 2. Update and revise a resident`s care plan after the physician discontinued the administration of apixaban (a medication that prevents blood clots [gel-like clumps of blood] from forming and treats the existing ones) for one of five sampled residents (Resident 2) reviewed under Anticoagulant (medications that prevent or reduce blood clotting) care area.This deficient practice had the potential to result in Resident 2 receiving inadequate care and supervision at the facility. Findings:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure three of six sampled residents (Residents 2, 6, and 13) received appropriate services to prevent a decline in range of motion (ROM, full movement potential of a joint) by failing to:1. For Resident 13, provide an orthotics (an external device to support, align, or correct a movable part of the body) assessment and training during Occupational Therapy (OT, rehabilitative profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) treatment prior to starting an Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) to wear a right hand orthosis for up to six hours seven days a week.2. For Resident 2, order an RNA program upon OT discharge after OT recommended an RNA program for active range of motion (AROM, movement at a given joint when the person moves voluntarily) or active assistive range of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Number of residents sampled:Number of residents cited: 1Resident 14 missed multiple days at the dialysis center. Findings:During a review of Resident 14's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including end stage renal disease (ESRD, irreversible kidney failure).During a review of Resident 14's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated [DATE], the MDS indicated Resident 14 was moderately impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 14 required setup assistance (helper sets up or cleans up) with eating and supervision (helper provides verbal cues and/or touching assistance as resident completes activity) with oral and personal hygiene. The MDS indicated Resident 14 required hemodialysis treatments.During a review of Resident 14…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents when curry chicken portions were two (2) ounces (oz, a unit of measurement) instead of three (3) oz portions. This failure had the potential to decrease nutrient intake of protein resulting in unplanned weight loss to 77 of 140 residents on regular texture (texture of food with no restrictions and modifications) diet getting food from the kitchen.Findings:During a review of the facility's daily spreadsheet (a list of food, amount of food that each diet would receive) titled Summer Menus, dated 7/15/2025, the spreadsheet indicated residents on regular texture diet would include the following foods on the tray: Curry lemon Chicken 3 oz Garlic [NAME] 1/2 cup (c, household measurement) Peas with onions 1/2 c Parsley garnish Wheat roll 1 Margarine 1 teaspoon Ice cream 1/3 c Milk 4 oz During an observation on 7/15/2025 at 12:15 p.m. of trayline (an area where foods were assembled from the steamtable to resident's plate) lunch service, observed small…

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

Based on observation, interview, and record review, the facility failed to prepare food by methods that conserve flavor and appearance when the fiesta salad was watery, and dressing did not taste like Italian dressing. This deficient practice placed 77 of 140 facility residents on regular texture diet (texture of food with no modifications and restrictions) at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen.Findings:During a review of the facility's daily spreadsheet (a list of food, amount of food that each diet would receive) titled Summer Menus, dated 7/16/2025, the spreadsheet indicated residents on regular diet would include the following foods on the tray: Taco casserole 1 serving Seasoned fresh zucchini 1/2 cup (c, household measurement) Fiesta salad 1/3 c Tangy Glazed Fresh fruit 1/2 c Milk 4 ounces (oz, unit of measurement) During a concurrent observation and interview on 7/16/2025 at 12:25 p.m. with the Dietary Supervisor (DS) and Registered Dietitian (RD), the test tray (a process of tasting, temping, and evaluating 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 safe and sanitary food storage and food preparation practices in the kitchen when: 1. The tub of jelly was not labeled and dated. The egg salad was not labeled with expiration or discard date.2. Kitchen equipment and kitchen areas were not cleaned and sanitized.a. The walk-in refrigerator vent had dust and dirt buildup and residues.b. The reach-in freezer had dry ice cream spill.c. Lentils were on the floor of the dry storage room.d. The food weighing scale had dust buildup.e. Scoop and utensils drawer and pots and pans dry storage areas had food dry spills, crumbs, food particles and dust.f. Stainless steel food preparation area had salt residues, grey and black dirt buildup. 3. Three (3) of 3 dented cans were stored with non-dented cans.4. The cook did not perform hand hygiene after handling wiping cloth and wiping the chopping board patty juices then proceeded to dish out food from trayline (an area where foods were assembled from the steamtable to resident's plate). 5. Improper cooling of food 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.

Based on observation, interview, and record review, the facility failed to dispose garbage and refuse properly when one (1) of two (2) dumpster (a movable waste container designed to be brought and taken away by a special collection vehicle, or to a bin that a specially designed garbage truck lifts) was propped (to keep something from closing by placing something underneath) open while not actively being used. This failure had potential to attract birds, flies, insects, pests and possibly spread infection to 136 of 140 facility residents.Findings:During a concurrent observation and interview on 7/16/2025 at 10:31 a.m. of the dumpster with the Dietary Supervisor (DS), observed 1 dumpster was not fully closed while not actively being used. The DS stated the dumpster was not full, however the housekeeping department did not throw the black trash bag all the way inside causing the dumpster door to be propped open. The DS stated there were already flies going in and out of the dumpster and this was the reason why they wanted the dumpster to be always closed. The DS stated flies could…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to establish and implement a policy and procedure regarding transportation to dialysis from the facility when one (Resident 14) of two sampled residents investigated for dialysis missed their dialysis treatments multiple times in the month of 5/2025.As a result, Resident 14 was transferred three times to a general acute care center (GACH, or simply hospital) for the dialysis treatment to be completed. By not having a policy regarding transportation to dialysis, other residents on dialysis have the potential for not receiving their dialysis treatments. Findings:During a review of Resident 14's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including end stage renal disease (ESRD, irreversible kidney failure). During a review of Resident 14's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated [DATE], the MDS indicated Resident 14 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain timely and accurate resident medical records in accordance with accepted professional standards for three of seven sampled residents (Residents 2, 4, and 6) by failing to:1. For Resident 4, obtain a complete and accurate informed consent (agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) prior to applying physical restraint (the use of a manual hold to restrict freedom of movement of all or part of a person's body, or to restrict normal access to the person's body). This deficient practice placed the resident at risk of not receiving appropriate care due to inaccurate medical care information and the potential to result in confusion in the care and services for Resident 4.2. For Resident 2, timely document an Occupational Therapy (OT, rehabilitative profession that provides services to increase and/or maintain a person's capability to participate in everyday life…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 appropriate infection control practices by failing to:1. Ensure a resident`s urinal was not hung on the trash bin for one of two sampled residents (Resident 45). This deficient practice had the potential to result in contamination (making something dirty) of the resident's care equipment and risk of transmission of bacteria. 2. Ensure the nasal cannula was not touching the floor and the urinal was labeled for one of residents (Resident 34) during an initial pool observation. This deficient practice had the potential to place Resident 34 at an increased risk of infection from cross-contamination and cause complications associated with oxygen therapy.3. Implement appropriate infection control practices when Restorative Nursing Aide (RNA 1) did not put on gloves during a Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) treatment with Resident 2, who was…

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

Based on observation, interview, and record review, the facility failed to maintain four of four electrical rehabilitation therapy (therapy given to restore an individual back to their highest possible level of physical, mental, and psychosocial well-being) equipment for resident use.This deficient practice had the potential for injury to any resident using the therapy equipment. Findings:During an observation and interview on 7/16/2025 at 9:02 a.m., in the rehabilitation therapy gym, the Director of Rehabilitation (DOR) stated there were four electrical therapy equipment. The DOR stated there was an exercise leg stepper, Therapy Equipment (TE 1), an upper and lower extremity bicycle (TE 2), an automatic parallel bars (TE 3), and an adjustable therapy mat (TE 4). The DOR stated TE 3 was currently broken and the height of the parallel bars could not move up or down. The DOR stated there was no vendor that came to calibrate the therapy equipment and stated she thought the facility maintenance staff checked the equipment.During an interview on 7/16/2025 at 3:56 p.m., the DOR stated…

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

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the food services department when three (3) flies (a type of insect) were observed in the kitchen and food preparation areas during trayline (an area where foods were assembled from the steamtable to resident's plate). This failure had the potential to result in 136 of 140 residents, who received food from the kitchen, to acquire food borne illnesses (illness caused by consuming contaminated foods or beverages) by consuming potentially contaminated food.Findings:During a concurrent observation and interview on 7/15/2025 at 12:46 p.m. with [NAME] 2, one (1) fly was flying around the trayline area. [NAME] 2 turned the fly away and stated there was a fly flying around the trayline area. [NAME] 2 stated the fly entered the kitchen when the staff opened the kitchen door.During an observation on 7/15/2025 at 12:53 p.m. by the trayline area, observed a fly flying above the trayline near the kitchen entrance door and staff chased it away. During an observation on 7/15/2025 at 12:58…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 call light (a device used by a resident to signal his/her need for assistance from staff) was within residents' reach while in bed for one of one sampled resident (Resident 91) investigated under the environment task.This deficient practice had the potential to delay the provision of services and resident`s needs not being met.Findings:During a review of Resident 91's admission Record, the admission Record indicated the facility admitted the resident on 12/1/2023 with diagnoses including type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and adult failure to thrive (a syndrome of decline in older adults characterized by weight loss, decreased appetite, and a decline in physical and cognitive function). During a review of Resident 91's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 5/7/2025, the MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to:1. Ensure a copy of the resident's Advance Directive (AD- a legal document indicating resident preference on end-of-life treatment decisions) was kept in the resident's medical chart and easily retrievable for two of six sampled residents (Resident 8 and 77) reviewed under the advance directive care area.This deficient practice had the potential to create confusion which could lead to conflict with the resident`s wishes regarding their health care.2. Provide the resident and the resident's representative information regarding formulating an AD for one of six sampled residents investigated during review of the advance directive care area (Resident 5).This deficient practice had the potential for Resident 5 and their representative not to be informed of their right to formulate an advance directive and not honor the resident's wishes regarding end-of-life care.1.a. During a review of Resident 8’s admission Record (Face Sheet), the admission Record…

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

Based on observation, interview, and record review the facility failed to ensure residents were free from any physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the patient's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) by failing to ensure a resident was able to self-release the ordered self-release seat belt (SRSB)for one of one sampled resident (Residents 93) investigated during review of physical restraints care area This deficient practice had the potential for Resident 93 to result in the restriction of residents' freedom of movement, a decline in physical functioning, and physical harm from entrapment.Findings:During a review of Resident 93's admission Record, the admission Record indicated the facility admitted Resident 93 on 11/13/2019 with diagnoses that include cerebral infarction (when blood flow to a part of the brain is blocked, causing brain tissue to die due to lack of oxygen and nutrients), hemiplegia (paralysis of one side 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 interview and record review, the facility failed to:1. Provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility.2. Provide a written bed-hold notice upon time of transfer to a general acute care facility (GACH, or simply hospital) for one (Resident 37) of four residents investigated for hospitalizations when the resident was not told they would possibly be admitted when they were transferred to a GACH emergency room for a CT scan (CT scan, a medical imaging procedure that uses X-rays and computers to create detailed cross-sectional images of the body).This deficient practice had the potential for the resident to not know the reason for the transfer and to not determine if the reason for transfer was appropriate. Findings:During a review of Resident 37's admission Record, the admission Record indicated the patient was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including rheumatoid arthritis…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 submit a new level 1 Preadmission Screening and Resident Review (PASARR - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) when serious mental illness diagnoses were identified for one of one resident (Resident 11) investigated under PASARR care area. This deficient practice had the potential for Resident 11 not receiving provisions for specialized services. Findings:During a review of Resident 11's admission Record (Face Sheet), the admission record indicated that the facility initially admitted the resident on 7/13/2018 and readmitted on [DATE], with diagnoses entered on 12/28/2023 including, but not limited to delusional disorder (a type of mental health condition in which a person cannot tell what is real from what is imagined), bipolar disorder (a mental health condition that causes extreme ups and downs in a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a smoking assessment upon a resident`s admission to the facility for one of three sampled residents (Resident 77) reviewed under Accidents care area. This deficient practice had the potential to place Resident 77 at risk for injuries.Findings: During a review of Resident 77's admission Record, the admission Record indicated that the facility originally admitted the resident on 8/10/2017 and readmitted the resident on 5/12/2025 with diagnoses including paraplegia (loss of movement and/or sensation, to some degree, of the legs), history of falling, tobacco use, and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) During a review of Resident 77's Minimum Data Set (MDS - a resident assessment tool) dated 6/20/2025, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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`s oxygen tubing had a label including the date and time of when it was last changed for one of one sampled resident (Resident 86) reviewed under Oxygen care area.This deficient practice had the potential to place Resident 86 at an increased risk of infection and cause complications associated with oxygen therapy. Findings:During review of Resident 86`s admission Record, the admission Record indicated that the facility originally admitted the resident on 7/28/2021 and readmitted the resident on 6/9/2025 with diagnoses including asthma (a condition that causes your airways to swell, narrow, and fill with mucus), sepsis (a life-threatening complication of an infection), and pneumonitis (inflammation in your lungs from an irritant or allergen) due to inhalation of food and vomit.During a review of Resident 86's Minimum Data Set (MDS-a resident assessment tool) dated 5/13/2025, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 was incapable of making decisions, was not given a binding arbitration (a private process where disputing parties agree that one or several other individuals can make a decision about the dispute after receiving evidence and hearing arguments) agreement (a written contract in which two or more parties agree to settle a dispute out of court) to sign for one (Resident 130) of three residents reviewed under the arbitration task.This deficient practice resulted in the resident not knowing or understanding what an arbitration agreement is and potentially causing feelings of doubt, confusion, or distress.During a review of Resident 130's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities).During a review of Resident 130's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated…

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

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) and/or their Responsible Party (RP- a person assigned to assist or make decisions on behalf of the resident), was provided the opportunity to choose or be informed of their right to choose their attending physician (a medical doctor in charge of the overall care of the resident). This deficient practice resulted in Resident 1 and Resident 1's RP not being made aware of Resident 1's right to select her physician and had the potential to interfere with Resident 1's RP's ability to make an informed choice regarding Resident 1's care and treatment. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 10/28/2020 with diagnoses that included cerebral palsy (group of movement disorders that can cause problems with posture, manner of walking (gait), muscle tone, and coordination), altered mental status (a disruption in how your brain works that causes a change in behavior), and quadriplegia (paralysis…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 treated with respect and dignity by failing to assist Resident 1 with obtaining personal belongings from Resident 1's previous facility. This deficient practice had the potential to affect Resident 1's sense of identity, autonomy and emotional comfort. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 10/28/2020 with diagnoses that included cerebral palsy (group of movement disorders that can cause problems with posture, manner of walking (gait), muscle tone, and coordination), altered mental status (a disruption in how your brain works that causes a change in behavior), and quadriplegia (paralysis [complete or partial loss of muscle function] of all four limbs). During a review of Resident 1's History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of findings) dated 10/29/2020, the H&P indicated Resident 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 interview and record review, the facility failed to ensure that one of three sampled residents (Resident 1's) correct responsible party (RP- a person assigned to assist or make decisions on behalf of the resident) was accurately documented in Resident 1's medical record, and failed to notify the correct RP of Resident 1's room change. This deficient had the potential to result in miscommunication regarding the resident's care and cause confusion for the RP. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 10/28/2020 with diagnoses that included cerebral palsy (group of movement disorders that can cause problems with posture, manner of walking (gait), muscle tone, and coordination), altered mental status (a disruption in how your brain works that causes a change in behavior), and quadriplegia (paralysis [complete or partial loss of muscle function] of all four limbs). During a review of Resident 1's History and Physical (H&P- a formal assessment by a healthcare provider that involves a 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 interview and record review the facility failed to ensure laboratory services were provided timely for one of three sampled residents (Resident 1). This deficient practice may result in a delay in identifying a medical condition and placed Resident 1 at risk of not receiving the necessary care, services and treatment in a timely manner leading to worsening medical conditions. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 5/1/2025 with diagnosis that included nontraumatic subarachnoid hemorrhage (refers to bleeding in the space between the brain and the thin tissues surrounding it, without any head trauma being involved), cirrhosis of liver (a chronic liver disease where healthy liver tissue is replaced by scar tissue, hindering the liver's ability to function properly), type two (2) diabetes mellitus (a long term medical condition in which the body has trouble controlling blood sugar and using it for energy) and bacteremia (the presence of bacteria in the blood). During a review of Resident 1'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 obtain one of four (Resident 1's) weight as ordered by the physician. This deficient practice may result in a delay in identifying significant weight loss or weight gain, and nutritional needs which may lead to a decline in the residents' condition. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted Resident 1 on 10/28/2020 and was readmitted on [DATE] with diagnoses that included cerebral palsy (group of movement disorders that can cause problems with posture, manner of walking [gait], muscle tone, and coordination), altered mental status (a disruption in how your brain works that causes a change in behavior), urinary tract infection (an infection in any part of your urinary system), heart failure (a condition in which the heart doesn't pump blood as well as it should), quadriplegia (a condition where all four limbs [arms and legs] experience loss of movement), and anxiety…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 laboratory services for one of four sampled residents (Resident 1) by failing to ensure Resident 1 ' s Complete Blood Count (CBC- a blood test that measures the different types and numbers of cells [basic structural and functional unit of all forms of life] in your blood); Comprehensive Metabolic Panel (CMP- a blood test that measures 14 different substances in the blood to assess overall health and metabolism [refers to all the physical and chemical processes in the body that convert or use energy]); Pre-albumin Level (a blood test that measures the amount of pre-albumin [a protein produced by the liver], used to assess a person ' s nutritional status); Serum Iron Test (a blood test that measures how much iron [essential mineral needed by our body for growth and development] is in the blood); Serum Ferritin Test (a blood test that measures the amount of ferritin [a protein that stores iron] in the blood) were obtained as ordered by Resident 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 provide reasonable accommodation of resident needs by failing to ensure the call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was within reach for one of four sampled residents (Resident 5). This deficient practice had the potential to result in a delay of care and services and possible injury to residents when unable to obtain the needed care and services. Findings: During a review of Resident 5's admission Record, the admission Record indicated the facility originally admitted the resident on 3/15/2022 and re-admitted on [DATE] with diagnoses including atherosclerosis of the aorta (refers to the build-up of plaque [a fatty deposit] inside the aorta [the main artery that carries oxygen-rich blood from the heart to the rest of the body]), paroxysmal atrial fibrillation (involves episodes of an irregular heart rhythm that start and stop spontaneously, typically lasting less than a week)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provision of medically-related social services to meet one of five sampled residents (Resident 2) needs by failing to follow up the status of Resident 2's missing dentures and ensure timely replacement of Resident 2's denture. On 4/4/2024, Resident 2 was discharged from the facility without providing Resident 2's upper and lower dentures. This deficient practice placed Resident 2 at risk for health and safety impacts such as impair Resident 2's ability to eat leading to weight loss, choke (a blockage of the upper airway by food or other objects, which prevents a person from breathing effectively) or aspirate (when something you swallow goes down the wrong way and enters your airway or lungs) food and may affect Resident 2's speech and social interaction. Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident on 1/2/2024 with diagnoses including spinal stenosis (a medical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 four sampled residents (Residents 1 and 2) received treatment and care in accordance with professional standards of practice by failing to measure Resident 1 and Resident 2 ' s wounds during the assessment of new wounds. This deficient practice had the potential to result in improper wound care and a delay in wound healing to Residents 1 and 2. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated the facility originally admitted the resident on 11/23/2024 and readmitted on [DATE], with diagnoses including but not limited to, encephalopathy (damage or disease that affects the brain), heart disease, and vascular dementia (a progressive state of decline in mental abilities caused by decreased blood flow to the brain). During a review of Resident 1 ' s Minimum Data Set (MDS – a resident assessment tool), dated 2/26/2025, the MDS indicated Resident 1 had severely impaired cognition (the…

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

Based on observation, interview, and record review, the facility failed to provide a resident who was at high risk for falls with floor mats (cushioned floor pads designed to help prevent injury should a person fall) as indicated in the care plan for one of five sampled residents (Resident 1). This deficient practice placed Resident 1 at an increased risk of sustaining an injury from a fall. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted the resident on 12/13/2022 and readmitted the resident on 7/7/2023 with diagnoses including, but not limited to, Guillain-Barre syndrome (a disorder where the body's immune system mistakenly attacks nerves which can lead to numbness, tingling, and paralysis), history of falling, and osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D) with a pathological fracture (broken bone caused by disease). During a review of Resident 1's History and Physical (H&P), dated 4/3/2025, the H&P indicated the resident was recently hospitalized from a fracture due to a…

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

Based on interview and record review, the facility failed to accurately complete a dietary communication slip including food allergy information (refers to details about the resident's food allergies [a condition that causes illness when someone eats certain foods or touches or breathes in certain substances]) for one of five sampled residents (Resident 2) upon re-admission to the facility on 3/25/2025 and prior to meal service. This deficient practice had the potential to place the resident at increased risk of being served with food containing food allergens (a substance that causes an allergic reaction) and had the potential to result in a life-threatening condition such as anaphylactic shock (severe allergic reaction including closure of airways). Findings: During a review of Resident 2 ' s admission Record, the admission Record indicated the facility re-admitted Resident on 3/25/2025 with diagnoses that included malnutrition (lack of proper nutrition), atrial fibrillation (irregular and very rapid heart rhythm) and parkinson ' s disease (a brain disorder that causes unintended…

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

Based on observation, interview, and record review, the facility failed to implement infection control practices by failing to ensure a resident ' s bed controller was cleaned and disinfected to prevent the spread of germs and infections for one of five sampled residents (Resident 3). This deficient practice had the potential to result in the spread of germs placing residents, staff, and visitors at risk to be infected. Findings: During a review of Resident 3 ' s admission Record, the admission Record indicated the facility admitted the resident on 3/12/2025 with diagnoses that included right foot fracture (broken bone). During a review of Resident 3 ' s Minimum Data Set (MDS - a resident assessment tool) dated 3/18/2025, the MDS indicated the resident ' s cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was intact. The MDS further indicated that the resident needed maximal assistance from staff with toileting hygiene and upper body dressing, needed moderate assistance 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.

Based on observation, interview, and record review, the facility failed to provide a safe and comfortable environment by failing to: 1. Ensure that the facility staff did not leave an unlabeled drinking cup that contained soap in a resident ' s room for one out of six sampled residents (Resident 1). 2. Ensure a drinking cup unlabeled that contained hair and body shampoo (H&BS) was not left in a utility room (UR - a dedicated area for tasks that involve cleaning, disinfecting, and storing items used in resident care, such as bedpans, urinals, and soap/shampoo/mouthwash). These deficient practices had the potential to place residents, staff, and visitors at risk for unsafe and/or uncomfortable environment. Findings: 1. During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted the resident on 3/12/2025 with diagnoses that included pelvis (the bony structure inside hips, buttocks and pubic region) fracture (broken bone). During a review of Resident 1 ' s Minimum Data Set (MDS - a resident assessment tool) dated 3/18/2025, the MDS 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 interview and record review, the facility failed to ensure a resident's notice of proposed transfer and discharge was provided to the resident at least 30 days prior to discharge or as soon as practicable for two of three sampled residents (Resident 2 and Resident 3). This deficient practice placed Resident 2 and Resident 3 at increased risk of an inappropriate discharge and had the potential to deny the resident of their right to file an appeal to the appropriate agency. Findings: a. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 2/14/2025 with diagnoses that included encephalopathy (a broad term for any brain disease that alters brain function or structure), memory deficit following nontraumatic intra cerebral hemorrhage (emergency condition on which a ruptured blood vessel causes bleeding inside the brain, and legal blindness. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 3/4/2025, 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 implement the facility's policy on urinary catheter (a flexible tube inserted into the bladder and left in place to continuously drain urine) care for one of three sampled residents (Resident 1), by failing to provide documented evidence that urinary catheter care was provided to Resident 1 and failing to provide documented evidence of staff monitoring Resident 1's urinary output. This deficient practice had the potential for Resident 1 not to attain their highest functional level. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 3/1/2025 with diagnoses that included malignant neoplasm of bladder (bladder [organ that stores urine] cancer), retention of urine (inability to completely empty the bladder), and encounter for surgical aftercare following surgery on the genitourinary system (organs and structures involved in both reproduction and urination). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's attending physician documented a resident's History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of findings) within 72 hours following admission for two of three sampled residents (Resident 2 and Resident 3). This deficient practice had the potential for inconsistent care coordination due to incomplete medical records for Resident 2 and Resident 3. Findings: a. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 2/14/2025 with diagnoses that included encephalopathy (a broad term for any brain disease that alters brain function or structure), memory deficit following nontraumatic intra cerebral hemorrhage (emergency condition on which a ruptured blood vessel causes bleeding inside the brain, and legal blindness. During a review of Resident 2's Minimum Data Set (MDS - a 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 interview and record review, the facility staff failed to ensure one of three sampled residents (Resident 1) had accurate nursing assessments completed daily and accurately documented regarding Resident 1's activities of daily living (ADLs-routine/tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). This deficient practice had the potential to negativity affect the resident's quality of life, quality of care, and the quality of services provided. Findings: During a review of Resident 1's admission Record dated 10/28/2020, the admission Record indicated the facility admitted the resident on 10/28/2020 with diagnoses including cerebral palsy (group of movement disorders that can cause problems with posture, manner of walking (gait), muscle tone, and coordination), altered mental status (a disruption in how your brain works that causes a change in behavior), urinary tract infection (UTI-an infection in any part of your urinary system), heart failure (a condition in which the heart doesn't pump blood as well as it should),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 physician orders were written accurately for one of three sampled residents (Resident 1) by failing to clarify with the physician Resident 1's potassium chloride (medication used in the management and treatment of low potassium) order for Resident 1 who was unable to self-administer medications. This deficient practice placed Resident 1 at risk for receiving an incorrect dosage of potassium, potentially leading to health complications. Findings: During a review of Resident 1's admission Record dated 10/28/2020, the admission Record indicated the facility admitted the resident on 10/28/2020 with diagnoses included cerebral palsy (group of movement disorders that can cause problems with posture, manner of walking (gait), muscle tone, and coordination), altered mental status (a disruption in how your brain works that causes a change in behavior). During a review of Resident 1's History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation 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 clarify with the physician a resident's gastrostomy tube (G-tube-a tube that is places directly into the stomach through an abdominal wall for administration of food, fluids, and medications) feeding order for one of three samples residents (Resident 1). Resident 1's G-tube feeding order did not indicate how many cubic centimeters (CC-unit of measure in volume) and calories (a measurement of the energy content of food) were provided to Resident 1 each day. This deficient practice had the potential to result in Resident 1 having unplanned weight loss or gain and altered nutritional status that can lead to health complications. Findings: During a review of Resident 1's admission Record dated 10/28/2020, the admission Record indicated the facility admitted the resident on 10/28/2020 with diagnoses included cerebral palsy (group of movement disorders that can cause problems with posture, manner of walking (gait), muscle tone, and coordination), altered mental status (a disruption in how your brain works that causes a change 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.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who has a diagnosis of cerebral palsy (group of movement disorders that can cause problems with posture, manner of walking (gait), muscle tone, and coordination) received specialized rehabilitative services (special health care services that help a person regain physical, mental, and/or cognitive [thinking and learning] abilities that have been lost or impaired as a result of disease, injury, or treatment). This deficient practice had the potential for Resident 1's to have a decrease in functional mobility, quality of life and higher risk for further decline. Findings: During a review of Resident 1's admission Record dated 10/28/2020, the admission Record indicated the facility admitted the resident on 10/28/2020 with diagnoses including cerebral palsy, and altered mental status (a disruption in how your brain works that causes a change in behavior), and urinary tract infection (an infection in any part of your urinary system During a review of Resident 1's History 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 implement the facility ' s Falling Star Program (a program that assesses a resident ' s risk for falling and identifies this at risk) by failing to place an identifying colorful star in the resident ' s personal areas (name plate on entrance to room) for a resident identified at risk for falls for one of three sampled residents (Resident 1). This failure had the potential for staff to be unaware that the resident is at risk for falls, which could increase the resident ' s risk for further falls. Findings: During a review of Resident 1 ' s admission Record, indicated that the facility admitted the resident on 08/17/2024 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood glucose [sugar]) and repeated falls. During a review of Resident 1 ' s History and Physical (H&P) dated 9/05/2024, the H&P indicated the resident does not have the capacity to understand and make decisions.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 three sampled residents (Resident 1) was provided with a safe and comfortable environment when on 11/8/2024, Resident 1 used an electric portable space heater (a device used to heat small rooms or partially enclosed areas) inside the resident's room. This deficient practice placed the residents, staff, and visitors at risk for injury associated with the use of an electric portable space heater including burns and fire. Findings: During a review of Resident 1's admission Record indicated the facility originally admitted Resident 1 on 3/7/2019 and readmitted on [DATE] with diagnoses that included rheumatoid arthritis (RA- a long-term condition that causes pain, swelling and stiffness in the joints), asthma (a chronic lung disease that causes the airways in the lungs to narrow and swell, making it difficult to breathe) and atrial fibrillation (a heart condition that causes an irregular heartbeat, usually faster than 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 observation, interview, and record review, the facility failed to ensure a call light (a device used by a resident to signal his/her need for assistance from staff) was within a resident ' s reach while in bed for one of three sampled residents (Resident 2). This deficient practice had the potential to delay the provision of services and the resident ' s needs not being met. Findings: During a review of Resident 2 ' s admission Record, the document indicated the facility admitted the resident on 9/28/2024 with diagnoses that included Parkinsonism (a disorder of the central nervous system [makes up of the brain and spinal cord] that affects movement, often including tremors [involuntary shaking or movement]), acquired absence of left upper limb below elbow, anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations), morbid (severe) obesity, and heart failure (heart is not pumping as well as it should be. During a review of Resident 2 ' s Minimum Data Set (MDS- a standardized assessment and screening tool) dated 8/16/2024, the document…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement the facility ' s policy on personal alarms by failing to check the functionality of a resident ' s bed pad alarm (a device that will sound if a resident moves) daily for one of three sampled residents (Resident 3). This deficient practice had the potential to place Resident 3 at risk for injuries and falls. Findings: During a review of Resident 3 ' s admission Record, the document indicated the facility admitted the resident on 9/24/2024 with diagnoses that included Alzheimer ' s disease (a progressive disease that destroys memory and other important mental functions), unspecified osteoarthritis (occurs when the flexible, protective tissue at the ends of bones, called cartilage, wears down), unspecified fracture (break in bone) of T11-T12 vertebra (each of the series of small bones forming the backbone) subsequent encounter for fracture with routine healing, and multiple fractures of ribs, left side, subsequent encounter for fracture 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 c. A review of Resident 489's admission Record indicated the facility originally admitted the resident on 9/13/2021 with diagnoses including but not limited to unspecified dementia, Alzheimer's Disease, psychosis, and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations). A review of Resident 489's MDS dated [DATE], indicated Resident 489 had severely impaired decision-making skills, physical behavioral symptoms directed towards others (behaviors that affect another person), experienced wandering, and required moderate assistance to complete dressing, toileting, and personal hygiene. During an interview on 8/6/2024 at 9:43 a.m., with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated Resident 489 had a history of wandering around the facility and into other residents' rooms as well as becoming agitated when staff tried to care for her. CNA 2 stated she was not aware of any care plan that addressed Resident 489's wandering. During a concurrent interview and record 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.

Based on observation, interview, and record review, the kitchen staff failed to ensure the proper storage, preparation, and distribution of food in accordance with professional standards for food service safety for 139 of 140 residents who receive food from the kitchen by: 1. Failing to ensure five open bags of bread and bagels had a documented open date (when a kitchen first opens the container and writes the date it is open to ensure it is removed from circulation in a timely manner). 2. Failing to ensure the ice machine lid (Cover) was not left open and exposed to the environment. These deficient practices had the potential to place residents at increased risk of experiencing foodborne illness (an illness that comes from eating contaminated food or drinks). Findings: 1. During a concurrent observation and interview with the Dietary Supervisor (DS) on 8/5/2024 at 7:45 a.m., observed the kitchen of the facility. Located inside the walk-in refrigerator was five open bags of bread and bagels without a documented open date. DS stated that the five open bags of bread and bagels did not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 infection prevention and control practices by: 1. Failing to ensure that Licensed Vocational Nurse 3 (LVN 3) wore gloves during the medication administration for one of two sampled resident (Resident 14) on enhance barrier precaution (EBP-a method of using personal protective equipment [PPE - equipment designed to protect the wearer from injury or the spread of illness or infection] to reduce the spread of pathogens [germs] between residents). 2. Failing to ensure that facility staff (Activities Assistant [AA]) did not eat personal food inside the resident's dining area alongside resident's eating lunch on 8/6/2024. These deficient practices had the potential to increase the risk of spreading infection amongst resident. Findings: 1. During a review of Resident 14's admission Record, the document indicated that the facility admitted Resident 14 on 12/27/2023 with diagnoses that included hypertension (high blood pressure) and bipolar disorder (a mental illness that causes unusual shifts in a person'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 ensure facility staff (Licensed Vocational Nurse 1 [LVN 1]) knocked on a resident's door before entering the resident's room for one of 31 sampled residents. This deficient practice had the potential to affect the resident's sense of self-worth and self-esteem. Findings: During a review of Resident 118's admission Record, the admission Record indicated the facility originally admitted Resident 118 on 7/5/2023 and readmitted Resident 118 on 7/25/2023 with diagnoses including hemiplegia (a symptom of paralysis [inability to move] on one side of the body, often affecting the arms, legs, and face) and hemiparesis (a medical term for partial weakness or paralysis on one side of the body, usually caused by a brain or spinal cord issue). During a review of Resident 118's History and Physical (H & P - a formal assessment that a healthcare provider conducts to evaluate a resident and the resident's medical issues), the H&P indicated the Resident 118 did not have the capacity to understand and make decisions. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure that an Advance Directives (AD-written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were discussed and written information were provided to the residents and or responsible parties for two of 10 sampled residents (Resident 34 and 81) 2. Obtain a copy of the Advance Directive for one of seven sampled residents (Resident 81) and place the Advance Directive in the chart to be available and retrievable at any time per facility policy. These deficient practices have the potential to create confusion which could lead to conflict with the resident`s wishes regarding his/her health care. Findings: 1. During a review of Resident 34's admission Record, the admission Record indicated the facility admitted the Resident 34 on 5/26/2024 with diagnoses that included hypertension (high blood pressure [the force of the blood pushing on 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 that facility staff (Licensed Vocational Nurse 1 [LVN 1]) provided privacy to one of 31 sampled residents (Resident 118) during the administration of medication via gastrostomy tube (g-tube - a small, soft tube that is surgically inserted through the abdomen and into the stomach). This deficient practice violated Resident 118's right to privacy. Findings: During a review of Resident 118's admission Record, the admission Record indicated the facility originally admitted Resident 118 on 7/5/2023 and readmitted Resident 118 on 7/25/2023 with diagnoses including hemiplegia (a symptom of paralysis [inability to move] on one side of the body, often affecting the arms, legs, and face) and hemiparesis (a medical term for partial weakness or paralysis on one side of the body, usually caused by a brain or spinal cord issue). During a review of Resident 118's History and Physical (H & P - a formal assessment that a healthcare provider conducts to evaluate a resident and the resident's medical issues), 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.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 440) was free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or next to the resident's body that he or she cannot easily remove and restricts freedom of movement or normal access to one's body) of a non-self-release seatbelt (NSRB - when the user of the restrain is unable to release it themselves). This deficient practice placed Resident 440 at increased risk for complications of restraint use such as decline in functioning, injury, and entrapment (event in which a resident is caught, trapped, or entangled in a space where they are being restrained). Findings: During a review of Resident 440's admission Record, the admission Record indicated the facility admitted Resident 440 on 7/25/2005 and readmitted Resident 440 on 7/25/2024 with diagnoses including, but not limited to, epilepsy (a brain disorder that causes recurring seizures [a sudden, uncontrolled burst of electrical activity in the…

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

Based on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse 1 (LVN 1) did not sign the Medication Administration Record (MAR - a report detailing the medications administered to a resident by a healthcare professional) for one (Resident 118) out of 31 sampled residents before the administration of Dorzolamide hydrochloride-Timolol maleate (medication eye drop used to treat increased pressure in the eye caused by open-angle glaucoma or a condition called hypertension of the eye) and Prednisolone acetate (medication eye drop used to treat certain eye conditions due to inflammation or injury). This deficient practice had the potential to result in the resident's medical records being inaccurate and not in accordance with professional standards of practice. Findings: During a review of Resident 118's admission Record, the admission Record indicated the facility originally admitted Resident 118 on 7/5/2023 and readmitted Resident 118 on 7/25/2023 with diagnoses including hemiplegia (a symptom of paralysis [inability to move] on one side of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to ensure that Licensed Vocational Nurse 2 (LVN 2) documented the presence of a hematoma (also known as a bruise, it is a discolored mark on your skin that forms when blood vessels under your skin break) to the left dorsal hand (back of the hand) of one of three sampled residents (Resident 61) as ordered by the physician. This deficient practice had the potential for Resident 61 to not to receive the care and services needed to treat Resident 61's discoloration. Findings: During a review of Resident 61's admission Record, the document indicated the resident was admitted to the facility on [DATE] with diagnoses that included dementia (the loss of the ability to think, remember, and reason to levels that affect daily life ). During a review of Resident 61's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/08/2024, the document indicated Resident 61 was severely impaired in cognition (the process of acquiring knowledge 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 that facility staff provided one of one sampled resident (Resident 47) with a scheduled toileting plan (or bladder training, which can involve assisting a resident to the restroom at specific timed intervals) This deficient practice has the potential for Resident 47 to not to achieve or restore normal bowel (a tube-shaped organ in the abdomen that helps the body digest food and absorb nutrients) and bladder (A sac-shaped muscular organ that stores the urine secreted by the kidneys) function. Findings: During a review of Resident 47`s admission Record, the admission Record indicated the facility admitted the resident on 05/15/2023, with diagnoses including gastro-esophageal reflux disease (GERD-a condition in which the stomach contents move up into the esophagus [food pipe]), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and presence of artificial knee joint (a man-made joint 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.

Based on interview and record review, the facility failed to ensure that the recommendation of the Consultant Pharmacist`s (CP) to monitor the respiratory rate (RR-the number of breaths a resident takes per minute) and adding a parameter to hold (do not give a medication) the medication of Oxycodone Hydrochloride (Oxycodone HCL -medication to treat pain) if the RR of a resident is less than 12 breaths per minute ( normal respiratory rate is 12-20 breaths per minute) for one of five sampled residents (Resident 47) was done during the Medication Regimen Review (MRR-A review of the medication regimen of a resident to identify and, if possible, prevent clinically significant medication issues) for 5/2024. This deficient practice had the potential for Resident 47 to receive unnecessary medication increasing the risk for adverse side effects (unwanted undesirable effects that are possibly related to a drug) such as respiratory depression (slow, shallow breathing). Findings: During a review of Resident 47`s admission Record, the admission Record indicated the facility admitted 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.

Based on observation, interview, and record review, the facility failed to ensure that Licensed Vocational Nurse 1 (LVN 1) locked one of three medication carts (Medication Cart 1) before leaving it unattended during a med pass observation. This deficient practice had the potential to result in unauthorized personnel or residents accessing the medications stored in the unlocked medication cart. Findings: During an observation on 8/6/2024 at 8:06 a.m., observed LVN 1 entering a resident's room while leaving Medication Cart 1 unlocked and unattended. Medication Cart 1 was not within LVN 1's line of sight (the direction in which a person must look in order to see a particular object). During an interview on 8/6/2024 at 8:53 a.m. with LVN 1, LVN 1 stated that he (LVN 1) forgot to lock Medication cart 1 before leaving it unattended to enter a resident's room. During an interview on 8/8/2024 at 9:13 a.m., with the Director of Nursing (DON), the DON stated that it was important to ensure the medication cart are locked and secured before leaving it unattended in order to prevent unauthorized…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prompt efforts were made to resolve the grievance of one of seven sampled residents (Resident 2). This deficient practice violated the residents' right to have their grievance addressed. Findings: A review of Resident 2's admission Record indicated the facility admitted Resident 2 on 1/29/2019 with diagnoses that included rheumatoid arthritis (RA - a condition that can cause pain, swelling and stiffness in joints), type 2 diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), hypertension (high blood pressure) and glaucoma (a disease that damages your eye's optic nerve [nerve in the back of the eye]). A review of Resident 2's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 5/3/2024 indicated Resident 2's cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. The MDS indicated Resident 2 required total assistance from staff with toileting…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 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 origin (injuries resulting without knowing how it happened) that occurred on 7/6/2024 for one of two sampled residents (Resident 3). 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 3's admission Record indicated the facility originally admitted Resident 3 on 6/16/2003 and readmitted on [DATE] with diagnoses that included cerebral infarction (known as stroke, occurs as a result of disrupted blood flow to the brain) and epilepsy (a disorder of the brain characterized by repeated seizures [a sudden, uncontrolled burst of electrical activity in the brain]). 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 accurately complete the Minimum Data Set (MDS - a standardized assessment and care planning tool) Assessment Section GG (Functional Abilities and Goals) on 5/3/2024 by failing to indicate the resident's use of a motorized wheelchair (known as powerchair or electric wheelchair, a wheelchair that is propelled by means of an electric motor rather than manual power) for one of two sampled residents (Resident 2). This deficient practice had the potential to negatively affect Resident 2's plan of care and delivery of services. Findings: A review of Resident 2's admission Record indicated the facility admitted Resident 2 on 1/29/2019 with diagnoses that included rheumatoid arthritis (RA - a condition that can cause pain, swelling and stiffness in joints), type 2 diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), hypertension (high blood pressure) and glaucoma (a disease that damages your eye's optic nerve [nerve in the back of the eye]). 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 interview and record review, the facility failed to develop a person-centered care plan (a document designed to facilitate communication among members of the care team that summarizes a resident's health conditions, specific care needs, and current treatments) and implement care plan interventions for two of seven sampled residents (Resident 1 and 2) to address the use of motorized wheelchair (known as powerchair or electric wheelchair, a wheelchair that is propelled by means of an electric motor rather than manual power) while alone and on out on pass (OOP - away from the facility). These deficient practices had the potential to result in lack of delivery of care and services and placed residents at risk for injury. Findings: a. A review of Resident 1's admission Record indicated the facility originally admitted Resident 1 on 7/1/2022 and readmitted on [DATE] with diagnoses that included type 2 diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 History and Physical (H&P- contains relevant information about the resident's past medical history, current medical concerns, including review of any pre-existing medical conditions, past hospitalizations and surgeries, allergies, medications being taken, family medical history, physical examination and assessment of mental status) Examinations for two of seven sampled residents (Resident 3 and Resident 4) were completed by the physician. This deficient practice had the potential for inconsistent care coordination due to incomplete H&P and placed Resident 3 and Resident 4 at risk for poor continuity of care and care needs. Findings: a. A review of Resident 3's admission Record indicated the facility originally admitted Resident 3 on 6/16/2003 and readmitted on [DATE] with diagnoses that included cerebral infarction (known as stroke, occurs as a result of disrupted blood flow to the brain) and epilepsy (a disorder of the brain characterized by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to notify the responsible party of a change in condition (COC- when there is a sudden change in a resident's health) for one of three sampled residents (Resident 1) when Resident 1 had a significant nine (9) pounds (lbs. - unit of measure) weight loss in a week (from 12/19/2020 to 12/26/2020). This deficient practice has the potential outcome to have had a negative effect on Resident 1's nutritional status if any decisions were needed at the time of the change of condition. Findings: A review of Resident 1's admission Record indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses that included cerebral palsy (group of movement disorders that can cause problems with posture, manner of walking [gait], muscle tone, and coordination), altered mental status (a disruption in how your brain works that causes a change in behavior), urinary tract infection (an infection in any part of your urinary system), heart failure (a 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 determine resident specific interventions for a comprehensive person-centered care plan (a plan for an individual's specific health needs and desired health outcomes) related to falls for one of three sampled residents (Resident 1). This deficient practice had the potential to result in a delay in or lack of delivery of care and services to Resident 1. Findings: A review of Resident 1 ' s admission record dated 10/28/2020 indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses that included cerebral palsy (group of movement disorders that can cause problems with posture, manner of walking [gait], muscle tone, and coordination), altered mental status (a disruption in how your brain works that causes a change in behavior), urinary tract infection (an infection in any part of your urinary system), heart failure (a condition in which the heart doesn't pump blood as well as it should), quadriplegia (a condition where all four limbs…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 physician order for monitoring intake (amount of fluid a person consumes) and output (the amount of fluid a person excretes from the body) was done for one of three sampled residents (Resident 1). This deficient practice had the potential for Resident 1 to experience a in delay in necessary care and services. Findings: A review of Resident 1 ' s admission record dated 10/28/2020 indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses that included cerebral palsy (group of movement disorders that can cause problems with posture, manner of walking [gait], muscle tone, and coordination), altered mental status (a disruption in how your brain works that causes a change in behavior), urinary tract infection (an infection in any part of your urinary system), heart failure (a condition in which the heart doesn't pump blood as well as it should), quadriplegia (a condition where all four limbs [arms and legs] experience loss of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that one of three sampled residents (Resident 1) was provided with the necessary behavioral health care and services by not obtaining a psychological (pertaining to mental or emotional) evaluation for Resident 1 as ordered by the physician. This deficient practice had the potential to negatively impact Resident 1 ' s mental health including increasing the risk for depression, anxiety, directly affecting the resident ' s psychosocial wellbeing. Findings: A review of Resident 1 ' s admission record dated 10/28/2020 indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses that included cerebral palsy (group of movement disorders that can cause problems with posture, manner of walking [gait], muscle tone, and coordination), altered mental status (a disruption in how your brain works that causes a change in behavior), urinary tract infection (an infection in any part of your urinary system), heart failure (a 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 that one of three sampled residents (Resident 1) was provided with social service assessments and needs as indicated in the facility ' s policy and procedures during the duration of Resident 1 ' s stay in the facility. This deficient practice had the potential for Resident 1 not to maintain the highest practicable physical, mental, and psychosocial well-being; and increased the risk of a delay in delivery of care and services needed for Resident 1. Findings: A review of Resident 1 ' s admission record dated 10/28/2020 indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses that included cerebral palsy (group of movement disorders that can cause problems with posture, manner of walking [gait], muscle tone, and coordination), altered mental status (a disruption in how your brain works that causes a change in behavior), urinary tract infection (an infection in any part of your urinary system), heart failure (a condition in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to inform and obtain written authorization from the resident prior to completing two government agency forms titled Request To be Selected as Payee (a person authorized by the government to act on behalf of the resident to manage financial matters) (a government form used to process a potential representative payee's application) and Physician's/Medical Officer's Statement of Patient's Capability to Manage Benefits (a government form used to collect information to make a determination regarding the resident's need for a representative payee) to manage the resident's personal funds for one of three sampled residents (Resident 3). This deficient practice resulted in the violation of Resident 3's rights and had the potential for misuse of Resident 3's personal funds. Findings: A review of Resident 3's admission Record indicated that Resident 3 was admitted to the facility on [DATE] with diagnoses that include type 2 diabetes (DM- a condition that happens…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 allegation of verbal abuse within two (2) hours of the incident for one of five 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 admitted Resident 1 on 4/14/2024 with diagnoses that included hypertension (when the pressure in your blood vessels is too high, normal range less than 120/80 millimeters of mercury [mmHg - unit of measure]) and urinary tract infection (a condition in which bacteria invade and grow in the urinary tract). A review of Resident 1 ' s Change in Condition (COC- when there is a sudden change in a resident ' s health) Interact Assessment Form dated 4/15/2024, timed…

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

Based on observation, interview, and record review, the facility failed to implement infection control practices by: 1. Failing to ensure one of six facility staff (Rehab Staff 1 [RS 1]) performed hand hygiene (washing of hands) before wearing gloves and after providing direct care. 2. Failing to ensure one of six facility staff (Certified Nursing Assistant 1 [CNA 1]) performed hand hygiene before entering and exiting an enhanced standard precaution (an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO - bacteria that have become resistant to certain antibiotics {medication used to fight infections}] in nursing homes) room. These deficient practices had the potential to spread infection and cross contamination (the physical movement or transfer of harmful bacteria [germs] from one person, object, or place to another) among staff and other residents. Findings: 1. During an observation on 4/10/2024, at 9:10 a.m., observed RS 1 entering an enhanced standard precaution room while wheeling a resident. RS 1 was observed putting on gloves…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Pre-admission Screening and Resident Review (PASARR- a federal requirement to help ensure individuals with mental disorders or intellectual disabilities are not inappropriately placed for in nursing homes for long term care) was accurately completed for one of four sampled residents (Resident 1). Resident 1's PASARR Level I Screening Document was inaccurately completed upon admission on [DATE]. This deficient practice resulted to Resident 1 not being referred to the PASARR Program and placed the resident at risk for not receiving care and services in an appropriate healthcare setting. Findings: A review of Resident 1's admission Record indicated the facility admitted Resident 1 on 10/28/2020 with medical diagnoses that included cerebral palsy (a condition caused by damage to the brain before birth that results in impaired muscle coordination and movement), quadriplegia (paralysis of both arms and both legs), and heart failure (a 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.

Based on interviews and record reviews the facility failed to protect the right of one of four sampled residents (Resident 1) to have their legal and medical decision maker, Family Member 1 (FM 1), be informed about Resident 1's care and to choose what care Resident 1 received while in the facility by: 1. Failing to obtain an informed consent (approval) for the administration of the antipsychotic medication (a potentially dangerous type of medication that effects mood, behavior, thoughts, and perceptions that are associated with increased risk of death) known as Seroquel from Resident 1's responsible party. 2. Failing to ensure Resident 1's responsible party participated in the resident's Interdisciplinary Team (IDT- an approach to healthcare that integrates multiple disciplines through collaboration) care plan meetings. This deficient practice resulted the facility administering a psychotropic medication (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) to Resident 1 without informed consent, 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 interviews and record reviews, the facility failed to maintain complete and accurate medical records for one of four sampled residents (Resident 1) by: 1. Failing to ensure facility staff did not document that Resident 1's responsible party (Emergency Contact 1 [EC 1]) was contacted and provided informed consent (approval) for the administration of the antipsychotic medication (a potentially dangerous type of medication that effects mood, behavior, thoughts, and perceptions that are associated with increased risk of death) known as Seroquel. 2. Failing to ensure facility staff did not document that Resident 1's responsible party (Emergency Contact 2 [EC 2]) was contacted and provided information regarding Resident 1's Physician Orders for Life-Sustaining Treatment (POLST - a written medical that helps give residents with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness). 3. Failing to ensure facility staff did not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews and record reviews, the facility failed to review the risks and benefits of side rail usage; and obtain informed consent (approval) prior to installation from the responsible party (Emergency Contact 1 [EC 1] and Emergency Contact 2 [EC 2]) for one of four sampled residents (Resident 1). These deficient practices resulted in Family Member 1 (FM 1) not having the chance to give informed consent for the facility's use of side rails on Resident 1's bed which could have resulted in Resident 1 suffering injury related to entrapment (to be trapped) in the side rails. Findings: 1. A review of Resident 1's admission Record indicated the facility admitted Resident 1 on 10/28/2020 with medical diagnoses that included cerebral palsy (a condition caused by damage to the brain before birth that results in impaired muscle coordination and movement), quadriplegia (paralysis of both arms and both legs), and heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs). The admission Record indicated Resident 1's Emergency Contact as EC…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain the right to privacy for one (1) of three (3) sampled residents (Resident 1) by taking an unauthorized photograph of Resident 1 while providing daily care. This deficient practice violated the right to privacy for Resident 1 and had the potential to have feelings of embarrassment and negativity impact Resident 1 ' s socialization. Findings: A review of Resident 1 ' s admission record (facesheet) dated 10/28/2020, indicated Resident 1 was admitted to the facility on [DATE] with the most recent readmission to the facility on 5/15/2023. Resident 1 was admitted with diagnoses that included chronic obstructive pulmonary disease (COPD-a group of diseases that cause airflow blockage and breathing-related problems), type 2 diabetes (a problem in the way the body regulates and uses sugar as a fuel), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 obtain paperwork and follow up information regarding a medical appointment for one of five sampled residents (Resident 1). Resident 1, who requires a hematologist (a doctor who specializes in diagnosing, treating, and preventing blood disorders) appointment that was scheduled for 11/21/2023, was not provided timely. This deficient practice resulted in a delay of necessary treatment, caused Resident 1 ' s appointment to be rescheduled to 12/29/2023 and could result in a decline in medical condition. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted Resident 1 on 10/28/2020 and readmitted the resident on 5/15/2023 with diagnoses including nonthrombocytopenic purpura (when purple, red, or yellowish-brown spots or patches develop under the skin due to inflammation [the body's immune system's response to an irritant], damaged blood vessels, or an underlying health condition). A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 10/27/2023,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 arrange transportation services to a resident ' s appointment with a hematologist (a doctor who specializes in diagnosing, treating, and preventing blood disorders) for one of five sampled residents (Resident 1). This deficient practice had the potential to result in negative health outcomes. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted Resident 1 on 10/28/2020 and readmitted the resident on 5/15/2023 with diagnoses including nonthrombocytopenic purpura (when purple, red, or yellowish-brown spots or patches develop under the skin due to inflammation [the body's immune system's response to an irritant], damaged blood vessels, or an underlying health condition). A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 10/27/2023, indicated Resident 1 was able to understand and make decisions and required maximum assistance from staff with bed mobility and transfer. A review of Resident 1 ' s Physician Orders dated 11/20/2023 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.

Based on interview and record review, the facility failed to ensure one of three sampled resident's (Resident 1) drug regimen ( the routine daily medication that a resident is prescribed) was free from unnecessary drugs. Resident 1 was administered a dose of the antibiotic (medication to treat infection) Levaquin (class of medication that treat infections) after it was identified that the resident was resistant ( when a medication is no longer effective) to the medication. This deficient practice resulted in the unnecessary usage of the antibiotic Levaquin and placed Resident 1 at increased risk for antibiotic resistance (when a treatable illness, becomes because the medications has lost their effectiveness). Findings: A review of Resident 1's admission record indicated the facility originally admitted the resident on 6/4/2021 and readmitted the resident on 7/23/2022 with diagnoses including Hemiplegia (weakness or partial paralysis [inability to move] of one side of the body), diabetes (a disease that occurs when the body is unable to regulate the amount of glucose (sugar) 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to administer the Intravenous (medications given into a vein) antibiotic (medication that help stop infection caused by a bacteria) as ordered for Extended Spectrum Beta-Lactamase (ESBL-are enzymes [proteins that helps speed up chemical reaction] produced by some bacteria that make them resistant to some antibiotic) urinary tract infection (UTI-bladder infection) in a timely manner for one of two sampled residents (Resident 3). The deficient practice resulted in the resident delayed treatment for UTI and had the potential to place resident at risk for sepsis (life threatening condition in response to infection that can lead to tissue damage, organ failure and death). Findings: A review of Resident 3's admission record indicated the facility originally admitted the resident on 12/17/2005 and recently readmitted on [DATE] with diagnoses including Coronavirus 2019 (COVID-19 - a highly contagious respiratory illness in humans capable of producing severe…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 timely report the abnormal (outside of normal range) laboratory test results to a resident's physician for one of two sampled residents (Resident 1). The facility received Resident 1's urinary culture (laboratory test to check for bacteria or other germs in the urine sample) results on 8/26/2023 at 9:26 p.m., and reported the results to Resident 1's physician approximately over 21 hours later on 8/27/2023 at 6:44 p.m. This deficient practice had the potential to cause a delay of obtaining appropriate medical treatment for Resident 1 which could have resulted in a negative impact to the resident's overall physical, mental, and psychosocial well-being. Findings: A review of Resident 1's admission record indicated the facility originally admitted the resident on 6/4/2021 and readmitted the resident on 7/23/2022 with diagnoses including Hemiplegia (weakness or partial paralysis [inability to move] of one side of the body), diabetes (a disease that occurs when the body is unable to regulate the amount of glucose [sugar] 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain infection prevention and control practices for two of six sampled residents (Resident 1 and Resident 2) by failing to: 1. Ensure that Certified Nursing Assistant 1 (CNA 1) wore a gown as proper personal protective equipment (PPE-specialized clothing or equipment used to protect workers from exposure to blood, body fluids and other potentially infectious materials) while providing a bed bath (bathing a resident while the resident remains in bed) to Resident 1 who was on enhanced standard precautions (measures that are intended to prevent transmission of multidrug resistant organism [MDROs-bacteria that have developed resistance to multiple types of antibiotics {medications used to treat infections}]). 2. Ensure Resident 2's nasal cannula tubing (a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels) was not touching the floor. These deficient practices had the potential to result in the…

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

Based on observation, interview, and record review, the facility failed to follow their policy and procedures by failing to: 1. Ensure controlled medication Schedule II (CII- medication with a high risk of abuse or theft) and Intravenous (IV, medications injected into a vein and directly into the bloodstream) Emergency Medication Kits (Ekits- tamper-evident sealed and secured container containing drugs used for either immediate administration, in emergency situation, or as a starter dose) were locked and securely stored in two of two medication storage rooms (Nursing Station 1 and Nursing Station 2 Medication Storage Room). 2. Ensure CII and Intramuscular (IM, an injection of medicine given into a muscle) Ekits were replaced once opened within 72 hours per facility's policy located in one of two medication storage rooms (Nursing Station 1 Medication Storage Room). These deficient practices of failure to adequately monitor, store medications and maintain secure controlled and noncontrolled emergency medications placed residents at risk of not having emergency medications available…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review, the facility failed to follow their policy and procedures by failing to: 1. Maintain a thermometer in the refrigeration to ensure residents medications requiring refrigeration was stored at appropriate temperatures in one of two medication storage rooms (Nursing Station 1 Medication Storage Room). 2. Ensure one opened vial of Aplisol Tuberculin Purified Protein Derivative (PPD) multidose vial (used to test for tuberculosis [a bacterial disease that usually attacks the lungs]) was dated with a first open date per manufacturer specifications stored in one of two nursing station medication rooms (Nursing Station 1 Medication Storage Room). These deficient practices had the potential to compromise the therapeutic effectiveness of the stored medications. 3. Ensure residents medications awaiting disposal was appropriately stored and not left in an unmarked drawer in one of two medication storage rooms (Nursing Station 1 Medication Storage Room). This deficient practice had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to include a copy of the advance directives (written statement of a person's wishes regarding medical tratement made to ensure those wishes were carried out should the person be unable to communicate to a doctor) and to provided a discussion to the residents and/or responsible parties for seven out of seven sampled residents (Resident 14, 31, 47, 52, 43, 54 and 103). These deficient practices violated the residents' and/or the representatives' right to be fully informed of the option to formulate their advance directives and had the potential to cause conflict with the residents' wishes regarding alternatives in the provision of health care. Findings: a. A review of the admission record indicated Resident 14 was admitted to the facility, on [DATE] with diagnoses that included Parkinson's disease (brain disorder that causes a gradual loss of muscle control), dementia (group of symptoms affecting memory, language, problem-solving, and other thinking…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 five of five sampled residents' (Resident 18, 43, 52, 108, and 115) environment remained free from accident hazards by: 1. Failing to ensure Resident 18 and Resident 43's environment was free of clutter and accidental hazards. This deficient practice has the potential to place Resident 18 and Resident 43 at an increased risk for falls. 2. Failing to ensure the side rails were padded per physician's order for Resident 52 who had a history of seizures (sudden, uncontrolled electrical activity in the brain). This deficient practice had the potential for Resident 52 to suffer an injury during a seizure episode. 3. Failing to ensure a resident received adequate supervision when staff used a sit-to-stand lift (a mechanical device used to assist mobility patients when they are unable to transition from a sitting position to a standing position on their own) for Resident 108. This deficient practice had the potential to result in accidental falls leading to injuries including fractures for Resident 108. 4.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure the Controlled Drug Record (CDR- accountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Record (MAR) for one of nine sampled residents (Resident 87) investigated during the facility task Medication Storage and Labeling. 2. Ensure Licensed Vocational Nurse 6 (LVN 6) documented the dispensing and administration of lorazepam (medication used to treat anxiety [intense, excessive, and persistent worry and fear about everyday situations]) on the CDR and on the MAR for one of nine sampled residents (Resident 1) investigated during the facility task Medication Storage and Labeling. 3. Ensure Licensed Vocational Nurse 8 (LVN 8) documented accurately in a resident's record regarding medications being administered for Resident 44. LVN 8 documented Resident 44's morning medications had been administered on 4/08/2022 but had not been administered to Resident 44. 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 implement infection control policy and procedures for five of five sampled residents (Resident 120, 18, 43, 104, and 27) by failing to: 1. Ensure Social Services Assistant (SSA) wore an N95 (filtering mask) before entering and speaking to Resident 120, who was in contact/droplet isolation precautions in the yellow zone (cohort of the facility consisting of mixed quarantine and symptomatic coronavirus disease-2019 (COVID-19 a highly contagious viral infection that can trigger respiratory tract infection). 2. Ensure Resident 120's Caregiver 1 (CG 1) removed the soiled gown and gloves before exiting the resident's room. 3. Ensure Screening for COVID-19 Form for Visitors and Employees were completed prior to entry to the facility. 4. Ensure Resident 18's and Resident 43's personal items were not on the floor. 5. Ensure Resident 104's suprapubic catheter (a hollow flexible tube that is used to drain urine from the bladder) drainage bag was not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assist a resident at eye-level for one of one sampled resident (Resident 103) during assistance with meals. This deficient practice had the potential to affect the resident's self-worth. Findings: A review of the admission record indicated Resident 103 was admitted to the facility, on 12/03/2021, with diagnoses that included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), hypertension (high blood pressure), and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). A review of the Minimum Data Set (MDS - a standardized assessment and screening tool), dated 03/11/2022, indicated Resident 103 had a BIMS (Brief Interview for Mental Status, evaluates cognitive impairment) score of 03 (cognition was severely impaired). The MDS indicated Resident 103 required extensive assistance with mobility, transfer, eating and dressing. A review of Resident 103's care plan, initiated on 12/06/2021, indicated impaired…

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

Based on interview and record review, the facility failed to identify and investigate a grievance concern of a missing tooth for one of one sampled resident (Resident 109). This deficient practice has the potential to delay in addressing Resident 109's needs. Findings: A review of the admission record indicated Resident 109 was admitted to the facility, on 12/06/2021, with diagnoses that included muscle spasm (painful contractions and tightening of your muscles) and hypertension (a condition in which the blood vessels have persistently raised pressure). A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/13/2021, indicated Resident 109 was cognitively intact. A review of the Social Services Progress Notes, dated 03/21/2022, indicated Resident 109 was seen by the dentist on 03/18/2022 and to view the consult in chart for details. During an interview, on 04/05/2022 at 11:44 a.m., Resident 109 stated one of her teeth was missing. Resident 109 stated she complained about it and was told they would handle it. Resident 109 stated she was…

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

Based on observation, interview, and record review, the facility failed to implement their abuse policy, for one (Resident 86) of one sampled residents, as evidenced by: 1. Ensuring Certified Nursing Assistant 1 (CNA 1) was suspended immediately following an abuse allegation. 2. Ensuring the allegation was investigated immediately the same day of the abuse allegation when the abuse allegation was first known by staff. These deficient practices had the potential for Resident 86 to feel isolated and unsafe in the facility. Findings: A review of the admission record indicated Resident 86 was admitted to the facility, on 2/23/2021, with diagnoses that included diabetes mellitus (high blood sugar) and hypertension (high blood pressure). A review of Resident 86's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 2/25/2022, indicated Resident 86 was cognitively (the process of acquiring knowledge and understanding through thought, experience, and the senses) intact in skills required for daily decision making. Resident 86 required one-person extensive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 sexual abuse allegation by facility staff was reported to the appropriate state agency within two hours for one of one sampled resident (Resident 86) on 1/09/2022. This deficient practice resulted in Resident 86 to feel unprotected and unsafe when the investigation was not acted upon in a timely manner. Findings: A review of the admission record indicated Resident 86 was admitted to the facility, on 2/23/2021, with diagnoses that included diabetes mellitus (high blood sugar) and hypertension (high blood pressure). A review of Resident 86's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 2/25/2022, indicated Resident 86 was cognitively (the process of acquiring knowledge and understanding through thought, experience, and the senses) intact in skills required for daily decision making. The MDS indicated Resident 86 required one-person extensive assistance (resident involved in activity, staff provide weight-bearing support) with transfer, toilet use, and personal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 28 sampled residents (Resident 26) care plan was reviewed and revised to reflect the current status and interventions being provided to the resident. This deficient practice placed the resident at risk of unrecognized change of condition and a delay of necessary intervention. Findings: A review of the admission record indicated Resident 26 was admitted to the facility, on [DATE] and readmitted on [DATE], with diagnoses that included COVID-19 (Coronavirus disease-2019, a highly contagious viral infection that can trigger respiratory tract infection), pneumonia (infection in one or both of the lungs) due to COVID-19, and chronic obstructive pulmonary disease (progressive lung disease). A review of the Minimum Data Set (MDS - an assessment and care screening tool), dated [DATE], indicated Resident 26 rarely/never made self-understood and rarely/never understood others. A review of Resident 26's Physician Orders for Life-Sustaining Treatment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assist Resident 270 to clean his fingernails during his morning care. This deficient practice has the potential to result in a skin infection and that may affect Resident 270's self-esteem without being clean. Findings: A review of the admission record indicated Resident 270 was admitted to the facility, on 03/24/2022, with diagnoses that included cerebral infarction (stroke, an illness in which part of the brain loses its blood supply) and Parkinson's disease (a brain disorder that leads to shaking, stiffness, and difficulty with walking, balance, and coordination). A review of the admission Assessment, dated 03/24/2022, indicated Resident 270 required assistance with grooming. A review of the History and Physical, dated 03/25/2022, indicated Resident 270 had the capacity to understand and make decisions. A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 03/31/2022, indicated Resident 270 required extensive assistance (resident involved in activity, staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 to provide the needed care and services, for two of two sampled residents, as evidenced by: 1. Failure to ensure psychological support was provided by Resident 86 following alleged abuse. 2. Failure to accurately monitor for complications related to anticoagulant (medication used to help prevent blood clots) use for one of one sampled resident (Resident 47). These deficient practices had the potential to result in a delay or lack of delivery of care and services for Resident 47 and 86. Findings: 1. A review of the admission record indicated Resident 86 was admitted to the facility, on 2/23/2021, with diagnoses that included diabetes mellitus (high blood sugar) and hypertension (high blood pressure). A review of Resident 86's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 2/25/2022, indicated Resident 86 was cognitively (the process of acquiring knowledge and understanding through thought, experience, and 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 tubing for the urinary catheter (device that is inserted into the bladder to collect and drain urine) was secured with an anchor as ordered by the physician for one of two sampled residents (Resident 31). This deficient practice had the potential for the urinary catheter to accidentally get pulled on and become dislodged, resulting in injury. Findings: A review of Resident 31's admission Record indicated the facility admitted the resident on 5/20/2021, with most recent admission date of 1/17/2022, with diagnoses that included neuromuscular dysfunction of bladder (problem in which a person lacks bladder control due to a brain, spinal cord, or nerve condition) and dementia (group of symptoms affecting memory, language, problem-solving, and other thinking abilities) without behavioral disturbance. A review of Resident 31's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/24/2022, indicated Resident 31 had the ability to make self usually understood and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide effective pain management for two of two sampled residents (Resident 109 and Resident 36) by failing to administer the residents' pain medications as ordered by the physician when Resident 109 and Resident 36 reported a pain scale level 7 or greater considered as severe pain according to the facility's pain management policy. This deficient practice had the potential to result in ineffective pain management and poor compliance to treatment and may result in poor recovery outcomes for the residents. Findings: a. A review of Resident 109's admission Record indicated the facility admitted the resident on 12/06/2021 with diagnoses that included muscle spasm (painful contractions and tightening of your muscles) and hypertension (a condition in which the blood vessels have persistently raised pressure). A review of Resident 109's Physician Orders indicated Oxycodone (used to treat moderate pain for resident) 10 milligrams (mg-unit of measurement),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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-up and ensure the physician provided a rationale (underlying reason) for disagreeing with the pharmacy consultant's recommendation for gradual dose reduction (GDR - stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) of psychotropic (drug that affects behavior, mood, thoughts, or perception) medications for one of five sampled residents (Resident 52) investigated under the care area of Unnecessary Medications, Psychotropic Medications, and Medication Regimen Review. This deficient practice had the potential for Resident 52 to continue to receive unnecessary medications, placing the resident at risk for possible adverse consequences (any unexpected or dangerous reaction to a drug). Findings: A review of Resident 52's admission Record indicated the facility admitted the resident on 8/2/2021 with diagnoses that included psychosis (condition that affects how the brain processes information and causes a person to lose…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 132 of 136 residents who are served food from the kitchen by: 1. Failing to ensure one dietary staff wore a hairnet while in the kitchen. 2. Failing to discard an open gallon of skim milk by its use-by-date (last date recommended for the use of the product). These deficient practices had the potential to result in cross contamination (unintentional transfer of bacteria/germs or other contaminants from one surface or substance to another) of food and equipment and can lead to foodborne illness (any illness resulting from the spoilage of contaminated food, pathogenic bacteria/germs, viruses, or parasites that contaminate food). Findings: During a concurrent observation and interview on 04/05/2022 at 8:25 a.m., observed [NAME] 1 in the kitchen food preparation area, not wearing a hair net. [NAME] 1 stated he should be wearing a hair net because it is used so hair won't fall into the food. During an…

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

Based on observation, interview, and record review, the facility failed to maintain a safe environment for one of one sampled resident (Resident 97) by failing to address an issue with a faulty door stop which allowed the bathroom door to hit the sliding glass door to the outdoor patio when it is opened. This deficient practice had the potential for the glass to break when the bathroom door is opened, resulting in possible injury of residents and staff. Findings: During an observation, on 4/8/2022 at 7:59 a.m., observed bathroom door inside Resident 97's room hitting the sliding glass door to the outside patio. Observed door stop on the upper right corner of the bathroom door bend upon contact with the bathroom door. During an interview, on 4/8/2022 at 8:03 a.m., Resident 97 stated she always unintentionally hits the sliding glass door to the outside patio while opening the bathroom door. Resident 97 stated the door stopper is in place but it bends every time with contact when she opens the bathroom door, resulting in the bathroom door hitting the glass. Resident 97 stated staff…

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