Mission Carmichael Healthcare Center

Based on interview and record review, the facility failed to ensure residents receiving dialysis (treatment to remove extra fluid and waste when kidneys fail) received care and services consistent with professional standards of practice for one of 27 sampled residents (Resident 5) when Resident 5's fluid restrictions (limits in the total daily intake of liquids) were not followed per physician's order.This failure placed Resident 5 at high risk for fluid overload (too much fluid in the body that could cause swelling, high blood pressure, breathing problems, and heart issues).During a review of Resident 5's admission records, the records indicated Resident 5 was admitted to the facility in March 2026 with diagnoses that included end stage renal disease (permanent kidney failure) and dependence on renal dialysis. Resident 5's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 4/6/26, indicated Resident had intact cognition and did not exhibit behaviors of rejection of care.During a review of Resident 5's physician order, dated 4/23/26, the order 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 Certified Nursing Assistants (CNAs) had an annual performance review for three of three sampled CNA staff (CNA 3, CNA 4, and CNA 7).This failure had the potential for CNA 3, CNA 4, and CNA 7 to provide inadequate care to residents. Findings: During an interview on 5/21/26 at 1:13 p.m. with the Director of Staff Development (DSD), the DSD stated he was responsible for conducting the performance evaluation for the CNAs. The DSD further stated he had not conducted a performance evaluation since he started last December. During a concurrent interview and record review on 5/21/26 at 5 p.m. with the DSD, the Payroll Action Form for the 3 CNAs was reviewed. The Payroll Action Form indicated CNA 3 was hired on 12/12/23, CNA 4 was hired on 10/17/23 and CNA 7 was hired on 8/1/21. The DSD further stated he cannot find the annual performance evaluation for the 3 CNAs. During an interview on 5/22/26 at 10:28 a.m., with the Director of Nursing (DON), the DON stated the performance evaluation for CNAs was done annually and the DSD…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dental services was provided for one of 27 sampled residents (Resident 113) when Resident 113's lower denture was missing. This failure increased the potential for Resident 113 to experience difficulty in chewing and weight loss. A review of the admission Record indicated Resident 113 was admitted [DATE] with diagnoses including hypothyroidism (the thyroid gland [small, butterfly -shaped gland in the neck] does not produce enough thyroid hormones leading to extreme fatigue, unintentional weight gain, and feeling cold all the time) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). A review of Resident 113's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 3/31/26 indicated Resident 113 was cognitively intact with a Brief Interview for Mental Status (BIMS- an assessment tool to screen and identify…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 device was accessible for 1 of 27 sampled residents (Resident 142) when Resident 142 was not able to reach his call light device to call for assistance. This failure placed Resident 142 at risk for his care needs to be unmet and at increased risk for falls. A review of Resident 142's admission Record indicated Resident 142 was admitted to the facility in May 2026 with multiple diagnoses including gangrene and necrosis of lung (complication of pneumonia causing death of lung tissue), chronic obstructive pulmonary disease (COPD-damage to the airways or lungs that blocks airflow that makes it difficult to breathe), diabetes (too much sugar in the blood), vascular dementia (inadequate blood flow to the brain causing changes in thinking skills and memory), and protein-calorie malnutrition (inadequate intake of protein and calories). A review of Resident 142's Minimum Data Set (MDS- federally mandated assessment tool), Cognitive Patterns, dated 5/11/26, indicated Resident 142 had a Brief…

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

Based on observation, interview, and record review the facility failed to ensure 2 of 5 sampled residents (Resident 1 and Resident 2) were properly positioned during feeding assistance as per care plan and facility's meal assistance policy and procedure. This failure placed Resident 1 and Resident 2 at risk for aspiration and possible discomfort when eating. Findings: 1a. A review of Resident 1's admission record indicated Resident 1 was admitted in March 2025 with multiple diagnoses including COPD (a lung disease that makes it difficult to breathe) and GERD (Gastroesophageal reflux disease- a condition where stomach acid and food can flow backward from the stomach into the throat). A review of Resident 1's Minimum Data Set (MDS- an assessment tool), Cognitive Patterns, dated 3/28/25, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 6 out of 15 that indicated Resident 1 had severe cognitive impairment. A review of Resident 1's MDS, Functional Abilities and Goals, indicated Resident 1 required maximum assistance for rolling left…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure that discontinued non-controlled medications (pharmaceutical preparations that can only be obtained through a medical practitioner's prescription and dispensed by a pharmacist but are not considered controlled substances under the Controlled Substance Act) and those which remained in the facility after discharge of the patient were destroyed in the presence of two licensed nurses. This failure had the potential risk for diversion (deflection of prescription drugs from medical sources into the illegal market) and/or misuse of non-controlled medications. Findings: During a concurrent interview and record review on [DATE] at 4:22 p.m. with the Infection Preventionist (IP), the non-controlled medication disposition logbook was reviewed. The IP confirmed that the destruction of non-controlled medications was not being signed consistently by two licensed nurses on multiple dates and with multiple medications. Some of the documents reviewed had only…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medication administration practices when the facility's medication error rate was more than 5% (percentage- number or ratio that expressed as a fraction of 100) for a resident census of 125. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of two errors out of 30 opportunities which resulted in a facility wide medication error rate of 6.67% in two out of eight residents (Resident 96 and Resident 132) observed for medication administration. These failures had the potential for unsafe and ineffective medication use of Resident 96 and Resident 132 and had the potential to affect the residents' medical conditions. Findings: 1. During a concurrent medication administration observation and interview which started on 3/24/25 at 11:48 a.m. with Licensed Nurse (LN) 3, LN 3 stated she already checked Resident 96's blood sugar level, and it was 217. LN 3 then administered a total of seven units of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medications and supplies were properly labeled and stored in accordance with manufacturer's guidelines, the facility's policies and procedures, and accepted professional standards for a census of 125 residents when: 1. An unlabeled, opened glucose gel tube (a medication administered for low blood sugars) was found in medication cart North 3; 2. A discharged resident's medications were found loose in a bag in the medication room; and 3. The refrigerator in the North Medication Room was not within the correct temperature range. These failures had the potential to result in unsafe medication administration and drug diversion. Findings: 1. During a concurrent observation and interview on [DATE] at 10:03 a.m. with Licensed Nurse (LN) 2, a glucose gel tube was found in the top drawer of medication cart North-3. LN 2 confirmed the gel had been opened and there was no label which indicated the date it had been opened, or when it expired.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and ensure food safety in accordance with professional standards for food service safety to prevent an outbreak of foodborne illness for the census of 125 residents when: 1. Food items found in the freezer were unlabeled with the open and the use by dates. a. opened bag of garlic bread; b. opened box of pork sausage links with net weight of 10 lb.; and c. opened box of fish fillet with net weight of 15 lb. 2. Food items found in the walk-in refrigerator unlabeled with the open and use by dates. a. mustard (condiments) with net weight of 48 oz; and b. honey mustard (dressing) with net weight of 1 gal. 3. Food items found in the dry storage room were unlabeled and had lapsed use by dates. a. corn meal with use by date of 2/17/25; b. cake mix with use by date of 2/30/25; c. soy sauce with net weight of 1 gal, unlabeled with the open and the use by date; and d. white powder with unreadable name label, the open date and the use by date. 4. four (4) dented cans were found in the dry storage room: a. artichoke…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 3. Upon the Team's entrance on 3/24/25 at 8 a.m., the DON instructed all surveyors to wear masks as they have current residents with an active respiratory infection in the facility. The DON emphasized that all employees are required to wear masks to promote infection control and decrease transmission of respiratory infection. During a concurrent observation and interview at the North Station hallway with the NP on 3/25/25 at 11:25 a.m., the NP was not wearing a mask, stood across from the North Nurses Station while reading documents. The NP acknowledged she should wear a mask as required by the facility to promote infection control. In a review of the facility's P&P titled, Management of Respiratory Syncytial Virus (RSV, respiratory virus that infects the lungs and respiratory tract), date implemented 12/19/22, indicated, .3. Infection control principles will be followed to decrease the risk of transmission based on federal, state or local guidance. These principles include .d. Appropriate personal protective…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 call light system was accessible for five out of 29 sampled residents (Resident 122, Resident 75, Resident 55, Resident 27, and Resident 112) when: 1. Resident 122 and Resident 75's call light button was not within reach; 2. Resident 55's call light was broken; and, 3. Bathroom call system was not available for Resident 27 and Resident 112. These failures had the potential to result in residents' needs not being met and prevent communication for assistance when needed. Findings: 1a. A review of Resident 122's clinical record indicated Resident 122 was admitted August of 2024 and had diagnoses that included dementia (a progressive state of decline in mental abilities), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). A review of Resident 122's Minimum…

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

Based on interview and record review, the facility failed to ensure a baseline care plan was initiated within 48 hours of a resident's admission for one of 29 sampled residents (Resident 482), who was admitted to the facility with a peripherally inserted central catheter (PICC) line (a thin flexible tube inserted into a vein in the upper arm and threaded into a larger vein near the heart to deliver medications) for antibiotic (a class of medications used to treat bacterial infections) administration. This failure had the potential to compromise the residents' care and could have resulted in serious health complications. Findings: A review of the admission Record indicated the facility admitted Resident 482 on 3/4/25 with a PICC line and a diagnoses that included, septic arthritis (an infection of the joint caused by bacteria, viruses, or fungi) of the right knee. A review of the Nurses Progress Note dated 3/4/25 at 10:17 p.m., indicated Resident 482 arrived at the facility at approximately 6:30 p.m., With a diagnosis of septic arthritis to right knee, on intravenous (administered…

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

Based on interview and record review, the facility failed to ensure physician orders were followed in accordance with professional standards of care for one out of 29 sampled residents (Resident 49), when Resident 49 did not receive wound care treatments consistently as ordered. This failure had the potential for Resident 49's wounds to worsen and for the resident to not achieve their highest practicable well-being. Findings: Resident 49 was admitted to the facility in April 2024 with multiple diagnosis which included morbid obesity, venous insufficiency (condition where the veins in the legs do not function properly, allowing blood to flow backward instead of upward to the heart), and immunodeficiency (failure of the immune system to protect the body adequately from infection). During a review of Resident 49's Treatment Administration Records (TAR, a legal document used to record treatments given to the residents) for February 2025 and March 2025, Resident 49 had the following orders: TX (treatment): Coccyx (tailbone) wound cleanse with wound cleanser, pat dry apply collagen,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an ordered contracture device (a soft device that gently straighten fingers that have become stiff and painful) for one of 29 sampled residents, Resident 70. This failure had the potential to result in Resident 70 not reaching their highest practicable level of functioning. Findings: Resident 70 was admitted in 2023 with multiple diagnosis which included Contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion) to the left and right hands. During an observation on 03/25/25 at 10:23 a.m. in Resident 70's room, Resident 70's was seen lying in bed without her contracture device applied to right hand. During a concurrent observation and interview on 03/25/25 at 11:08 a.m. in Resident 70's room, with CNA 4 (Certified Nursing Assistant 4) Resident 70's right hand was observed without a contracture device. CNA 4 confirmed the contracture device was not applied to Resident 70's right hand. CNA 4 stated she is supposed to have devices on both hands and feet to avoid any…

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

Based on interview and record review, the facility failed to provide adequate services and assistance for prevention and/or early detection of possible urinary tract infection (UTI- an infection in the bladder/urinary tract) for one out of 29 sampled residents (Resident 84) when Resident 84's order for STAT (immediate) urinalysis (UA- a medical test that examines urine to check for various conditions, including urinary tract infections) was not done timely. This failure had the potential to result in delayed detection of a UTI subsequently causing delayed care and treatment which negatively affected Resident 84's health condition. Findings: A review of Resident 84's clinical record indicated Resident 84 was admitted November of 2022 and had diagnoses that included metabolic encephalopathy (a condition where the brain does not receive enough nutrients or oxygen to function properly, leading to altered brain function), UTI, sepsis (a life-threatening blood infection), extended-spectrum beta-lactamase (ESBL) resistance (and infection that is resistant to common antibiotics and may…

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

Based on observation, interview, and record review, the facility failed to ensure proper delivery of respiratory care consistent with the facility's policy and procedures (P&P) for one out of 29 sampled residents (Resident 4) when Resident 4's physician's order for oxygen therapy was not followed. This failure had the potential to result in unsafe delivery of oxygen to Resident 4 and for Resident 4 to not achieve her highest practicable well-being. Findings: A review of Resident 4's clinical record indicated Resident 4 was admitted March of 2025 and had diagnoses that included respiratory failure (is a serious condition that develops when the lungs can't get enough oxygen into the blood and makes it difficult for a person to breathe on his own), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently), asthma (a condition in which a person's airways become inflamed, narrow, and swell, and produce extra mucus, which makes it difficult to breathe), and need for assistance with personal care. A review of Resident 4's Minimum Data Set…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 irregularities reported by the pharmacist to the facility were acted upon for one out of 29 sampled residents (Resident 2). This failure put Resident 2 at an increased risk for developing adverse (unwanted, uncomfortable or dangerous) drug reactions related to medication therapy and had the potential for Resident 2 to not achieve their highest practicable physical, mental, and psychosocial well-being. Findings: Resident 2 was admitted to the facility in February 2025 with multiple diagnosis which included heart failure, depression, anxiety disorder, and myalgia (pain in a muscle or group of muscles). A review of Resident 2's Minimum Data Set (MDS, an assessment tool) dated 2/11/25, indicated, Resident 2 had intact cognition. During a review of Resident 2's Order Summary Report, dated 3/26/25, Resident 2 had an order for, Esomeprazole Magnesium [blocks acid from being made in the stomach] Oral Capsule Delayed Release 40mg [milligrams, measure of unit] Give 1 capsule by mouth one time a day for chronic N/V [nausea and…

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

Based on observation, interview and record review, the facility failed to ensure safe and sanitary practices were instituted for food brought in to residents by family or visitors from outside the facility when food saved for resident consumption was unlabeled and undated for 25 sampled residents. This failure had the potential to result in consumption of food that is unsafe and cause foodborne illness in residents who received food from outside sources. Findings: During an interview with the Dietary Manager (DM) on 3/26/25 at 12:20 p.m., the DM stated, nurses should label the food brought from home with the date received and the use by date to assure that the resident's food is safe to eat. A review of the facility's signage posted on the refrigerator's front door, undated, indicated, Please label the resident's food with the following details before putting it in the fried: [sic] Name and Rm# .Date Received .Used-by date (3 days from received). Any and all food items must have a date. Any food items that are not dated will be discarded. During a concurrent observation 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 provide appropriate treatment and services to maintain or improve mobility and prevent decline in range of motion (ROM) for one out of five sampled residents (Resident 5) when Resident 5's frequency for Physical Therapy Rehabilitation (therapy given to restore an individual back to their highest possible level of physical, mental, and psychosocial well-being) were not followed. This failure had the potential for Resident 5 to experience decline in range of motion or impairment in mobility. Findings: A review of Resident 5's clinical record indicated Resident 5 was admitted May of 2024 and had diagnoses that included polyosteoarthritis (a chronic condition that causes the cartilage and bone in joints to break down in at least five joints at the same time), fusion of spine (permanently joined two or more backbone), and chronic pain syndrome (a condition that occurs when chronic pain causes other symptoms that interfere with daily life). A review of Resident 5's Minimum Data Set (MDS- a federally mandated assessment tool)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medication administration to one resident (Resident 1) of two sampled residents when medications were left unattended at bedside. This decreased the facility's potential to ensure medications were safely ingested by the intended resident. Findings: A review of an admission record indicated Resident 1 was admitted to the facility in 2024 with diagnoses which included anxiety (a feeling of fear, dread, and uneasiness that can be a normal reaction to stress) and chronic pain syndrome (a condition that involves chronic pain that interferes with daily life and is accompanied by other symptoms). A review of Resident 1's care plan initiated on 7/31/24 indicated a focus on, Resident accusing NOC [nocturnal shift] nurse of not giving her medications that were scheduled . Licensed nurses were supposed to, increase communication between [Resident 1] .about care and living environment .Explain all procedures and .medications . A review of Resident 1's care plan initiated on 8/27/24 indicated a focus on,…

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

Based on observation, interview, and record review, the facility failed to protect one of two sampled residents (Resident 1) from physical abuse when Resident 2 hit Resident 1 with a cane. This failure resulted in Resident 1 sustaining injury and pain to the right lower leg . Findings: A review of Resident 1's admission Record indicated Resident 1 was most recently admitted to the facility in October 2023 with multiple diagnoses including paraplegia (paralysis of the legs), Stage 4 pressure ulcer (full thickness skin loss extending into deep tissues due to prolonged pressure to area) of the sacral region (bottom of the spine), diabetes (too much sugar in the blood), and dementia (loss of memory and thinking abilities). A review of Resident 1's Minimum Data Set (MDS- an assessment tool), Cognitive Patterns, dated 5/29/24, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 11 out of 15 which indicated Resident 1 had moderate cognitive impairment. A review of Resident 1's Change in Condition Evaluation, dated 8/25/24, 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 observation, interview, and record review, the facility failed to implement policies and procedures (P&P) for ensuring the reporting of a reasonable suspicion of abuse in accordance with section 1150B of the Act for one of five sampled residents (Resident 1) when Resident 1 alleged that a female staff grabbed him firmly on the right arm. This failure resulted in a delayed investigation of Resident 1's abuse complaint and had placed Resident 1 and other residents in the facility at risk for further abuse, and possible serious physical and/or psychosocial harm. Findings: A review of Resident 1's clinical record indicated Resident 1 was admitted January of 2024 and had diagnoses that included parkinsonism (a clinical syndrome characterized by tremor, slowed movement, rigidity, and postural instability), care provider dependency, weakness, and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest that can interfere with daily lives). A review of Resident 1's Minimum Data Set (MDS- an assessment tool used to guide care) Cognitive Patterns,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 hire a Director of Food and Nutrition Services who had the qualifications required. This had the potential of leading to food borne illness for the 124 residents eating facility prepared meals. Findings: During the initial kitchen tour on 3/18/24 at 8:38 a.m., there was not a certificate or degree in the Food and Nutrition Services office. In a subsequent interview with the Dietary Manager (DM) at 8:45 a.m., she stated that she had worked as the Food and Nutrition Services manager for the past year. She further explained that she had not yet completed the process to become a Certified Dietary Manager, nor had she received the required six hours of Title 22 instruction. During an interview on 3/19/24 at 9:08 a.m. with the Consultant Registered Dietitian (CRD) , she stated that her usual schedule was 35 hours per week. These hours were split between clinical nutrition and being a resource for the kitchen. She further explained that she does…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, and distribute food in accordance with professional standards for food service safety for a total of 124 residents who received facility prepared foods when: 1. Proper food labeling was not followed, 2. Expired foods were not discarded, 3. Perishable salads were not kept in safe food temperature range, 4. Foods were not kept covered while in storage, 5. Freezer had an ice drip from the fan onto the food box, 6. Cutting boards were found with debris on the cutting surface, and 7. Can opener tip was found rusted and missing metal. These failures had the potential to lead to food borne illness. Findings: 1. During the initial kitchen tour on 3/18/24 beginning at 8:38 a.m., the following items were observed not having proper labeling: - a container of graham crackers without year, label indicated, Prep Date 3-11, Use by 5-11 - two whipped toppings without year, labels for both items indicated, Prep Date 3-18, Use Date 3-20 - a tray of butterscotch pudding without year, label indicated, Prep Date…

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

Based on observation, interview, and record review, the facility failed to ensure three out of 43 sampled residents (Resident 91, Resident 4, and Resident 46) were assisted with nail care as part of their Activities of Daily Living (ADLs- normal daily functions required to meet basic needs) when; 1. Resident 91 had long fingernails with blackish substance underneath the fingernails; 2. Resident 4 had long fingernails with brownish substance underneath the fingernails; and, 3. Resident 46 had jagged fingernails with sharp edges with blackish substance underneath the fingernails. These failures had the potential for Resident 91, Resident 4, and Resident 46 to sustain injury and/or for the residents to acquire an infection. Findings: 1. A review of Resident 91's clinical record indicated Resident 91 was admitted August of 2021 and had diagnoses that included atherosclerotic heart disease (build-up of fats, cholesterol, and other substances in and on the artery walls causing obstruction of blood flow), diabetes mellitus (a chronic condition causing too much sugar in the blood 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.

Based on observation, interview, and record review, the facility failed to ensure that pharmacy services were maintained when controlled drug (medication that may be abused or cause addiction) record forms were inaccurately signed for a census of 126. The failure had the potential to result in diversion of the residents' medication. Findings: During a review of the controlled drug record forms for five discharged residents, under the section titled Disposition of Remaining Doses, there were two sections that the nurse who received the controlled medications could sign. The first section indicated, Doses Disposed and the second section indicated Doses discharged with Patient. Further review of the controlled drug forms indicated that the nurse received the controlled medications and signed the section indicating Doses discharged with Patient. During a concurrent observation and interview on 3/19/24 at 10:31 a.m., of the controlled medication storage in the Director of Nursing's (DON) office, the DON verified that the controlled drug record forms were signed in the wrong section 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 ensure medications were stored and labeled correctly, when: 1. Loose pills and were found in the South wing medication cart one. 2. Opened vials and one bottle of perishable medications were not dated with open or expiration dates in the North wing medication room. 3. Packets of medicated powder did not have an expiration date in the North wing treatment cart three. 4. Opened inhaler and glucose strips were not dated with open or expiration dates in the North wing medication cart three. 5. Expired and discontinued medications were in the North wing medication cart three. 6. A bag containing medications for a resident was found in the nursing office closet. 7. Prescription eye ointment was found in a resident's room at the bedside and was not labeled with an open date. These failures had the potential for medication misuse, drug diversion, and diminish the medication effectiveness. Findings: 1. During an inspection of medication cart one on the South wing with Licensed Nurse 1 (LN 1) on 3/18/24 at 12:40 p.m.,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to prepare foods that conserved nutritive value, flavor, and appearance; and served food at unappetizing temperatures. This had the potential of leading to poor intake, malnutrition and weight loss for the 124 residents eating facility prepared meals when: 1. Vegetables were heated for over 2 hours, 2. Pureed meals were prepared without measuring ingredients, and 3. Pureed food was prepared in a dirty food processor bowl. Findings: 1. During the initial kitchen tour on 3/18/24 at 9:12 a.m., the steamer doors were opened, and a large pan of green beans were being heated. During the dining observation on 3/18/24 at 12:08 p.m. the first cart of lunch trays exited the kitchen. Review of John Hopkins Medicine website on How to Keep the Nutrients in your Veggies indicated, Cooking decreases some of the nutrients in vegetables. Higher temperatures and longer cooking times are the two variables that can cause more nutrient loss. 2. During a return…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accommodate food allergies and food preferences for six of 43 sampled residents (Resident 100, Resident 26, Resident 34, Resident 57, Resident 97, and Resident 89). This had the potential of leading to allergic reactions (including death), as well as lead to poor intake and weight loss in the 124 residents receiving facility prepared meals. Findings: 1. Resident 100 was admitted in the middle of 2022 with diagnoses which included failure to thrive. During the lunch meal observation on 3/18/24 at 12:32 p.m., Resident 100 was unable to get coffee with his meal. He stated, As an American, usually we drink coffee and it has been scarce. The resident added, Sometimes I don't get ice cream. I prefer ice cream. Noted on the resident's meal tray was a piece of cake for dessert. On the meal card it indicated the resident's preference was ice cream. Licensed Nurse 13 (LN 13) brought Resident 100 two small cups of ice cream, and stated, So, the kitchen staff are supposed to know your preference for ice cream because it…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure an effective infection prevention and control program was followed and maintained for a census of 126 when: 1. A clean-linen delivery cart and two clean linen storage shelves were found with a thick layer of dusts in the laundry room; 2. A nasal cannula (oxygen tubing) had no labeled date for Resident 27; 3. An empty intravenous (IV) medication bag with no administration date and licensed nurse (LN) initial hanged in Resident 682's room; 4. An IV tubing was not labeled for Resident 131; 5. A urinary bag was found on the floor in Resident 19's room. These failures had the potential to result in the transmission of infection and cross-contamination in a vulnerable population. Findings: 1. During a concurrent observation and interview on 3/20/24, at 8:39 a.m., in the Laundry Room, with Laundry Staff (LS), the clean-linen delivery cart was stocked with clean linens and was found with thick layers of dust on its side corners. LS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 essential kitchen equipment (ice machine and oven) were in safe operating conditions. This had the potential of leading to food borne illness for the 124 residents eating facility prepared meals. Findings: During the initial kitchen tour on 3/18/24 at 8:52 a.m., the Maintenance Supervisor (MS) opened the ice machine to explain the cleaning process. He stated that the ice machine had problems with randomly shutting off. During the initial kitchen tour on 3/18/24 at 9:33 a.m., the right side of the oven was not working. During a revisit to the kitchen on 3/19/24 at 9:45 a.m. to observe lunch preparation, the survey team requested to calibrate our thermometers with the facility's. [NAME] 1 (CK 1) stated that she would be unable to use the ice bath method as the ice machine is not working again today. During a revisit to the kitchen on 3/19/24 at 10:14 a.m., CK 1 reported she had to change meal preparation and timing due to the right side of oven not working. Review of the US Food and Drug Administration'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 the right for privacy and dignity was promoted to maintain the resident's self-worth for one of 43 sampled residents (Resident 33), when the privacy curtains were not pulled, or the door not closed during resident care. This failure resulted in not attaining or maintaining the resident's highest practicable physical, mental, emotional, and psychosocial well-being. Findings: Resident 33 was admitted to the facility in early 2023 with diagnoses which included memory impairment and muscle weakness. During a review of Resident 33's Nursing Care Plan (NCP), dated 11/24/23, the NCP indicated, [Resident 33] is dependent on staff for meeting emotional, intellectual, physical, and social needs. During a review of Resident 33's Minimum Data Set (MDS, an assessment tool), dated 2/21/24, the MDS indicated Resident 33 had severe memory impairment and had been totally dependent on staff for all activities of daily living (ADLs). During an observation on 3/21/24 at 10:18 a.m. in Resident 33's room, two staff members…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accommodate the needs for two of 43 sampled residents (Resident 588, Resident 28) when: 1. Resident 588's call light button was not within reach; and 2. Resident 28 was not assessed and provided with the appropriate call light type to call staff when needed. These failures resulted in the residents' not attaining their needs and not maintaining their highest practicable physical, mental, emotional, and psychosocial well-being. Findings: During a review of an admission Record, Resident 588 was admitted to the facility on [DATE] with diagnoses of Malignant Neoplasm of lung (lung cancer) and Secondary malignant neoplasm of brain (brain cancer). During a review of Resident 588's Nursing Care Plan (NCP) titled, Falls/ADLs/Mobility, dated revision of 3/18/24, the care plan indicated Place the resident's call light within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a comprehensive assessment was performed in accordance with the regulatory time frame for one of 43 sampled residents (Resident 681), when the admission MDS (Minimum Data Set, an assessment tool) was not completed. This failure had the potential to result in the resident not attaining the highest practicable physical, mental and psychosocial well-being. Findings: Resident 681 was admitted in late 2018 with diagnoses which included stroke, muscle weakness, malnutrition, and difficulty swallowing. During a review of Resident 681's MDS, dated [DATE], the MDS indicated the assessment was incomplete, still in progress, and overdue. During a concurrent observation and interview on 3/18/24 at 10:23 a.m., Resident 681 was in bed, alert and verbal but minimally responsive, and stated, I am just new here. Let me go back to sleep. During a concurrent observation and interview on 3/19/24 at 7:15 a.m., Resident 681 was in bed, awake and verbally…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 baseline care plan (BCP, document that outlines initial care needs) for two of 43 sampled residents (Resident 681 and Resident 6) when the BCP was not completed within 48 hours after the resident's admission. This failure had the potential to place the residents at risk for unmet care needs. Findings: 1. Resident 681 was admitted in late 2018 with diagnoses which included stroke, muscle weakness, malnutrition, and difficulty swallowing. During a review of Resident 681's Nursing Care Plan (NCP), dated 3/4/24, the NCP indicated, Malnourished .complete mini nutritional evaluation. Evaluate for signs of impaired swallowing. During a review of Resident 681's Minimum Data Set (MDS, an assessment tool), dated 3/5/24, the MDS indicated the assessment was incomplete, still in progress, and overdue. During a review of Resident 681's Baseline Care Plan (BCP), dated 3/15/24, the BCP indicated the Dietary/Nutritional Status section had no…

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

Based on interview, and record review, the facility failed to provide appropriate treatment and services to maintain or improve mobility and prevent decline in range of motion (ROM) for two out of 43 sampled residents (Resident 107 and Resident 44) when Resident 107 and Resident 44's restorative nursing program (RNA program- interventions that actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning) frequency was not followed. This failure had the potential for Resident 107 and Resident 44 to experience decline in range of motion or impairment in mobility. Findings: 1a. A review of Resident 107's clinical record indicated Resident 107 was admitted October of 2023 and had diagnoses that included wedge compression fracture of vertebra (collapse of a bone in the front of the spine which can lead to loss of strength, sensation, and/or reflexes), multiple fractures on bilateral (both sides) ribs, and muscle weakness. A review of Resident 107's Minimum Data Set (MDS- an assessment tool used to guide care) Cognitive Patterns, dated 1/13/24,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 environment was free from accident hazards, for one of 43 sampled residents (Resident 57), when there was an uneven pathway leading to, from and inside the designated smoking area. This failure resulted in Resident 57 feeling unsafe navigating the pathway to the smoking area and had the potential to result in accidents and injuries. Findings: Resident 57 was admitted to the facility in late 2019 with diagnoses of Spinal Stenosis (narrowing of the spinal canal), abnormalities of gait and mobility and Major Depressive Disorder (feelings of sadness and/or loss of interest in daily activities). Review of the clinical record for Resident 57 included: A Minimum Data Set (MDS- an assessment tool), dated 12/25/23, indicated Resident 57 had no memory impairment. A smoking safety assessment, dated 1/3/24, indicated safety concerns for Resident 57 included her impaired gait and balance. During an interview with Resident 57, on 3/18/24 at 12:01 p.m., she stated, I feel unsafe with the cracks in the sidewalks…

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

Based on observation, interview, and record review, the facility failed to ensure proper delivery of respiratory care was consistent with the facility's policy and procedures (P&P) and the professional standards of practice for one out of 43 sampled residents (Resident 18) when Resident 18's physician's order for oxygen therapy was not followed. This failure had the potential to result in unsafe delivery of oxygen to Resident 18 that could lead to respiratory problems. Findings: A review of Resident 18's clinical record indicated Resident 18 was originally admitted March of 2016 and had diagnoses that included chronic obstructive pulmonary disease (COPD- a group of diseases that causes airflow blockage and breathing-related problems), respiratory failure ( a serious condition that develops when the lungs can't get enough oxygen into the blood and makes it difficult for a person to breathe on his own), and dementia (impairment of the ability to remember, think, or make decisions that interferes with everyday activities). A review of Resident 18's Minimum Data Set (MDS- an assessment…

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

Based on observation, interview, and record review, the facility failed to ensure clinical records were complete and accurate for one of three sampled residents, (Resident 1). This failure had potential to result in under- and over-medicating a resident for pain. Findings: During an interview on 3/5/24 at 2:30 p.m. with Resident 1, Resident 1 stated on Friday night 3/1/24, she had pain seven-eight (7-8)/10 (pain scale with 10 being the most pain) in right knee, and pressed the call light at 3 a.m. In between 3:30 a.m. and 4 a.m., a nurse came in with two Tylenol® (a medication commonly used for pain relief) pills, did not turn on the light, did not offer Resident 1 water, and turned off the call light. Resident 1 further stated she did not know the name of the nurse and described them as an African American nurse. A review of Resident 1's Medication Administration Record (MAR), dated March 2024, indicated on 3/1/24, for 3 a.m. to 4 a.m. administration time, the licensed nurse did not sign the administering Tylenol® to Resident 1 for pain. A review of Resident 1's Case Management…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident call system was functioning for three residents out of 65 sampled residents (Resident 1, Resident 2, and Resident 3). This failure decreased the potential for the residents to get assistance from staff in a timely manner. Findings: During an observation on 3/5/24 at 12:30 p.m. in the North Hall, a light outside room number one above the door was lit up red. At the nurse's desk, the resident call system was not working for room number one. During an Interview on 3/5/24 at 12:34 p.m. with Infection Preventionist (IP) Nurse at the nurse's desk in North Hall, IP Nurse verified the resident call system for room number one was not working and mentioned to notify the maintenance person. IP stated she was not aware of how long it had not been working. During an observation on 3/5/24 at 12:40 p.m. in the North Hall, a light outside room [ROOM NUMBER] above the door was lit red. At the nurse's desk, the resident call system did…

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