Chatsworth Park Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to reconcile (the process of comparing transactions and activity to supporting documentation) eight (8) medication emergency kit (eKIT) containing Controlled Medications ([CM] - medications which have a potential for abuse and may also lead to physical or psychological dependence, also known as Controlled Drugs or Controlled Substances [CS]) for 4/2025, in one (1) of one (1) inspected medication room (Medication room [ROOM NUMBER].) As a result, control and accountability of medications and CMs did not follow state and federal regulations and facility policy and procedures. This deficient practice increased the opportunity for CM diversion (the transfer of a controlled medication or other medication from a lawful to an unlawful channel of distribution or use,) and the risk that residents in the facility could have adverse drug reactions [unwanted, uncomfortable, or dangerous effects that a medication may have, such as coma (a state of deep unconsciousness)…

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

Based on observation, interview, and record review, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injuries (PI/PU, injuries to the skin and underlying tissue resulting from prolonged pressure) by failing to follow physician's order to apply heel protectors while in bed for one of one sampled resident (Resident 4). This deficient practice had the potential for the worsening of or the development of PI/PU. Findings: During a review of Resident 4's admission Record, the admission Record indicated the facility admitted Resident 4 on 10/23/2024 with diagnoses that included, but not limited to palliative care (specialized medical care that focuses on providing relief from pain and other symptoms of a serious or life-threatening illness), polyneuropathy (disease or dysfunction of one or more peripheral nerves [nerves located outside of the brain and spinal cord], typically causing numbness or weakness), and heart failure (a condition where the heart is unable to pump blood effectively enough to meet the body'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 maintain the safety of residents by failing to ensure Resident 1's bed brake lock was engaged. This deficient practice placed Resident 1 at risk for injury. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 4/13/2020 and re-admitted the resident on 6/15/2024, with diagnoses that included failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity). During a review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 3/12/2025, the MDS indicated Resident 1 was severely 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 1 was dependent on staff for showering, toileting, dressing, and personal hygiene. During a review of Resident 1's Care Plan 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 a resident's indwelling catheter (a tube that is inserted into the bladder, allowing urine to drain) did not have a loop or kink (unwanted twist or bend) for one of one sampled resident (Resident 15). This deficient practice had the potential for the resident to develop a urinary tract infection (UTI- an infection in any part of the urinary system). Findings: During a review of Resident 15's admission Record, the admission Record indicated the facility admitted Resident 15 on 7/11/2021 and readmitted the resident on 2/7/2025 with diagnoses that included, but not limited to palliative care (specialized medical care that focuses on providing relief from pain and other symptoms of a serious or life-threatening illness), dementia (a progressive state of decline in mental abilities), and history of falling. During a review of Resident 15'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…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to follow professional standards of practice by failing to administer an intravenous (IV - into or through the vein) antibiotic (a medication that kills or stops the growth of bacteria) at the rate ordered by the physician for one of one resident (Resident 57) during a random observation. This failure had the potential to increase the risk of Resident 57 experiencing adverse (undesirable outcome) effects such as fluid overload (too much fluid volume in the body), infiltration (an IV fluid or medication leaks from the vein into the surrounding tissue), pain and phlebitis (inflammation of the vein). Findings: During a review of Resident 57's admission Record, the admission Record indicated the facility admitted Resident 57 on 11/10/2024 and readmitted on [DATE] with diagnoses including dysphagia (difficulty swallowing), heart failure (a condition where the heart is unable to pump blood effectively enough to meet the body's needs), unspecified…

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

Based on interview and record review, the facility failed to ensure the hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) center completed a post-dialysis assessment (evaluation done after hemodialysis by the hemodialysis licensed nurses) by failing to: 1. Follow up with the dialysis center when there was no documentation of the resident's post dialysis weight. 2. Follow up with the dialysis center when a resident's weight is staying the same or increasing after dialysis treatments (it is usual for a resident's weight to be slightly reduced after dialysis since some fluid is removed). for one (Resident 59) of two sampled residents upon returning to the facility from a dialysis session. This deficient practice had the potential for Resident 59 to have unidentified complications after dialysis treatment such as abnormal vital signs (pulse rate, temperature, respirations, and blood pressure, that indicate the state of a patient's essential body functions). Findings: During a review of Resident 59'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 ensure licensed nurses attempted non-pharmacological interventions (any type of healthcare intervention which is not primarily based on medication) prior to administering as needed (prn) alprazolam (medication used to treat anxiety disorder [intense, excessive, and persistent worry and fear about everyday situations]) to one of five residents reviewed for unnecessary medications (Resident 31). This deficient practice had the potential to place the resident at increased risk of experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention) from alprazolam. Findings: During a review of Resident 31's admission Record, the admission Record indicated the facility originally admitted the resident on 2/04/2025 and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD- a lung disease that makes breathing difficult) and muscle weakness. During a review of Resident 31's Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation interview and record review the facility failed to ensure residents were free of any significant medication errors by failing to administer an intravenous (IV - into or through the vein) antibiotic (a medication that kills or stops the growth of bacteria) at the rate ordered by the physician for one of one resident (Resident 57) during a random observation. This failure had the potential to increase the risk of Resident 57 experiencing adverse (undesirable outcome) effects such as fluid overload (too much fluid volume in the body), infiltration (an IV fluid or medication leaks from the vein into the surrounding tissue), pain and phlebitis (inflammation of the vein). Cross reference F694 Findings: During a review of Resident 57's admission Record, the admission Record indicated the facility admitted Resident 57 on 11/10/2024 and readmitted on [DATE] with diagnoses including dysphagia (difficulty swallowing), heart failure (a condition where the heart is unable to pump blood effectively enough…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to store and label one (1) Aplisol (medication used to diagnose tuberculosis [infection in the lungs]) vial in the refrigerator, in accordance with manufacturer's requirements and facility policy and procedures in one (1) of one (1) inspected medication rooms (Medication room [ROOM NUMBER].) This deficient practice increased the risk to residents in the facility to receive medication that had become ineffective or toxic due to improper storage or labeling, possibly leading to inaccurate treatment for tuberculosis (a contagious bacterial disease that's usually spread through the air when someone with tuberculosis coughs, sneezes, or spits) resulting in hospitalization or death. Findings: During an observation on [DATE] at 12:54 p.m., with Registered Nurse (RN) 1, in Medication room [ROOM NUMBER] there was one (1) open vial of Aplisol for facility stock found stored in the refrigerator without a label indicating when storage or use began.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 nasal cannula (a medical device that delivers supplemental oxygen therapy to people with low oxygen levels) oxygen tubing was not touching the floor for one of one sampled resident (Resident 66). This deficient practice had the potential to result in contamination of the resident's care equipment and risk of transmission of bacteria that can lead to infection. Findings: During a review of Resident 66's admission Record, the admission Record indicated the facility originally admitted the resident on 10/24/2024 and readmitted the resident on 10/10/2024 with diagnoses including dysphagia (difficulty swallowing) and anemia (a condition in which the blood doesn't have enough healthy red blood cells). During a review of Resident 66's Minimum Data Set (MDS - a resident assessment tool), dated 3/11/2025, 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 antibiotic stewardship program by failing to conduct infection surveillance and complete the infection control reporting form once a resident was prescribed an antibiotic for one (Resident 57) of one resident investigated who was prescribed an antibiotic. This deficient practice had the potential for Resident 57 to develop antibiotic resistance from unnecessary or inappropriate antibiotic use for future infections. Findings: During a review of Resident 57's admission Record, the admission Record indicated the facility admitted Resident 57 on 11/10/2024 and re-admitted the resident on 4/06/2025 with diagnoses including osteomyelitis of vertebra, sacral and sacrococcygeal region (inflammation of bone or bone marrow, usually due to infection, in the lower back and tailbone). During a review of Resident 57's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 4/10/2025, the MDS indicated Resident 57 was severely impaired in cognition (the process of acquiring knowledge and understanding…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents' attending physician documented residents' History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of findings) in a timely manner per the facility's policy and procedure for three out of three sampled residents (Resident 2, Resident 4, and Resident 5). This deficient practice had the potential for inconsistent care coordination due to incomplete records for Resident 2, Resident 4, and Resident 5. Findings: a. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident on 12/7/2024 with diagnoses of, but not limited to, fracture (break in the bone) of the right femur (thigh bone), presence of right artificial hip joint, and pneumonitis (swelling of the lung tissue). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 12/11/2024, the MDS indicated the resident…

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

Based on interview and record review, the facility failed to implement the facility's theft and loss policy by failing to document a resident's lost jewelry on the facility's theft and loss report form for one of three sampled residents (Resident 1). This deficient practice violated the resident's right to have Resident 1's property protected and conserved. Findings: During review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 2/27/2014 with diagnoses of major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest) and essential hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 10/31/2024, the MDS indicated the resident had intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). During a review of the facility's Theft and Loss Log, the document indicated no theft…

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

Based on interview and record review, the facility failed to ensure the Discharge Summary was accurate and complete for one of three sampled residents (Resident 2). This deficient practice had the potential to lead to confusion about Resident 2's discharge status and a delay in attaining services needed for Resident 2 after discharge. Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident on 12/7/2024 with diagnoses of, but not limited to, fracture (break in the bone) of the right femur (thigh bone), presence of right artificial hip joint, and pneumonitis (swelling of the lung tissue). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 12/11/2024, the MDS indicated the resident had intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). During a review of Resident 2's Progress Note dated 12/12/2024 at 2:48 p.m., the progress note indicated Resident 2 was adamant about leaving the facility and being…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pain medication as ordered by the physician and follow the physician's order for pain medication parameters (a set of defined limits) for one (1) of three (3) sampled residents (Resident 2). This deficient practice had the potential to result in Resident 2 being overmedicated and experience an adverse reaction (undesired harmful effect resulting from a medication or other intervention). Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident on 12/7/2024 with diagnoses of, but not limited to, fracture (break in the bone) of the right femur (thigh bone), presence of right artificial hip joint, and pneumonitis (swelling of the lung tissue). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 12/11/2024, the MDS indicated the resident had intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). During a review of Resident 2's Order…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a resident received their prescribed amoxicillin-pot clavulanate (antibiotic- used to treat many different infections caused by bacteria) in a timely manner as ordered by the physician for one of three sampled residents (Resident 2). This deficient practice resulted in the delay of medication administration of an antibiotic which had the potential to cause bacteria to reproduce. Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident on 12/7/2024 with diagnoses of, but not limited to, fracture (break in the bone) of the right femur (thigh bone), presence of right artificial hip joint, and pneumonitis (swelling of the lung tissue). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 12/11/2024, the MDS indicated the resident had intact cognition (the mental action or 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 2) received treatment and care in accordance with the physician's order by failing to continue Resident 2's daily probiotic (live microorganisms intended to maintain or improve the good bacteria in the body) as ordered by the physician. This deficient practice resulted in Resident 2 not receiving their probiotic as ordered by the physician and had the potential to affect Resident 2's health. Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 9/14/2023 with diagnoses that included Parkinson's disease (a movement disorder of the nervous system that worsens over time), bipolar disorder (mental disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks), and encounter for surgical aftercare following surgery on the digestive system. During a review of Resident 2's History and Physical (H&P- a formal assessment by a healthcare provider…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one of three sampled residents (Resident 1) copies of Resident 1's clinical records to Resident 1's representative upon written request. This deficient practice violated the rights of Resident 1's representative to obtain copies of Resident 1's clinical records when requested. Findings: During a review of Resident 1's admission Record indicated the facility admitted the resident on 9/14/2023 with diagnoses that included Parkinson's disease (a progressive disease of the nervous system marked by tremor [shaking or trembling movements], muscular rigidity, and slow, imprecise movements) and bipolar disorder (a mental illness that causes unusual shifts in mood). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 12/2/2024, 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 moderately impaired. The MDS further indicated that the resident needed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 call light (a device used by a resident to signal his/her need for assistance from staff) was within reach for one of three sampled residents (Resident 2). This deficient practice had the potential to delay the provision of services and residents' needs not being met. Findings: During a review of Resident 2 ' s admission Record, the admission Record indicated the facility admitted the resident on 7/11/2021 with diagnoses that included dementia (a progressive state of decline in mental abilities) and cerebral infarction (also known as a stroke, refers to damage to tissues in the brain due to a loss of oxygen to the area). During a review of Resident 2 ' s Minimum Data Set (MDS – a resident assessment tool) dated 10/1/2024, the MDS indicated Resident 2 sometimes made self-understood and sometimes had the ability to understand others, and Resident 2 ' s cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was severely…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and revise a comprehensive person-centered care plan (a plan for an individual's specific health needs and desired health outcomes) for one of three sampled residents (Resident 3) by failing to ensure Resident 3 was provided with bilateral (both sides) floormats (padding placed on the floor to help prevent injuries related to falls) and was monitored for placement. This deficient practice had the potential to negatively affect the delivery of care and services to Resident 3 and miscommunication among the care team regarding the resident ' s needs. Findings: During a review of Resident 3 ' s admission Record indicated the facility admitted the resident on 11/25/2024 with diagnoses that included Huntington ' s disease (HD - inherited brain disorder that causes nerve cells to break down, leading to a variety of symptoms included uncontrolled movements), epilepsy (a disorder of the brain characterized by repeated seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause…

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

Based on interview and record review, the facility failed to ensure the facility provided transportation for one of two sampled residents (Resident 4) who had an appointment on 10/28/2024. This deficient practice resulted in Resident 4 missing his scheduled appointment on 10/28/2024 and had the potential for Resident 4 to not attain his highest practicable physical well-being. Findings: During a review of Resident 4's admission Record, the admission Record indicated the facility originally admitted Resident 4 on 4/28/2018 and readmitted Resident 4 on 12/6/2020 with diagnoses that included polyneuropathy (disease or dysfunction of one or more peripheral nerves [nerves located outside of the brain and spinal cord], typically causing numbness or weakness), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and bipolar disorder (mental disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks). During a review of Resident 4's Minimum Data Set (MDS- a resident 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure dialysis (the removing of waste and excess fluid to prevent build up in the body for residents who have loss of kidney [organs that remove waste products from the blood and produce urine] function) residents received care in accordance with standards of practice for two of three sampled residents (Resident 2 and Resident 3) by: 1. Failing to complete a post-dialysis assessment for Resident 2 on 10/28/2024. 2. Failing to assess Resident 3's dialysis access site (way to reach the blood for dialysis) after returning from dialysis on 10/28/2024 and 11/4/2024. These deficient practices placed Residents 2 and 3 at risk for complications of dialysis such as redness at the dialysis access site, edema (too much fluid trapped in the body's tissues), excessive bleeding, and a change in vital signs (clinical measurements that indicate the state of a resident's essential body functions). Findings: a. During a review of Resident 2's admission Record, the…

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

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 allegation of physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) within two (2) hours of the incident for one of four 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: During a review of Resident 1's admission Record indicated the facility originally admitted Resident 1 on 3/21/2023 and readmitted on [DATE] with diagnoses that included end stage renal (the kidney) disease (ESRD - irreversible kidney failure) and dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that one of four sampled residents ( Resident 2), who was experiencing significant weight loss (when a resident experiences unplanned and undesired weight loss of five percent [%-unit of measure] total weight in a one-month period) and severe weight loss(when a resident experiences unplanned and undesired weight loss of 10% in six months), was weigh weekly as per facility policy and procedure. This deficient practice placed Resident 2 at increased risk for undetected weight loss. Findings: During a review of Resident 2's admission Record, the admission Record indicated that Resident 2 was admitted to the facility on [DATE], with diagnoses that included orthostatic hypotension (a condition where blood pressure drops when standing or sitting up), intestinal obstruction (blockage of the tube-shaped organ) and Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements). During a review of Resident 2'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: 1. Notify the physician for one of four sampled residents (Resident 1) when Resident 1 verbalized getting skin reaction from the blood pressure cuff (a medical device used to measure blood pressure by wrapping it around the upper arm and inflating it). 2. Notify the physician for one of four sampled residents (Resident 1's) refusal to take her Furosemide (a medication used to treat fluid retention and swelling caused by certain disease or medical conditions) medication. This deficient practice placed Resident 1 at risk for swelling of extremities caused by fluid retention, increase blood pressure (the force of your blood pushing against the walls of your arteries [artery - a blood vessel that carries blood from the heart to tissues and organs in the body]) and electrolyte imbalances (occurs when you have too much or not enough of certain minerals [a nutrient that is needed in small amounts to keep the body healthy] in your body). Findings: During a review of Resident 1's admission Record indicated the facility originally…

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

Based on interview and record review, the facility failed to provide pharmaceutical services that assured the accurate administration of Sinemet (medication used to treat symptoms of Parkinson's disease [a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination]) and Midodrine (used to treat low blood pressure when standing up from a sitting position or when already standing) for one of eight sampled residents (Resident 1). This deficient practice had the potential to result in ineffective treatment and management of Resident 1's Parkinson's disease and hypotension (low blood pressure). Findings: During a review of Resident 1's admission Record indicated the facility admitted the resident on 9/14/2023 with diagnoses that included Parkinson's disease and orthostatic hypotension (a condition where blood pressure drops when standing up from a sitting or lying position). During a review of Resident 1's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 6/6/2024, indicated Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who is incontinent (having no or insufficient voluntary control) of bladder and bowel (B&B) function, receives appropriate care and services to prevent urinary tract infection (UTI- an infection in any part of the urinary system) for one of seven sampled residents (Resident 3) by failing to implement its policy and procedures (P&P) on Perineal (the area of the body between the anus and the genitals) Care when two Certified Nursing Assistants (CNA 2 and CNA 3) used a soiled towel to wipe the perineal area and did not rinse the perineal area while providing perineal care. This deficient practice had the potential to result in urinary tract infection, skin irritation and unpleasant odor. Findings: During a review of Resident 3's admission Record indicated the facility admitted the resident on 7/18/2021 and readmitted on [DATE] with diagnoses that included UTI. During a review of Resident 3's Minimum Data Set (MDS- a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement infection control practices by failing to ensure two of two sampled staff (Certified Nursing Assistant 2 [CNA 2] and CNA3) performed hand hygiene (HH - cleaning hands by either washing with soap and water, or by using a hand sanitizing [removing germs] gel) after providing Resident 3's perineal (the area of the body between the anus and the genitals) care and before touching Resident 3's body to fix the resident's position while in the bed. These deficient practices had the potential to result in the spread of infection placing residents, staff, and visitors at risk to be infected with germs. Findings: During a review of Resident 3's admission Record indicated the facility admitted the resident on 7/18/2021 and readmitted on [DATE] with diagnoses that included urinary tract infection (UTI- an infection in any part of the urinary system). During a review of Resident 3's Minimum Data Set (MDS- a standardized assessment and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain a written order from a physician to provide Physical Therapy (PT- used to preserve, enhance, or restore movement and physical function impaired or threatened by disease, injury, or disability and that utilizes exercise, physical modalities [uses transmission of energy to or through the resident], assistive devices [tools, products or types of equipment that help a resident perform tasks and activities], and resident education and training) for one of six sampled residents (Resident 1). This deficient practice had the potential to result in negative physical outcome. Findings: A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (a common lung disease causing restricted airflow and breathing problems). A review of Resident 1's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening 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 observation, interview, and record review, the facility failed to implement infection control practices by failing to ensure Licensed Vocational Nurse 1 (LVN 1) performed hand hygiene (HH- washing of hands with water and soap or applying an alcohol-based hand rubs) for one of four sampled residents (Resident 1) on 6/27/2024 after touching Resident 1 with bare hands to check the resident's identification band and blood pressure (the pressure of circulating blood against the walls of blood vessels). This deficient practice had the potential to spread the infection and cross contamination (the physical movement or transfer of harmful bacteria [germs] from one person, object, or place to another) among residents. Findings: A review of Resident 1's admission Record indicated the facility originally admitted Resident 1 on 10/19/2021 and readmitted on [DATE] with diagnoses including heart failure (a condition that develops when the heart does not pump enough blood to support the needs of the body) 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 ensure that six of six residents (Residents 123, 102, 60, 32, 48, and 67) interviewed during the Resident Council Meeting (a group of nursing home residents who meet regularly to discuss their rights, quality of care, and quality of life) were aware of how to contact the State Survey Agency (the department) to file a complaint. This deficient practice had the potential to deprive the residents of assistance from resident advocacy groups should unresolved issues arise in the facility. Findings: A review of Resident 123's admission Record indicated the facility originally admitted the resident on 5/24/2022 and readmitted the resident on 10/8/2023 with diagnoses including end stage renal disease (when the kidneys can no longer function on their own to meet the body's needs). A review of Resident 123's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/29/2024, indicated the resident severely impaired…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide care in accordance with professional standards by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) administration sites of insulin (a hormone that lowers the level of sugar in the blood) for one of two sampled residents (Resident 69) investigated under insulin. The deficient practice had the potential for adverse effects (undesired harmful effect resulting from a medication or other intervention) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (a rare disease that occurs when a protein called amyloid builds up in organs). Findings: A review of Resident 69's admission Record indicated the facility admitted the resident on 6/11/2023 with diagnoses including type two (2) diabetes mellitus (a chronic condition that affects the way the body processes blood glucose [sugar]) and heart…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Ensure one of one sampled resident (Resident 67) received morning medications scheduled for 9 a.m. on time and not given at 11:15 a.m. These deficient practices resulted in the omission of medications, receiving medications before they are due, or giving medications after they are due which could have resulted in severe health complications. 2. 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 Records (MAR) for two of five sampled residents (Resident 44 and 48). These deficient practices had the potential to result in medication error and/or drug diversion (illegal distribution or abuse of prescription drug). Findings: 1. A review of Resident 67's admission Record indicated the facility admitted the resident on 9/20/2022 with diagnoses that included hypertension (high blood pressure [the force of the blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure psychotropic drugs (any medication capable of affecting the mind, emotions, and behavior) were not used unnecessarily for one of six sampled residents (Resident 56) when receiving a duplicate therapy of Zyprexa (antipsychotic- a medication used to treat psychosis [a mental condition in which thought, and emotions are so affected that contact is lost with external reality]) at nighttime for 41 days. 2. Address a resident's behavior of physical/verbal aggression due to complaints of her room being too cold with non-pharmacological interventions (non-invasive actions that can prevent, treat, or cure health problems without medication) prior to administering as needed (prn) haloperidol (antipsychotic medication) for one (Resident 106) out of six sampled residents investigated under the care area of unnecessary medications. 3. Ensure that the administration of prn lorazepam (medication used to treat anxiety [intense, excessive, and persistent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. A review of Resident 106's admission Record indicated the facility admitted the resident on 12/25/2023 with diagnoses that included hyperlipidemia (abnormally high concentration of fats in the blood), dementia (progressive impaired ability to think, remember or make decisions that interferes with doing everyday activities), and difficulty in walking. A review of Resident 106's MDS dated [DATE], indicated Resident 106 had severely impaired cognition. A review of Resident 106's Change in Condition Evaluation, dated 4/7/2024 at 7:55 a.m., indicated the resident was verbally and physically aggressive and Resident 106's primary physician renewed Resident 106's previous Haldol order. A review of Resident 106's discontinued physician orders indicated the last order for Haldol injection solution for agitation manifested by physical and verbal aggression was ordered on 3/12/2024 for 14 days. During an interview on 4/15/2024 at 3:45 p.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated the medical intervention…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complete and accurate medical records for one of four sampled residents (Resident 12) by failing to document wound care treatments conducted on Resident 12 in Resident 12's Treatment Records (TAR, a legal document indicating the dates a treatment was conducted for a resident) for 1/2024. This deficient practice had the potential to result in confusion regarding Resident 12's condition and what care and services were provided to Resident 12. Findings: A review of Resident 12's Face Sheet indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included dysphagia (difficulty swallowing) and a gastrostomy tube (G-tube, a plastic tube inserted into one's stomach to administer medications and nutrition for those having trouble with swallowing). A review of Resident 12' s Minimum Data Set (MDS - an assessment and screening too), dated 2/06/2024, indicated Resident 12 was severely impaired 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 rightfully inform in advance of the risks and benefits of the proposed plan in medication for two of eight sampled residents (Resident 106 and 56) by failing to: 1. Obtain an informed consent (a process in which patients are given important information, including possible risks and benefits, about a medical procedure or treatment) when Resident 106's Seroquel (antipsychotic- a medication used to treat psychosis [a mental condition in which thought, and emotions are so affected that contact is lost with external reality]) dosage was increased. This deficient practice violated the resident's and his/her representative's right to make an informed decision regarding the use of an antipsychotic medication. 2. Obtain an informed consent when Resident 56's Zyprexa (antipsychotic medication) dosage was increased. These deficient practices violated the resident's and his/her representative's right to make an informed decision regarding the use of 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 interview and record review, the facility failed to develop a baseline care plan (a written document that summarizes a patient's needs, goals, and care) within 48 hours of admission for one of one sampled resident (Resident 378) who tested positive for coronavirus disease -2019 (COVID-19, a highly contagious viral infection that can trigger respiratory tract infection). This deficient practice had the potential to result in a negative impact on residents' health and safety, as well as the quality of care and services received. Findings: A review of Resident 378's admission Record indicated the facility admitted the resident on 4/10/2024 with diagnosis including COVID-19. A review of Resident 378's History & Physical indicated Resident 378 had the capacity to understand and make decisions. A review of Resident 378's Order Summary Report dated 4/10/2024, indicated Resident 378 was on transmission-based precautions (steps taken to prevent spread of infection to others): respiratory (used for patients that have an infection that can be spread over long distances when suspended…

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

Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan (a plan for a resident's specific health needs and desired health outcomes) related to constipation (a bowel dysfunction that makes bowel movements [BM] infrequent or hard to pass) for one of four sampled residents (Resident 408); when Resident 408 was first identified as being at risk for constipation on 5/19/2024. This deficient practice had the potential to result in failure to deliver necessary care and services. Findings: A review of Resident 408's admission Record indicated the facility initially admitted the resident on 11/30/2023 and readmitted the resident on 5/19/2024 with diagnoses including right hip dislocation (bones in the hip being pushed out of their usual place) and osteoarthritis (a condition that causes joints to become painful and stiff). A review of Resident 408's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 3/6/2024, indicated Resident 408's cognition (ability to think and make decisions) was intact. The MDS further…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a medicine cup of diclofenac sodium gel (gel used to relieve pain) was not left at the bedside table of one of three sampled residents (Resident 330). This deficient practice had the potential to place residents at risk for theft and loss of medication and increased risk for drug overdose and or medication errors. Findings: A review of Resident 330's admission Record indicated the facility admitted the resident on 4/5/2024 with diagnosis of wedge compression fracture (small breaks or cracks) of second lumbar vertebra (second bone in the lumbar spine). A review of Resident 330's History and Physical Examination (H&P- a term used to describe a physician's examination of a resident) dated 4/7/2024, indicated the resident had the capacity to make decisions. A review of Resident 330's physician's orders dated 4/13/2024, indicated an order for diclofenac sodium external gel 1% apply to affected area topically four times a day for pain management. During a concurrent observation and interview on 4/15/2024…

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

Based on interview and record review, the facility failed to the facility failed to ensure effective pain management was done by failing to administer pain medication for the appropriate pain scale as indicated by the physician's orders for one of two sampled residents (Resident 100). This deficient practice had the potential to result in confusion on the delivery of care and services rendered and may lead to inadequate management of residents' pain. Findings: A review of Resident 100's admission Record indicated the facility admitted the resident on 3/4/2023 with diagnoses that included a history of falling, difficulty in walking, and hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]). A review of Resident 100's History and Physical (H&P- a term used to describe a physician's examination of a resident) dated 3/9/2023, indicated, Resident 100 had the capacity to understand and make decisions. A review of Resident 100's Minimum Data Set (MDS, a standardized resident assessment and care screening tool) dated 3/1/2024, 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 complete a post-hemodialysis (HD, the removing of waste and excess fluid to prevent build up in the body for residents who have loss of kidney [organs that remove waste products from the blood and produce urine] function) assessment for one of two sampled residents (Resident 38) investigated addressing the dialysis care area. This deficient practice placed Resident 38 at risk for complications of dialysis such as redness at the dialysis access site (way to reach the blood for hemodialysis), edema (too much fluid trapped in the body's tissues), excessive bleeding, and a change in vital signs (clinical measurements that indicate the state of a patient's essential body functions). Findings: A review of Resident 38's admission Record indicated the facility admitted the resident on 3/21/2023 and readmitted the resident on 3/1/2024 with diagnosis that included dysphagia (difficulty swallowing) and end stage renal disease (a condition in which the kidneys no longer function normally). A review of Resident 38'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.

Based on interview and record review, the facility failed to ensure the Medication Regimen Review (MRR - review of a resident's drug therapy to assure appropriateness of medication usage completed each month by the consultant pharmacist) was acted upon for one of five residents (Resident 67) by failing to act upon the facility consultant pharmacist's recommendation for Resident 67's prednisone (a medication used to treat many conditions associated with inflammation) to give with food. This deficient practice has placed the resident at an increased risk of experiencing adverse side effects (unwanted undesirable effects that are possibly related to a drug) and had the potential for the resident to experience stomach irritation. Findings: A review of Resident 67's admission Record indicated the facility admitted the resident on 9/20/2022 with diagnoses that included gastroesophageal reflux disease (GERD, stomach contents flow backward, up into the esophagus, the tube that carries food from your throat into stomach). A review of Resident 67's Minimum Data Set (MDS - a standardized…

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

Based on observation, interview, and record review, the facility failed to ensure residents were free from any significant medication errors for one of five sampled residents (Resident 67) by failing to ensure Licensed Vocational Nurse 6 (LVN 6) checked Resident 67's blood pressure before giving a blood pressure medication. This deficient practice had the potential to cause complications such as low blood pressure, resulting in hospitalization. Findings: A review of Resident 67's admission Record indicated the facility admitted the resident on 9/20/2022 with diagnoses that included hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]), atrial fibrillation (an irregular and often very rapid heart rhythm), and depression (mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 67's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 3/20/2024, indicated Resident 67 was cognitively (the mental processes that take place in the brain) intact with skills required…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 proper food handling practices by failing to ensure that food found inside a refrigerator designated for residents were labeled with the date they were placed in the refrigerator. This deficient practice had the potential to place 111 out of 117 residents living in the facility at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages). Findings: During a concurrent observation and interview on 4/15/2024 at 8:57 a.m., with the Dietary Supervisor (DS), observed a refrigerator designated for residents who bring in food from the outside. The following were found inside the refrigerator: - An undated container of chicken and rice. - An undated bag with pickled vegetables. - An undated container of rice. The DS stated the food will have to be discarded, since they were not labeled with the date they were brought in. The DS stated the food cannot be in the refrigerator for more than 72 hours to ensure safety from foodborne pathogens. During an interview on…

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

Based on interview and record review, the facility failed to ensure that a post fall risk evaluation (form completed after a resident has fallen to determine risk factors related to falls) was completed after a fall for one of two sampled residents (Resident 3). This deficient practice placed Resident 3 at risk of not receiving the needed care and services and had the potential to result in undetected pain or injury after a fall incident. Findings: A review of Resident 3 ' s admission Record indicated the facility admitted the resident on 2/26/2024 with diagnoses that included urinary tract infection (an infection in your urinary system), repeated falls, contusion (an injury in which the skin is not broken, bruise) of the head, muscle wasting and atrophy (decrease muscle size). A review of Resident 3 ' s Minimum Data Set (MDS- a standardized assessment and screening tool) dated 2/29/2024, indicated Resident 3 had severely impaired cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled Medication Administration- General Guidelines by not informing the physician for one of three sampled residents (Resident 1), who refused Zyvox (an antibiotic [medication that inhibits the growth of or destroys microorganism] medication used to treat bacterial infections) for more than two consecutive doses. This deficient practice resulted in Resident 1 ' s physician not being informed of Resident 1 ' s continued refusal of Zyvox which placed Resident 1 at risk for complications of untreated bacterial infections which can cause, sepsis (a serious condition in which the body responds improperly to an infection), hypotension (low blood pressure), and even death. Findings: A review of Resident 1 ' s admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included atrial fibrillation (an irregular and often very rapid heart rhythm),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one of six sampled residents (Resident 1) of the results of their urinalysis (involves checking the appearance, concentration, and content of urine) and urine culture test (a test to check urine for germs that cause infections). This deficient practice had the potential for the resident to not be well-informed of the urine test result and help identify the cause of their symptoms. This deficient practice also had the potential to cause a delay in care and services if the resident decided to seek further alternatives in treatment or diagnostic tests. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 4/8/2018 and readmitted on [DATE] with diagnoses that included acute kidney failure (AKF - a condition in which the kidneys suddenly can't filter waste from the blood) and vesicointestinal fistula (a form of fistula [an abnormal connection between two body parts] between the bladder and the bowel). 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 implement and follow its policy and procedure (P&P) titled Medication Administration and failed to ensure Licensed Vocational Nurse 1 (LVN 1) administered and documented accurately the medication Midodrine (a medication that works by constricting the blood vessels and increasing blood pressure) as ordered, for one of three sampled residents (Resident 1). This deficient practice had the potential to result in medication errors, had the potential to result in confusion on the delivery of care and services, and had the potential to result in ineffective management of Resident 1's blood pressure. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), bipolar disorder (a mental health condition that causes unusual shifts in a person's mood,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to follow its policy and procedure (P&P) titled Release of Information and failed to provide copies of medical record in a timely manner (within 48 hours as per the P&P) for one of three sampled residents (Resident 1). This deficient practice violated the right of Resident 1 to obtain a copy of the requested medical records. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), bipolar disorder (a mental health condition that causes unusual shifts in a person's mood, energy, activity levels and concentration), and anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells). A review of Resident 1's History and Physical Examination form dated 9/19/2023 indicated Resident 1 has the capacity to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's written notice of the proposed discharge was provided to the State Long-Term Care (LTC) Ombudsman (assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences) as soon as practicable for eight of nine sampled residents (Resident 6, 8, 9, 10, 11, 12, 13, and 14). This deficient practice violated the resident ' s rights to appeal the discharge and resulted in the State LTC Ombudsman being unaware of the residents ' status and whereabouts; placing the residents at risk for being inappropriately discharged from the facility. Findings: 1. A review of Resident 6 ' s admission Record indicated the facility admitted the resident on 10/18/2023. A review of Resident 6 ' s physician order dated 11/20/2023, indicated that the physician ordered Resident 6 to discharge home with a home health (a nursing specificality in which a nurse provides resident care at the resident ' s…

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

Based on interview and record review, the facility failed to ensure two of two sampled residents (Resident 6 and Resident 7) were provided a discharge summary with a complete reconciliation of medications (a process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over-the-counter medications that includes the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care) by failing to document what post-discharge medications the residents were to take and were provided and the amount of medications provided upon discharge to the residents or responsible party (RP). This deficient practice had the potential to result in an unsafe discharge and for the residents and RP to be unaware of what medications are needed to be continued after being discharged from the facility. Findings: a. A review of Resident 6 ' s admission Record indicated the facility admitted the resident on 10/18/2023 with diagnoses including dementia (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 develop a facility policy and procedure (P&P) for a resident's written notice of the proposed discharge to be provided to the State Long-Term Care (LTC) Ombudsman (assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences) as soon as practicable for facility-initiated transfers/discharges (transfers or discharges which the resident objects to, or did not originate through a resident ' s verbal or written request). This deficient practice resulted in the State LTC Ombudsman being unaware of the facility ' s residents ' status, whereabouts, and placed the residents at risk for being inappropriately discharged from the facility. Findings: A review of the facility Notice of Transfer/Discharge Tracking Log and the facility fax verifications to the LTC Ombudsman indicated the following: 1. The Notices of Transfer/discharge for total 20 residents who discharged from 8/1/2023 through 8/30/2023 were faxed to the LTC Ombudsman on 9/1/2023 at 5:06 p.m. 2. 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 develop a comprehensive person-centered plan of care (a plan for an individual's specific health needs and desired health outcomes) for four of four sampled residents (Resident2,3,4 and 6) by: 1. Failing to develop a care plan related to Coronavirus Disease 2019 (COVID-19 - a highly contagious respiratory illness) for Resident 2, 3 and 4. 2. Failing to develop a care plan related to Clostridioides difficile (C-Diff - a germ that causes diarrhea) and peripherally inserted central catheter line (PICC line-type of catheter that is placed in a large vein that allows for medications to be given intravenously) for Resident 6 . This deficient practice can result to a delay in providing intervention if the residents signs and symptoms worsens and could potentially result in a delay in or lack of delivery of care and services. Findings: 1. A review of Resident 2`s admission Record indicated that the facility admitted the resident on 06/23/2021 with diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain infection control practices by: 1. Failing to ensure one of five sampled staff (Certified Nursing Assistant 2 [CNA 2]), performed hand hygiene (washing of hands) after disposing a bag of soiled linen after leaving Resident 10's room and before entering Resident 12's room. 2. Failing to ensure that one of five sampled staff (Treatment Nurse 1 [TN 1]) performed hand hygiene after providing wound treatment to Resident 10. 3. Failing to ensure that one of five sampled staff (TN 1) disinfected Wound Medication Cart 1 (Med Cart 1) before gathering supplies to start wound treatment to Resident 9 and failed to perform hand hygiene entering Resident 9's room and returning to Med Cart 1 to gather additional wound care supplies. 4. Failing to ensure one of five sampled residents (Resident 8) was provided rehabilitation services either inside the resident's room or inside the rehabilitation room while wearing a face mask after Resident 8 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that one of three sampled residents (Resident 6), with a peripherally inserted central catheter line (PICC line-a long, flexible catheter [thin tube] that's put into a vein) was provided with a PICC line dressing change (a PICC line requires that the dressing be changed every seven (7) days or as needed due to the high risk of infection) as ordered by the physician on 9/25/2023. This deficient practice placed Resident 6 at increased risk for sepsis (the body's extreme response to an infection. Sepsis is a life-threatening medical emergency) from a central line-associated bloodstream infection (CLABSI- a serious infection that occurs when germs [usually bacteria or viruses] enter the bloodstream through the central line [a tube that is placed in a large vein to give fluids, blood, medications or used to do medical tests]). Findings: A review of Resident 6's admission Record indicated the resident was admitted on [DATE] with diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain complete and accurate medical records for one of three sampled residents (Resident 6), when Registered Nurse 1 (RN 1) falsely documented that she provided a peripherally inserted central catheter (PICC line-a long, flexible catheter [thin tube] that's put into a vein) dressing change (a PICC line requires that the dressing be changed every seven [7] days or as needed due to the high risk of infection) on 9/25/2023 as ordered by the physician. This deficient practice had the potential to result in confusion regarding Resident 6's condition and what care and services were provided to Resident 6. Findings: A review of Resident 6's admission Record indicated the resident was admitted on [DATE] with diagnoses including sepsis (the body's extreme response to an infection), enterocolitis (inflammation of the intestine) due to clostridium difficile (C. diff- is a germ that causes diarrhea), and low blood pressure. A review of Resident 6's Minimum Data…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a Coronavirus disease-2019 (COVID-19, a highly contagious viral infection that can trigger respiratory tract infection) positive resident (Resident 4) was kept separated from COVID-19 negative residents (Residents 1, 2, and 3) while in the smoking area for three out of four sampled residents. This deficient practice had the potential to place COVID-19 negative residents at increased risk of contracting COVID-19. Findings: A review of Resident 1's admission Record indicated the facility originally admitted the resident on 4/28/2018 and readmitted the resident on 12/6/2020 with diagnoses including acute kidney failure (a sudden loss of kidney function) and nicotine dependence (occurs when you need nicotine [chemical in tobacco] and can't stop using it). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 8/25/2023, indicated the resident had intact cognition (the mental process of acquiring…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 on 8/7/2023 during the morning shift (7 a.m. to 3 p.m.), licensed nurses provided medications as ordered by the physician to four of five sample residents (Resident 1, Resident 3, Resident 4 and Resident 5). This deficient practice compromised the health and safety of the residents and had the potential to ineffectively manage the resident ' s health issues. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 7/13/2023 with diagnoses that included HTN and diabetes mellitus (DM, the body ' s inability to regulate sugar in the blood). A review of Resident 1 ' s MDS, dated [DATE], indicated Resident 1 had intact cognition. The MDS indicated Resident 1 required one-person supervision (oversight, encouragement or cueing) with walking, and eating. A review of Resident 1 ' s Physician ' s Orders, indicated orders for: 1. Metformin tablet (a medication to lower blood sugar) 500 mg by mouth two…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 protect a resident ' s right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) by Resident 1 for one of three sampled residents (Resident 2) when Resident 1 hit Resident 2. On 8/10/2023, at approximately 11:00 a.m., Certified Nursing Assistant 1 (CNA 1) witnessed Resident 1 punch Resident 2 in the face. This deficient practice resulted in Resident 2 being subjected to physical abuse by Resident 1 while under the care of the facility and had the potential for Resident 2 to experience fear from further abuse. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 7/13/2023 with diagnoses that included schizoaffective disorder (a combination of symptoms of schizophrenia [a mental condition in which one sees or hears people or things that do not exist] and a mood disorder, such as depression [feelings of sadness] or bipolar disorder [feelings 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 residents, who did not have an assessment as safe to self-administer medications for two (Resident 20, Resident 86) of two sampled residents investigated for medication self-administration. Resident 20 self-administered a breathing treatment. Resident 86 had unattended medications at the bedside. This failure had the potential for the resident not to take the medications, take them at the wrong time, or administer them incorrectly. Findings: a. A review of Resident 20's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs). A review of Resident 20's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 09/18/2021, indicated Resident 20 was cognitively (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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that residents receive proper treatment to maintain vision by not explaining to Resident 19 and the resident's responsible party the resident's ophthalmology physician assessments for one (Resident 19) of one sampled resident investigated for vision and hearing services. This deficient practice placed Resident 19 with impaired vision longer than necessary and prevented her and her responsible party from proceeding with cataract surgery. Findings: A review of Resident 19's admission Record indicated Resident 19 was admitted to the facility on [DATE], with diagnoses that included stroke (when the blood supply to part of one's brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients) and diabetes mellitus (high blood sugar). A review of Resident 19's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 09/11/2021, indicated Resident 19 was moderately impaired in cognition…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an element of the care plan for a resident who has a pressure ulcer (injury to skin and underlying tissue due to prolonged pressure over a bony structure) by: 1. Failing to implement care planned interventions to assess and document the status of wound perimeter, wound bed, and healing process, for two of three sampled residents (Resident 47 and 78), investigated for pressure ulcers/injury. 2. Failing to implement care planned interventions to assess low air loss mattress for proper functioning every shift, for two of three sampled residents (Resident 47 and 78) with existing pressure ulcers, investigated for pressure ulcers/injury. 3. Failing to assess and document a comprehensive skin assessment upon readmission, for one of three sampled residents (Resident 78), investigated for pressure ulcers/injury. These deficient practices had the potential to result in the development of worsening and newly acquired pressure ulcers 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 administer 19 doses of Advair (fluticasone-salmeterol, a circular inhaler device that administers medication to a resident to aide in breathing), to one (Resident 20) of eight sampled residents investigated for medications between the dates, 11/16/2021 and 12/01/2021. The deficient practice of failing to administer medications in accordance with physician's orders increased the risk that Resident 20 could have experienced serious health complications such as respiratory arrest (the inability to breathe). Findings: A review of Resident 20's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs). A review of Resident 20's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 09/18/2021, indicated Resident 20 was cognitively (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 proper food handling practices by: 1. Failing to ensure two opened bags of corn tortilla were labelled with an opened date in the reach-in refrigerator. 2. Failing to discard one container of ice cream with a dent on the side and one ice cream container with a dented cover exposing the contents, in the reach-in freezer. 3. Failing to discard one opened bag of sugar cookie dough inside a box in the reach-in freezer. These deficient practices had the potential to result in foodborne illness (an infection or irritation of the gastrointestinal tract [including the stomach and intestines] caused by food or beverages that contain harmful bacteria/germs, chemicals, or other organisms) for residents who receive and consume food prepared from the facility kitchen. Findings: On 11/30/2021 at 8:14 a.m., during an initial observation tour of the kitchen, and a concurrent interview with Dietary Assistant (DA), observed two opened bags of corn tortilla with no indication of when they were both opened in the reach-in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility: 1. Failed to follow infection prevention protocol by not instructing visitors to wear eye protection (face shield or goggles) and N-95 mask (a mask containing multiple layers of protective fabric that can capture up to 95% bacteria and viruses) before entering a yellow cohort (area for residents who have been in contact with a person who has coronavirus disease 2019 (Covid-19, a highly contagious respiratory illness in humans cable of producing severe symptoms leading ) resident room for four visitors visiting two residents (Resident 149, Resident 150). This deficient practice placed the residents and visitors at risk for infection and had the potential to spread infection throughout the facility. 2. Failed to implement infection control measures for one of 21 sampled residents (Resident 48) by failing to follow Los Angeles County (local public health) department of public health coronavirus-19 (COVID-19, an illness caused by a virus that can…

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

Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhance a resident's dignity and respect in full recognition of their individuality, for one of two sampled residents (Resident 57), as evidenced by: -Resident 57's urinary collection bag was observed not covered with a privacy bag (cover around catheter to ensure privacy). This deficient practice had the potential to affect the self-esteem, self-worth, sense of independence and psychosocial well-being of the residents. Findings: A review of the admission Record indicated Resident 57 was admitted to the facility, on 12/24/2018, with diagnosis that included paraplegia (paralysis of the legs and lower body), bipolar disorder (a mental condition marked by alternating periods of elation and depression), neurogenic bladder (when a person lacks bladder control due to brain, spinal cord or nerve problem),and anxiety (feeling of fear, dread, and uneasiness) A review of the Annual History and Physical examination, dated 10/07/2021, indicated Resident 57 was alert, oriented…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents' call light was within reach, for two of two sampled residents (Resident 78 and 71). These deficient practices placed the residents at risk for inability to summon health care workers as needed. Findings: A. A review of the admission Record indicated Resident 78 was admitted to the facility, on 10/12/2019 and readmitted on [DATE], with diagnoses that included sepsis (body's extreme response to infection), encounter for other specified surgical aftercare, and difficult in walking. A review of the Minimum Data Set (MDS- a standardized assessment and care-screening tool), dated 11/06/2021, indicated Resident 78 had severe impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and required extensive assistance for dressing, toilet use, personal hygiene, bed mobility, transfers, and eating. A review of Resident 78's Care Plan, dated 11/04/2021,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review, and interview, the facility failed to provide treatment and care in accordance with professional standards of practice for one of five sampled residents (Resident 76) as evidenced by: -Resident 76 had an episode of nosebleed and there was no documented evidence of an assessment and/or further monitoring from staff. This deficient practice placed Resident 76 at risk for complications such as bleeding and bruising resulting in the delay of care. Findings: A review of the admission Record indicated Resident 76 was admitted to the facility, on 07/28/2021, with diagnoses including aftercare following joint replacement surgery and presence of left artificial hip joint. A review of physician order indicated Resident 76 was to receive Pradaxa capsule 75 milligrams (mg - unit of measurement) by mouth two times a day for deep vein thrombosis (DVT, a blood clot in a deep vein, usually in the legs) prophylaxis (measures taken for disease prevention). A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/03/2021,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a safe environment for one of two residents (Resident 5) investigated under the Accidents Care Area as evidenced by: -Resident 5's fall risk reassessment (screening tool to identify fall risk factors) and neuro checks (evaluation of mental status) were not completed after a fall on 11/26/2021. This deficient practice had the potential to result in increased risk for further falls and further injury. Findings: A review of the admission Record indicated Resident 5 was admitted to the facility, on 08/23/2021, with diagnosis including trimalleolar (three different areas in the ankle) fracture (break-in bone) of right lower leg and dementia (memory loss that gets worse over time). A review of the History and Physical, dated 08/23/2021, indicated Resident 5 did not have the capacity to understand and make decisions. A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 08/29/2021, indicated Resident 5's was cognitively (the process of acquiring knowledge and understanding…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, Licensed Vocational Nurse 4 (LVN 4) failed to follow physician's orders and administered three Tums tablets instead of two for one sampled resident (Resident 86). This had the potential for Resident 86 to receive too much medication and may result in unpleasant effects like nausea, vomiting, or headache. Findings: A review of Resident 86's admission Record indicated Resident 86 was admitted to the facility on [DATE], with diagnoses that included depression (feelings of sadness) and hypertension (HTN, high blood pressure). A review of Resident 86's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 11/11/2021, indicated Resident 86 was cognitively (the process of acquiring knowledge and understanding through thought, experience, and the senses) intact in daily decision making. Resident 86's MDS indicated Resident 86 made herself understood and had the ability to understand others. Resident 86's MDS indicated Resident 86 needed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 label and store drugs and biologicals in accordance with accepted professional principles as evidenced by: -Failure to ensure one opened tuberculin (solution) vial was dated when opened, for one of one medication storage room. This deficient practice had the potential for residents to receive medication that had become ineffective or toxic due to improper labeling. Findings: During a concurrent observation and interview, on 12/01/2021 at 4:22 p.m., the Registered Nurse 3 (RN 3) confirmed one of one tuberculin vial was opened and not dated. RN 3 stated it should be dated. RN 3 stated since it had been opened and not dated, she would discard it and reorder from pharmacy. RN 3 stated the tuberculin vial was to be discarded when opened product after 30 days. During an interview, on 12/03/2021 at 4:24 p.m., the Director of Nursing (DON) stated tuberculin vial was multi-use and could be used multiple times. DON stated the vial had to be used within 30 days from the date it was opened. DON stated the licensed nurses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 extension cords and/or power strips were not interconnected (daisy chained [connection of two or more extension cords or power strips] to provide more receptacles and/or reach greater distances) and failed to use a medical grade electrical extension for Resident 47's room. This deficient practice had the potential to pose a fire hazard to the resident. Findings: A review Resident 47's admission Record indicated the facility originally admitted resident on 01/10/2021 and readmitted on [DATE], with a diagnoses that included pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure on skin), of sacral region (triangular-shaped bone a the bottom of the spine), metabolic encephalopathy (damage or disease that affects the brain), and diabetes mellitus type 2 (disease with too much sugar in blood) with foot ulcer (open sore or canker). A review of Resident 47's Minimum Data Set (MDS- an assessment and care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that the call light was connected to the power source and was functioning well for one of two sampled residents (Resident 71). This deficient practice had the potential to result in Resident 71 not being able to call for facility staff assistance and increase resident's risk for injury or fall. Findings: A review of Resident 71's admission Record indicated, resident was originally admitted on [DATE] and was readmitted on [DATE] with diagnoses that included osteoarthritis (most common form of arthritis and causes pain, swelling, and reduced motion in your joints), abnormal posture (tendency to hold a particular body position or move one or more parts of the body in an abnormal way), anemia (lack of enough red blood cells in the blood, resulting in being pale and weakness), and osteoporosis (a medical condition in which the bones become brittle and fragile from loss of tissue). A review of Resident 71's Minimum Data Set (MDS, a…

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