Stoney Point Healthcare Center

Based on observation, interview, and record review, the facility failed to follow the menu and did not meet nutritional needs when dietary staff did not follow the portion size of three (3) ounces (oz, unit of measurement) and served two (2) oz and four (4) oz of roast beef for regular and therapeutic diets (a personalized meal plan prescribed by a doctor to treat medical condition or manage symptoms). This failure had the potential to result in decrease in food flavor, decrease and increase in food and nutrient intake to 70 of 126 residents on regular, therapeutic diets, resulting in unplanned weight loss or unplanned weight gain. Findings: During a review of the facility's menu spreadsheet (a sheet containing the kind and amount of food each diet would receive) titled, Summer Menus, dated 7/13/2026, the spreadsheet indicated residents on regular texture would include the following foods on the tray: French dip-roast beef 3 oz Soft sandwich roll one (1) piece Au Jus 2 oz Sweet potato fries 1/2 cup (c, a household measurement) Ketchup 1 Tablespoon (tbsp, a household measurement)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to notify the physician of a change in condition for one of one residents (Resident 14) investigated under edema (swelling), by failing to notify the physician of Resident 14's left and right hand edema. This deficient practice had the potential for delay of necessary care and services and worsening of Resident 14's condition. Findings: During a review of Resident 14's admission Sheet (the front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility originally admitted Resident 14 on 7/27/2022, and re-admitted on [DATE] with diagnoses that included congestive heart failure (CHF - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) , acute respiratory failure (the lungs rapidly stop functioning properly), and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident were free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for one of one sampled residents (Resident 121) by failing to ensure that a wedge pillow (special triangle-shaped pillows that raise the top half of the body while sleeping) was not placed under the mattress on the right side at the foot of the bed. This failure had the potential to result in the restriction of Resident 121's freedom of movement, a decline in physical functioning, injuries related to entrapment (a state in which a person is trapped by the bed rail in a position that they cannot move from, or death.Findings: During a review of Resident 121's admission Record, the admission Record indicated that the facility originally admitted Resident 121 on 4/30/2026 with diagnoses including history of falling, right femur displaced…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident who had a Preadmission Screening and Resident Review (PASARR - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) Level 1 positive received Level II (a resident is assessed on a Level I first which is a determination if a resident is suspected of having a serious mental illness. If a resident is positive for Level 1, then they are referred to Level II; a Level II Contractor from California Department of Health Services [DHCS, a government agency that provides health care to low-income individuals, children, older adults, and people with disabilities] comes to evaluate further) evaluation by the state-designated authority for one (Resident 7) of six sampled resident reviewed under PASARR. This failure had the potential for Resident 7, who has a diagnosis of Post-Traumatic Stress Disorder (PTSD, a…

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

Based on observation, interview, and record review, the facility failed to ensure a resident unable to carry out activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) to maintain grooming and personal hygiene was free off yellow/white discharge on her bilateral eyes and cheeks for one of one sampled resident (Resident 54) investigated under the ADL care area. This deficient practice had the potential to negatively affect Resident 113's dignity and placed Resident 113 at risk for eye infections.Findings: During a review of Resident 54's admission Record, the admission Record indicated the facility admitted Resident 54 on 5/6/2024 with diagnoses that included dysphagia (swallowing difficulties), unspecified dementia (a progressive state of decline in mental abilities) and limitation in activities due to disability. During a review of Resident 54's Minimum Data Set (MDS, a resident assessment tool), dated 6/16/2026, the MDS indicated Resident 54 was never/rarely understood, and required substantial assistance (when helper does…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to perform and document an assessment of edema (swelling) of the hands for one of one residents (Resident 14), who has a diagnosis of congestive heart failure (CHF - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and was receiving Lasix (a medication that helps remove extra fluid from the body). This failure had the potential for delay of necessary care and services that places Resident 14's at increased risk of complications, such as shortness of breath that results in hospitalization. Findings: During a review of Resident 14's admission Sheet (the front page of the chart that contains a summary of basic information about the resident), the admission sheet indicated the facility originally admitted Resident 14 on 7/27/2022 and re-admitted on [DATE] with diagnoses that included CHF, acute respiratory failure (the lungs rapidly stop functioning properly), and chronic obstructive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the necessary care and services to prevent pressure ulcer (a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) from developing for one of one sampled resident (Resident 121) by failing to offload (to reduce or remove pressure on the affected area to promote healing and prevent further damage) Resident 121's heels when in bed, in accordance with the Resident 121's care plan titled, At Risk for Skin Breakdown, initiated on 4/30/2026. This failure placed the Resident 121 at increased risk for the development or worsening of pressure ulcers/injuries. Findings: During a review of Resident 121's admission Record, the admission Record indicated that the facility originally admitted Resident 121 on 4/30/2026 with diagnoses including history of falling, right femur displaced comminuted fracture (shattered injury of the thigh bone), bilateral (both side) artificial hip joint (a procedure in which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for two of four sampled residents (Resident 10 and Resident 68) investigated under accidents by failing to ensure: 1. Resident 10 did not have a wheelchair on top of the landing pad (a cushioned floor pad designed to help prevent injury should a person fall) on the right side of the bed. 2. Resident 68 wore a soft helmet with a chin strap as ordered by the physician. These deficient practices had the potential to place Resident 10 and Resident 68 at risk for injuries. Findings: 1. During a review of Resident 10's admission Record, the admission Record indicated that the facility originally admitted Resident 10 on 5/27/2026 with diagnoses including type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) with diabetic polyneuropathy (a condition in which a person's peripheral nerves are damaged) and foot ulcer, difficulty…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident who was receiving hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) treatment received services consistent with professional standards of practice by failing to ensure the hemodialysis communication assessment was completed on dates from 3/27/2026, 4/20/2026, and 6/19/2026 for one of one sampled residents (Resident 3). This deficient practice placed Resident 3 at risk for developing complications related to renal disease like swelling, high blood pressure, and shortness of breath. Findings: During a review of Resident 3's admission Record, the admission Record indicated the facility initially admitted Resident 3 on 11/29/2022 with diagnoses that included anemia (a condition where the body does not have enough healthy red blood cells), end stage renal disease (ESRD-irreversible kidney failure), and dependence on renal (kidney) dialysis. During a review of Resident 3's Minimum Data Set (MDS- a resident assessment…

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

Based on interview and record review, the facility failed to place a duration of therapy for one of one sampled resident's (Resident 4) medication, Lovenox (an anticoagulant [or blood thinner] medication injected through the skin subcutaneously [through the fat of the skin] to prevent blood clots [gel-like clump of blood]). This failure had the potential for Resident 4 to be subjected to unwanted subcutaneous injections and unnecessary medication.Findings: During a review of Resident 4's admission Record, the admission Record indicated the facility admitted the resident on 6/12/2026 with diagnoses that included subdural hematoma (a collection of blood that pools between the brain and the dura mater [tough outer protective covering] caused by a broken blood vessel). During a review of Resident 4's Minimum Data Set (MDS, a resident assessment tool) dated 6/19/2026, the MDS indicated Resident 4 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 by not ensuring a resident's carboxymethylcellulose sodium drops 0.5% (over-the-counter artificial tear lubricant) had been labeled with the resident's name for one of five sampled residents (Resident 82). This deficient practice had the potential for residents to receive medication that was not intended for them. Findings: During a review of Resident 82's admission Record, the admission Record indicated the facility admitted the resident on 4/13/2023 and re-admitted the resident on 12/4/2024 with diagnoses that included hypertension (high blood pressure). During a review of Resident 82's Minimum Data Set (MDS, a resident assessment tool) dated 4/11/2026, the MDS indicated Resident 82 was moderately impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. Resident 82's MDS indicated the resident was independent with personal hygiene. During a review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement infection prevention and control measures for two of four sampled residents (Resident 14 and Resident 34) by failing to: 1. Label Resident 14's nasal cannula (NC - a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) oxygen tubing. This deficient practice had the potential to place Resident 14 at increased risk for infection. 2. Ensure Licensed Vocational Nurse 6 (LVN 6) did not leave Resident 34's room who was on enhanced barrier precautions (EBP, a method of using personal protective equipment [PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments]) during medication administration while still wearing an isolation gown (provides protection against splashing and spraying of body fluids). This deficient practice had the potential to increase the risk of spreading infection to other residents. Findings: 1. During a review…

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

Based on interview and record review, the facility failed to ensure the medical records of one of three sampled residents (Resident 1) were released in a timely manner to Resident 1's Responsible Party 1 (RP 1) after receiving a valid request for the medical records from RP 1 on 5/27/2026. This deficient practice resulted in a delay in RP 1's ability to review Resident 1's medical records. During a review of Resident 1's admission Record, the admission Record indicated that the facility admitted Resident 1 on 5/27/2026 with diagnoses that include dementia (a progressive state of decline in mental abilities), anemia (a condition where the body does not have enough healthy red blood cells), bipolar disorder (a mental health condition that causes extreme, uncontrollable shifts in mood, energy, activity levels, and concentration) and schizophrenia (a mental illness that affects a person's ability to think, feel and behave clearly). During a review of Resident 1's History and Physical (H&P- a comprehensive assessment of a resident's medical condition) dated 5/30/2011, the H&P indicated…

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

Based on observation, interview and record review the facility failed to ensure that the medical record for one of three sampled residents (Resident 2) was complete and accurately documented after Resident 2 reported to Licensed Vocational Nurse (LVN) 1 that Resident 2 had hit Resident 2's left eye on the bedside table (a table positioned at the bedside of resident to assist with meals). This deficient practice had the potential to result in delays in care and services, compromise the continuity of care, and negatively affect Resident 2's overall health status.During a review of Resident 2's admission Record, the admission Record indicated that the facility admitted Resident 2 on 5/2/2025 with diagnoses that include pneumonia (an infection/inflammation in the lungs), type 2 diabetes (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN- high blood pressure), dementia (a progressive state of decline in mental abilities), and history of falling. During a review of Resident 2'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.

Based on observation, interview, and record review, the facility failed to ensure the proper use of a low air loss mattress (LALM- a specialty bed that alternates pressure to help heal and prevent pressure ulcer/injuries [ PU/PI-injuries that breakdown the skin and underlying tissue when an area of skin is placed under pressure]) for one of five sampled residents (Resident 1) when on 5/28/2026 a cloth pad and a sheet were placed over the mattress surface while Resident 1 was also wearing an incontinence (loss of bowel or bladder control) brief (diaper). This deficient practice had the potential to compromise the effectiveness of the LALM by reducing airflow and pressure redistribution, thereby increasing the risk of skin breakdown, development or worsening of PU/PI, excess moisture retention and delayed wound healing. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 1/30/2026 with diagnoses that included, but were not limited to, peripheral autonomic neuropathy (a condition where the nerves that automatically…

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

Based on interviews and record review, the facility failed to ensure one of three sampled residents' (Resident 1) rights were respected by not changing Resident 1's room assignment as requested by Resident 1's Responsible Party (RP) 1 in a timely manner. This deficient practice violated the resident's right to be treated with respect and dignity, which had the potential to affect the resident's sense of self-worth and self-esteem.Findings: During a review of Resident 1's admission Record, the admission Record indicated that the facility admitted the resident on 1/7/2026 with diagnoses that included encephalopathy (a syndrome of general brain dysfunction causing confusion and memory loss), depression, and dementia (a progressive state of decline in mental status). During a review of Resident 1's History and Physical (H&P) dated 1/8/2026, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 1/9/2026, the MDS indicated Resident 1's cognition (ability to think and make…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 privacy and confidentiality of personal and medical records for one of three sampled residents (Resident 2) when Resident 2's personal and medical records were provided to Resident 1's responsible party (RP 1). This deficient practice violated Resident 2's right to personal privacy and confidentiality of the resident's personal and medical records.Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident on 1/8/2026 with diagnoses that included a fracture ( a break in the bone) of the fifth lumbar vertebra (a bone in the low back), type 2 diabetes (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and dementia (a progress state of decline in mental status).During a review of Resident 2's History and Physical (H&P) dated 1/9/2026, the H&P…

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

Based on interview and record review, the facility failed to provide respiratory care services consistent with professional standards of practice for one of three sampled residents (Resident 1) by failing to ensure high concentration oxygen (a compressed gas cylinder containing oxygen at a high-pressure level, delivering pure oxygen with very high purity [up to 99.5 percent {%}] for medical use) was administered and correct oxygen delivery device (a piece of medical equipment that provides supplemental oxygen [a medical treatment that provides additional oxygen to the body when the air we normally breathe doesn't contain enough for organs to function correctly] to a resident who is unable to get enough oxygen on their own) was used when on 8/30/2025 at 9:20 a.m., Resident 1 had an oxygen saturation level (amount of oxygen that is circulating in the blood, normal range: 95% to 100%) of 80 % while receiving oxygen via nasal cannula (a medical device, typically a thin, flexible tube with two prongs, that delivers supplemental oxygen to a person's nostrils). This deficient practice had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure three (Resident 12, Resident 65, Resident 121) of 6 sampled residents were free from unnecessary medication by failing to:1. Ensure the following conditions existed for Seroquel (brand name for an antipsychotic medication, a drug that affects brain activities associated with mental processes and behavior) to be prescribed: the symptoms are identified as being due to mania (mental state of an extreme highs or depressive lows) or psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) or delusions, (having false or unrealistic beliefs such as paranoia [unjustified mistrust of others]/grandiosity [inflated sense of superiority]; the behavioral symptoms (sudden anger outburst) present a danger to the resident or others; and the symptoms are significant enough that the resident is experiencing inconsolable/persistent distress for Resident 12. There was no documentation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure three of seven sampled residents (Residents 7, 79, and 85) received appropriate services to prevent a decline in range of motion (ROM, full movement potential of a joint) by failing to:1a. For Resident 7, provide Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) treatment for passive range of motion (PROM, movement at a given joint with full assistance from another person) to both lower extremities (BLE, hip, knee, ankle, foot) seven times a week in May 2025 and June 2025 as ordered by a physician and in accordance with Resident 7's care plan.1b. For Resident 7, complete a quarterly joint mobility screen timely.2. For Resident 79, complete a quarterly joint mobility screen timely.3. For Resident 85, complete a quarterly joint mobility screen timely.These deficient practices had the potential to cause stiffness and pain for Resident 7 and decline in ROM 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 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 three of six sampled residents (Resident 116, Resident 12, and Resident 121 by failing to: Complete an EKG (electrocardiogram - a simple, painless test that measures the heart's electrical activity) for the usage of Quetiapine (antipsychotic medication) for Resident 116. This deficient practice could have resulted in missed dangerous heart rhythms that Quetiapine can cause in high-risk populations such as the elderly. 2. Follow the pharmacist consultant's recommendation to have documentation to support the use of Seroquel (brand name for an antipsychotic medication, a drug that affects brain activities associated with mental processes and behavior) for by failing to:a. Ensure the following conditions existed for Seroquel to be prescribed: the symptoms are…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 leftover food brought from outside by residents' family and visitors were labeled with a resident identifier and use-by-date in one of one resident refrigerator (Refrigerator 1).This deficient practice had the potential to result in foodborne illness (also called food poisoning, illness caused by eating contaminated food) for the residents.Findings:During a concurrent observation and interview on 6/30/2025 at 8:44 a.m., with the Administrator in Training (AIT), observed the residents' refrigerator in the nurse's station. Observed in the refrigerator, two plastic bags of undetermined leftover food with no name, date or resident identifier. The AIT stated that this refrigerator is used to store resident's food and when placing resident's leftover food, the leftover food must be labeled with an identifier and date. During an interview on 7/3/2025 at 8:16 a.m., with the AIT, the AIT stated that residents are informed that leftover food will be refrigerated and will be discarded after 48 hours. The AIT…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurate clinical records in accordance with accepted professional standards and practices for four (Resident 7, Resident 79, Resident 85, and Resident 12) of 32 sampled residents by failing to:1.a. Ensure therapy staff did not accurately document a late Rehab Joint Mobility Screen, for Resident 7, dated 4/3/2025 and completed on 7/1/2025.b. Ensure therapy staff did not accurately document a late Rehab Joint Mobility Screen, for Resident 79, dated 4/30/2025 and completed on 7/1/2025.c. Ensure therapy staff did not accurately document a late Rehab Joint Mobility Screen, for Resident 85, dated 4/9/2025 and completed on 7/1/2025.These deficient practices resulted in inaccurate medical documentation and had the potential for a decline in range of motion (ROM, full movement potential of a joint) in Residents 7, 79, and 85.2. Ensure Resident 7's diagnosis of anxiety was included in the diagnosis list in the resident's medical record.This deficient…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a facility staff knocked and asked permission prior to entering a resident's room for two of two sampled residents (Resident 18 and 44). This deficient practice violated the residents' rights to be treated with respect and dignity, which had the potential to affect the residents' sense of self-worth and self-esteem.Findings:a. During a review of Resident 18's admission Record, the admission Record indicated the facility admitted the resident on 5/30/2025 with diagnoses including, Alzheimer`s Disease (a progressive disease that destroys memory and other important mental functions) and lack of coordination.During a review of Resident 18's Minimum Data Set (MDS- a resident assessment tool) dated 6/6/2025, the MDS indicated the resident had severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and senses. The MDS indicated that Resident 18 was totally dependent on…

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

Based on observation, interview, and record review, the facility failed to ensure a call light (a device used by a resident to signal his/her need for assistance from staff) was within a resident's reach while in bed for one of one sampled resident (Resident 25). This deficient practice had the potential to delay the provision of services and the resident's needs not being met.Findings:During a review of Resident 25's admission Record, the admission Record indicated the facility admitted the resident on 9/23/2024 with diagnoses that included dysphagia (difficulty swallowing) and schizophrenia (mental disorder in which people interpret reality abnormally). During a review of Resident 25's Minimum Data Set (MDS- a resident assessment tool) dated 3/27/2025, the MDS indicated Resident 25's cognition (a mental process of acquitting knowledge and understanding) was impaired. The MDS indicated Resident 25 required supervision with activities of daily living (ADLs - activities related to personal care). During a concurrent observation and interview on 6/30/2025 at 10:07 a.m., with Certified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 copy of the resident's Advance Directive (AD- a legal document indicating resident preference on end-of-life treatment decisions) was kept in the resident's medical chart and easily retrievable for two of eight sampled residents (Resident 40 and 81).This deficient practice had the potential to create confusion which could lead to conflict with the resident`s wishes regarding their health care.Findings: a. During a review of Resident 40’s admission Record, the admission Record indicated that the facility admitted the resident on 7/5/2025, with diagnoses including dysphagia (difficulty swallowing), type 2 diabetes (DM- a chronic condition that affects the way the body processes blood glucose [sugar]), and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 40’s Minimum Data Set (MDS – a resident assessment tool) dated 5/1/2025, the MDS indicated that Resident 40 could understand others…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complete baseline care plan (a document designed to facilitate communication among members of the care team that summarizes a resident's health conditions, specific care needs, and current treatments) within 48 hours of a resident`s admission to the facility by failing to address the resident`s indwelling catheter (a hollow tube inserted into the bladder to drain or collect urine) for one of two sampled residents (Resident 81). This deficient practice had the potential for Resident 81 to not receive appropriate care and treatment in the facility. Findings:During a review of Resident 81's admission Record, the admission Record indicated that the facility originally admitted the resident on 1/3/2025 and readmitted the resident on 6/17/2025, with diagnoses including dysphagia (difficulty swallowing), dementia (a progressive state of decline in mental abilities), obstructive uropathy (a blockage in the urinary tract that prevents urine from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a person-centered care plan (a document designed to facilitate communication among members of the care team that summarizes a resident's health conditions, specific care needs, and current treatments) for two of four sampled residents (Resident 75 and 114) by failing to: 1. Develop a care plan addressing Resident 75's use of olanzapine (medication used to treat schizophrenia (mental disorder in which people interpret reality abnormally) 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). 2. Develop a care plan addressing Resident 114's use of amphetamine-dextroamphetamine (medication used to treat attention-deficit/hyperactivity disorder [ADHD - a chronic condition including attention difficulty, hyperactivity, and impulsiveness]). These deficient practices had the potential to result in failure to deliver the necessary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 update and revise a resident`s dental care plan (a document that summarizes a resident's needs, goals, and care/treatment) after the resident`s upper dentures went missing for one of three sampled residents (Resident 69). This deficient practice had the potential to result in Resident 69 receiving inadequate care and services. Findings:During a review of Resident 69's admission Record, the admission Record indicated that the facility originally admitted the resident on 5/12/2022 and readmitted the resident on 12/3/2024, with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), type two diabetes mellitus (a chronic condition that affects the way the body processes blood glucose [sugar]), and schizophrenia (a mental illness that is characterized by disturbances in thought).During a review of Resident 69's Minimum Data Set (MDS - a resident assessment tool) dated 4/30/2025, the MDS indicated that the resident`s cognitive skills (brain's ability 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:1. Ensure fall risk assessments were completed accurately for one of ten sampled residents (Resident 7).This deficient practice had the potential to place Resident 7 at an increased risk of falling.2. Ensure a fall risk assessment was completed for one of ten sampled residents (Resident 119) after the resident`s fall on 6/25/2025. This deficient practice placed Resident 119 at an increased risk for recurrent falls and injuries. Findings: a. During a review of Resident 7’s admission Record, the admission Record indicated the facility admitted the resident on 7/20/2020 with diagnoses including, but not limited to, metabolic encephalopathy (the loss of brain function due to a chemical imbalance in the blood), lack of coordination, and mild cognitive impairment (a decline in mental abilities, including thinking, learning, remembering, and decision-making) of unknown etiology (the cause of a disease or abnormal condition). During a review of Resident 7’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 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 ensure the dialysis center recorded a resident's post dialysis weight (the weight after fluid is removed during the dialysis treatment) on 6/25/2025.This deficient practice had the potential for Resident 46 to have unidentified complications after dialysis treatment such as abnormal vital signs (pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions). Findings:During a review of Resident 46's admission Record (or face sheet, the front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the patient was admitted to the facility on [DATE] with…

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

Based on interview and record review, the facility failed ensure resident's drug regimen was free from unnecessary drugs by failing to adequately monitor potential adverse effects of amphetamine-dextroamphetamine (stimulant medication to treat ADHD [differences in how the brain develops and works causing problems with a person's attention, ability to sit still, and practice self-control]) for one of one sampled resident (Resident 114). This deficient practice had the potential for adverse effects including psychosis (hallucinations, delusions, paranoia, aggression, hostility) and heart issues such as fast heartbeat and hypertension.Findings:During a review of Resident 114's admission Record, the admission Record indicated the facility admitted Resident 114 on 4/15/2025 with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), hypertension (HTN-high blood pressure), and unspecified atrial fibrillation (an irregular and often very rapid heart rhythm in the upper part of the heart). During a review of Resident…

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

Based on observation, interview, and record review, the facility failed to accommodate a resident's food allergies and preferences for one of six residents (Resident 7) investigated under nutrition by:1. Failing to document Resident 7's allergy to eggs on the tray ticket (a document that accompanies a meal tray with essential information about the meal and the resident receiving it).2. Failing to ensure Resident 7 received a substitution for breakfast when eggs were not served.These failures placed Resident 7 at risk of:1. Being served eggs and having a reaction such as a rash, hives, diarrhea, vomiting, dehydration (occurs when your body loses too much water and other fluids), and/or anaphylactic shock (severe allergic reaction including closure of airways). 2. Not receiving the needed nutrition, they require. Findings: 1. During a review of Resident 7’s admission Record, the admission Record indicated the facility admitted the resident on 7/20/2020 with diagnoses including, but not limited to, metabolic encephalopathy (the loss of brain function due to a chemical imbalance in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the provision of medically-related social services to meet one of five sampled residents (Resident 4) needs by failing to follow up the status of Resident 4's missing rollator walker (a mobility aid designed for residents who need support while walking) and ensure timely replacement of Resident 4's missing rollator walker. On 10/26/2024, Resident 4 was discharged from the facility without providing Resident 4's rollator walker. This deficient practice placed Resident 4 at risk for health and safety impacts such as impairing Resident 4's ability to walk safely leading to fall and injury, reduced mobility (movement), and loss of independence which can lead to decreased self-esteem (confidence in one's own abilities or worth) and a sense of helplessness. Findings: During a review of Resident 4's admission Record, the admission Record indicated the facility admitted the resident on 3/27/2024 with diagnoses that included systemic lupus erythematosus…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one of three sampled residents (Resident 1) discharge planning process included, providing Resident 1 and Resident 1 ' s Responsible Party (RP) 1 with information including services and quality measures (quantify healthcare processes, outcomes, patient perceptions, and organizational structure and/or systems) of the accepting skilled nursing facility Resident 1 was transferred to. This deficient practice had potential for decreased quality of care, decreased quality of life and continuity of care. Findings: During a review of Resident 1 ' s admission Record (facesheet) dated 2/16/2025, the admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a change in how your brain works due to an underlying condition), pneumonia (an infection/inflammation in the lungs), cerebral infarction (CVA-stroke, loss of blood flow to a part of the brain), dementia (a progressive state of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) verification from a resident responsible party (RP - a person who makes medical decision for a resident) for one of four sampled residents (Resident 1) regarding the administration of antipsychotic (a medication used to treat psychosis [a severe mental condition in which thought, and emotions are so affected that contact is lost with reality] related symptoms and conditions) medication known as Olanzapine (a medication used to treat and manage psychosis) from Resident 1's RP. This deficient practice resulted in the facility administering a psychotropic (a medication that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) medication to Resident 1 without informed consent and denied Resident 1's RP the right to make informed treatment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a person-centered care plan (a document designed to facilitate communication among members of the care team that summarizes a resident's health conditions, specific care needs, and current treatments) for seven of 30 sampled residents (Resident 34, 117, 65, 7, 72, 59, and 27) by failing to: 1. Develop a care plan addressing Resident 34, 117, and 65's insulin (hormone that regulates the level of glucose [sugar] in the blood) use. 2. Develop a care plan addressing Resident 7's use of psychotropic medications (medications capable of affecting the mind, emotions, and behavior). 3. Develop a care plan addressing Resident 72's diagnosis of viral hepatitis C (a viral infection that causes liver inflammation (swelling). 4. Develop a care plan addressing Resident 59 and Resident 27's diagnosis of urinary tract infection (UTI, an infection in any part of the urinary system) and antibiotic (medications that fight bacterial infections) use…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medication administration was supervised and medications were not left at bedside for one of 30 sampled residents (Resident 7). This deficient practice had the potential to allow Resident 7 to miss a dose of medications and allow other residents to consume the medications. 2. Ensure a resident's bed was positioned in the lowest position while the resident was in bed, as ordered by the physician, for one of 30 sampled residents (Resident 22). This deficient practice had the potential to place the resident at increased risk of sustaining a fall with injuries. 3. Ensure one of one resident (Resident 118), who was at high risk for falls, had bilateral landing mats placed in her room next to her bed as ordered by physician. This deficient practice had the potential to place the resident at increased risk of sustaining an injury. Findings: 1. A review of Resident 7's admission Record indicated the facility readmitted the resident on…

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

Based on interview and record review, the facility failed to ensure licensed nurses documented that they attempted non-pharmacological interventions (any type of healthcare intervention which is not primarily based on medication) prior to administering as needed (prn) opioid medications (medication used to treat moderate to severe pain) on multiple days for one of 30 sampled residents (Resident 29). 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 opioid pain medication. Findings: A review of Resident 29's admission Record indicated the facility admitted the resident on 5/3/2024 with diagnoses including 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 chronic pulmonary edema (a condition that occurs when fluid builds up in the lungs over time, making it difficult to breathe). A review of Resident 29'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 observation, interview, and record review the facility failed to ensure a resident was free from significant medication error by failing to administer several medications as ordered by the physician for one of 30 sampled residents (Resident 7). This deficient practice resulted in Resident 7 receiving her medications late and had the potential to result in Resident 7 missing a dose of her medications. Findings: A review of Resident 7's admission Record indicated the facility readmitted the resident on 4/30/2024 with diagnoses that included end stage renal disease (ESRD- a condition in which the kidneys [organs that remove waste products from the blood and produce urine] no longer function normally). A review of Resident 7's Minimum Data Set (MDS, a standardized resident assessment and care screening tool) assessment dated [DATE], indicated Resident 7 had severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). 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 2. A review of Resident 7's admission Record indicated the facility readmitted the resident on 4/30/2024 with diagnoses that included end stage renal disease (ESRD- a condition in which the kidneys [organs that remove waste products from the blood and produce urine] no longer function normally). A review of Resident 7's MDS dated [DATE], indicated Resident 7 had severely impaired cognition. A review of Resident 7's Order Summary Report, dated 7/25/2024, indicated an order for oxygen inhalation at two (2) liters per min (LPM, unit of measurement) via nasal cannula as need for shortness of breath and comfort with a titration (adjusting the dose of a medication) of three (3) to five (5) liters as needed, ordered 5/8/2024. During a concurrent observation and interview on 7/22/2024 at 10:25 a.m., with Registered Nurse 1 (RN 1) in Resident 7's room, observed Resident 7's oxygen concentrator (medical device that gives oxygen) humidifier and nasal cannula were both unlabeled with the nasal cannula around the oxygen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 lights (a device used by patients to call for assistance from hospital staff) were within reach for two of 30 sampled residents (Resident 27 and 28) . This deficient practice had the potential to result in the residents not being able to call for facility staff assistance and delay in the provision of necessary care and services that can negatively affect the residents' comfort and well-being. Findings: a. A review of Resident 27's admission Record indicated the facility admitted the resident on 1/27/2022 with diagnosis of chronic obstructive pulmonary disease (COPD, a common lung disease that damages the airways or other parts of the lungs, making it difficult to breathe), difficulty in walking, and lack of coordination. A review of Resident 27's History and Physical (H&P, a comprehensive assessment of a resident and their problem) dated 6/5/2023, indicated that does not have the capacity to understand and make…

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

Based on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse 3 (LVN 3) provided privacy to a resident before administering medications via gastrostomy tube (g-tube - a tube that's surgically inserted through the abdomen and into the stomach used for medication and nutrition) for one of 30 sampled residents (Resident 62). This deficient practice violated the resident's right to privacy. Findings: A review of Resident 62's admission Record indicated the facility admitted the resident on 11/2/2019 with diagnoses including aphasia (a language disorder that makes it difficult to understand and express language, as well as read and write), hemiplegia (partial or complete paralysis on one side of the body) and hemiparesis (mild loss of strength or paralysis on one side of the body), and encounter for attention to gastrostomy (a surgical procedure that creates an opening in the skin and into the stomach to insert a feeding tube). A review of Resident 62's Minimum Data Set (MDS - a 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.

Based on observation, interview, and record review, the facility failed to follow safe food handling practices by failing to discard two bags of hotdog buns 12 days past their best by date. This deficient practice had the potential to place 24 out of 121 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 kitchen observation on 7/22/2024 at 8:11 a.m., with Kitchen Supervisor 1 (KS1), observed two bags of hotdog buns containing 12 buns in each bag with a Best By date of 7/10/2024. KS 1 stated he is going to discard the hotdog buns. KS 1 further stated that the hotdog buns are no longer safe for the residents to consume if past its Best By date. KS 1 stated that hotdog buns may already have mold and if eaten could result to foodborne illnesses. A review of the facility's policy and procedure titled, Food Receiving and Storage, last reviewed on 1/16/2024, indicated, Foods shall be received and stored in a manner that complies with safe food handling practices .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility staff failed to follow the facility ' s policy related to smoking for two of five sampled residents (Resident 3 and 4) when they allowed Resident 3 to share a cigarette with Resident 4. This deficient practice has the potential for Resident 4 to be place at risk for accidents such as burns. Findings: A review of Resident 3 ' s admission Record indicated the facility admitted the Resident 3 on 1/15/2024 with diagnosis that included Type 2 Diabetes Mellitus (A long-term condition in which the body has trouble controlling blood sugar and using it for energy), and respiratory disorders (diseases related to the lungs). A review of Resident 3 ' s History and Physical dated 1/16/2024 indicated that Resident 3 has the capacity to understand and make decisions. A review of Resident 3's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 1/22/2024, indicated that Resident 3 had moderately impaired cognition (the mental action or…

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