Autumn Creek Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Resident Representative (RP) had the right to retrieve the resident's personal belongings, when the RP of one of five sampled residents (Resident 5) was not given personal property back to them following the death of Resident 5. This failure by the facility had the potential to impact further property transfers, if not corrected. During a review of facility policy titled Personal Property, dated [DATE], indicated that the facility is required to ensure they take reasonable steps to protect resident's personal property, and the facility will return inventoried personal items to residents or their representative upon discharge in a timely manner, and take reasonable steps to safeguard the belongings in the interim. The facility policy also indicated that Upon the death of a resident, the resident representative will review the resident's inventory to ensure all personal items are taken at this time.During a review of Resident 5's clinical record,…

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

Based on interview and record review the facility failed to notify the Responsible Party (RP- the person who is responsible for making health care decisions for a resident) of falls and a change of condition for one of two residents (Resident 1) sampled for falls, when Resident 1 had four unwitnessed falls, her indwelling catheter (a soft tube that is inserted into the bladder and allows urine to drain into a collection bag) fell out and was not replaced, a change in condition due to a head injury, was transferred to an emergency department (ED) and the RP was not notified.Refer to F689.This failure prevented the family from knowing about Resident 1's falls, condition changes, and transfer to the emergency department, hindering their ability to make informed decisions and participate in Resident 1's care.Findings.A review of the facility's policy titled Change in Condition dated 8/25/22 indicated A Licensed nurse will notify the resident's Physician/APP (advanced practice providers) and legal representative or an appropriate family member when there is an: a. Incident/accident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an injury of unknown origin and major accident for one of two residents (Resident 1) sampled for falls, was reported to the California Department of Health (CDPH) when Resident 1 had a bruise and bump on her head of unknown origin, unwitnessed falls, and a change in condition which sent Resident 1 to the hospital and eventually die due to a brain bleed.This failure to report had the potential for delaying investigations into injuries of unknown origin by facility and required reporting agencies to be able to rule out abuse.FindingsA review of the facility's policy and procedure (P&P) titled Unusual Occurrence Reporting dated [DATE], indicated The Facility reports the following events by phone and in writing to the appropriate State or Federal agencies (California Department of Health, CDPH) c. Other Occurrences. ii. Major accidents. iv. Other occurrences that. affect the welfare, safety, or health of residents. Unusual occurrences are reported 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.

Based on interview and record review the facility failed to ensure one of two sampled residents (Resident 1), who was admitted with an indwelling catheter (a soft tube that is inserted into the bladder and allows urine to drain into a collection bag), had care and services to maintain normal bladder function when Resident 1('s): Did not have an assessment for the need of an indwelling catheter. Indwelling catheter was discontinued without a physician's order. Was not provided bladder training to restore normal bladder function after the indwelling catheter was removed. Did not have a care plan created with interventions concerning her bowel and bladder function.These failures caused Resident 1 to get up and down to the bathroom many times without assistance and have multiple falls.Findings:A review of the facility's policy titled Nursing Policy and Procedure (P&P)- Bowel and Bladder, Indwelling Catheter - insertion, maintenance and Discontinuation of. revision date of 7/22/25, indicated, A Licensed Nurse will assess the need for continued use of a catheter. The Licensed Nurse will…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 This requirement was not met when a staff member reportedly spoke to a resident (Resident 1) using profane language and with a disrespectful tone. This had the potential to cause the resident to feel unsafe or that his environment was not home-like.Review of Resident 1's medical record indicated that he was admitted to the facility for Parkinson's Disease (a gradual worsening of coordination and movement caused by diseased brain cells), cognitive communication deficit (trouble speaking and thinking), depression and dementia (age related decline in brain function).A review of Resident 1's Basic Interview for Mental Status (BIMS) performed on 5/28/25 indicated his cognitive (thinking, memory) function was 12 on a scale of one to 15, or moderate cognitive impairment (lessened ability to think and remember).Review of the facility's policy titled, Residents' Rights -- Quality of Life, dated March 2015 indicated: XI. Demeaning practices and standards of care that compromise dignity are prohibited. Facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and interview this requirement was not met when one of three sampled medication carts were left unlocked and unattended. This had the potential for unauthorized access including nearby residents with dementia, and the potential for harm. In an observation on 8/18/25 at 3:15 PM, one of three sampled treatment carts on nursing station 4 was observed to be unattended and unlocked. Drawers were opened and inspected; accessible supplies and medicines included six, 1-ml hypodermic syringes, and a 12-ounce bottle of what was labeled to be povidone iodine whose plastic top was broken off with brown residue visible on the cap. Residents were observed to be sitting in wheelchairs in the hallway directly adjacent to nursing station 4. No staff stopped or intervened as the drawer was inspected.In a concurrent interview and observation on 8/18/25 at 3:20 PM, the closest nurse to the cart, LVN A, stated she wasn't sure where the nurse was who was responsible for the cart. LVNA confirmed that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement Advance Directive (AD - a legal document that outlines a person's wishes for medical treatment in case they become unable to make their own decisions due to illness or injury) for one of three sampled resident's (Resident 1)This had the potential for Resident 1 to receive medical treatments that were against his wishes and negatively impact his quality of life.During a record review of facility policy titled, Advance Directives, revised 12/1/13, indicated Upon admission, the admission Staff of designee will obtain a copy of a resident's AD. A copy of the resident's AD will be included in the resident's medical record. Facility policy also indicated if a resident does not have an AD, the facility will provide the resident and/or resident's next of kin with information about AD upon request. Facility policy further indicated the director of social services or designee will also ask the resident whether he or she has a written AD.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 physician's orders were appropriate for one of three sample residents (Resident 1) when Medical Director (MD) based Resident 1's ability to make healthcare decisions on a diagnosis of cerebral palsy (neurological disorders that affect movement, posture, and muscle tone) with no further explanation.This failure increased the potential for an inadequate medical evaluation of Resident 1 which could potentially result in unidentified or unmet medical and care needs.During a record review of Resident 1's admission record, Resident 1 was admitted to the facility on [DATE] with diagnoses that included cerebral palsy (neurological disorders that affect movement, posture, and muscle tone), acute respiratory failure with hypoxia (life-threatening condition where the lungs cannot adequately oxygenate the blood, resulting in low blood oxygen levels) and severe protein-calorie malnutrition (condition resulting from inadequate intake of both…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observation and record review, the facility failed to meet this requirement when nursing staff failed to develop nursing care plans (a roadmap of care to be provided) for two of 9 sampled residents (Residents 1 and 2) who were involved in resident-to-resident altercations. This had the potential for additional resident-to-resident altercations, injury, and to negatively impact residents' sense of security and well-being. A review of the facility's medical record indicated that Resident 1 was admitted on [DATE] for conditions that included stroke, morbid obesity (life-threatening weight gain), anxiety, chronic pain, and a history of alcohol abuse. A review of Resident 1's Basic Interview for Mental Status (BIMS), a test for memory and brain function, indicated that her score was 5, cognitively impaired (reduced ability to think and act).A review of the facility's medical record indicated that Resident 2 was admitted on [DATE] for conditions that included leg fracture, stroke, muscle weakness,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observation and record review, the facility failed to meet this requirement when two of six medication carts were observed to be unlocked, with medication accessible, while unattended by nursing staff. This had the potential to result in residents, unlicensed staff, and visitors to have unauthorized access to prescribed medications and their misuse. On 7/15/25 at 10:03 AM, two medication carts were observed to be unlocked and openable at the facility's Nursing Station Three. Topical medications and creams were observed to be accessible to residents with dementia (loss of memory and ability to think). Surveyor opened the cart and was unquestioned and unobserved by nearby staff. On 7/15/25 at 10:05 AM, Licensed Vocational Nurse (LVN C) was observed returning to the cart and confirmed that she was the on-call treatment nurse responsible for the cart, and that it should have been locked.Review of the facility's policy titled Medication Storage in the Facility, dated 1/2018, indicated: Medications and biologicals are stored safely, securely, and properly, following…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observation and record review, the facility failed to meet this requirement when the care plan for a resident who had nine falls was not followed and the resident did not have a fall mat beside the bed. This had the potential to contribute to additional falls and injuries. Findings: Review of the facility ' s medical record for Resident 1 indicated that the resident was admitted to the facility on [DATE] following cranial surgery for a brain tumor. The record indicated Resident 1 had a need for assistance with personal care, difficulty in walking, and generalized muscle weakness. Resident 1 also had visual loss in her left eye from the tumor, which was a contributor to her fall risk. Review of Resident 1's Minimum Data Set (MDS, a comprehensive nursing home assessment of the resident) indicated that Resident 1 used walker and wheelchair to move, and required Substantial/Maximum assist to get from a sitting to standing position, partial assist to transfer from bed to chair or vice-versa.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not follow their infection prevention protocol when Certified Nurses Assistant (CNA 1) failed to wear the appropriate personal protective equipment (PPE) when in a room with a resident that was COVID positive. This failure had the potential to spread COVID-19 to other residents. Findings: During a review of a facility document titled, Guidance for Infection Prevention and Control for Residents with Suspected or Confirmed COVID-19, section III. Personal Protective Equipment (PPE), subsection B. Respirators and Face Masks, revised September 16, 2020, indicated, N95 respirators must be worn when entering a room or care area of a Resident who has been diagnosed with COVID-19. Subsection C. Gowns, Disposable isolation gowns are worn when entering a Resident room and discarded before leaving the room. During a review of California Department of Public Health document titled, All Facilities Letter-23-12 (AFL-23-12), dated January 24,2023, Resources:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record and facility policy review, the facility failed to ensure that call lights (an electronic sound and light communication device in the residents room that allows a resident to alert staff when they need help), was available for use and within the residents' reach for three of five residents sampled for call lights being within their reach. (Residents 1, 2, and 12) This failure had the potential for the residents not to be able to alert staff that they needed help which could lead to unmet needs, falls, and emotional frustration for the residents. Findings: A review of the facility's policy titled, Communication-Call System revised 8/24/24, indicated that, 2.The Call alert device will be placed within the resident's reach. 3. Facility Staff will answer call alerts promptly and in a courteous manner. A review of Resident 1's admission record indicated Resident 1 was admitted on [DATE] with diagnoses that include heart failure, dysphagia (difficulty swallowing foods or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an infection control program was implemented by Infection Preventionist (IP) to reduce the spread of infection in the facility for three of the three sampled residents (Resident 1, 2, and 3) when: 1. Resident 1 was tested positive for Multidrug-resistant organisms (MDROs - microorganisms or germs, such as bacteria or fungi, that are resistant to one or more classes of antimicrobial agents) in the urine (on 3/21/25) and wound (on 3/31/25). Resident 1 continued residing in a shared room (ROOM A) with two other residents (Resident 2, 3). 2. Resident 2 was transferred to ROOM A on 3/25/25, where Resident 1 resided. These failures had the potential to contribute to the spread of infection for residents who shared the room with Resident 1. Findings: During a review of The Centers for Disease Control and Prevention (CDC - the nation's leading science-based, data-driven, service organization that protects the public's health)'s website, the guideline 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 report to the California Department of Public Health (CDPH), an allegation of misappropriation of resident property when Resident 1's Bank Debit card (ATM card) was missing. This had the potential for resident financial abuse to go unrecognized and unresolved in the facility. Findings: The facility's policy revised 5/30/24, Abuse Prevention and Management , indicated, The facility does not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation, and/or mistreatment. The facility will report all allegations of abuse and criminal activity as required by law and regulations to the appropriate agencies .any suspicion off crimes are promptly reported . A review of Resident 1's clinical record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that include atherosclerotic heart disease (hardening of arteries from build-up of fat, cholesterol and other substances, known as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 narcotic (controlled drugs, also called opioid pain relievers with potential for abuse) medications for pain control were accurately used and documented in the medical records for one out (Resident 1) of eight sampled residents. This deficient practice had the potential for medication errors and risk of drug diversion. Findings: During a review of the facility policy titled, Medication – Administration , revised 1/1/2012, indicated: · The purpose of the policy is to ensure the accurate administrate of medications for residents in the facility. · Medication Rights: - Nursing staff will keep in mind the seven rights of medication wen administering medication. - The seven rights of mediation are: The right medication; the right amount; the right resident; the right time; the right route; Resident has right to know what the medication does; Resident has the right to refuse the medication (unless court ordered). During a review of the…

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

Based on interview, and record review, the facility failed to ensure three of 10 sampled residents (Resident 6, 8 and Resident 9) were treated with dignity and respect when Licensed Nurse (LN) D spoke to the residents with a demeaning tone, was rushing with medication administration, and was not gentle with medication administration. This failure had the potential to result in emotional stress, embarrassment, feelings of neglect, increased anxiety, fear, and isolation. Findings: The facility's policy revised 1/2012, titled, Residents' Rights, indicated the purpose of this policy is to promote and protect the rights of all residents at the facility. Employees are to treat residents with kindness, respect and dignity and honor the exercise of residents' rights. The facility's policy revised 3/2017, titled, Quality of Life-Dignity, indicated that each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. All residents shall be treated with dignity and respect at all times. Demeaning practices and standards of care that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and the facility's policy, the facility failed to update a change of condition for one of three sampled residents (Resident 1) when: 1.The Licensed Nurse (LN) did not update the physician when Resident 1 needed oxygen for a new onset of shortness of breath. 2. The LN did not notify Resident 1's family or responsible party when there was a major decline in health status. This failure resulted in a poor negative clinical outcome for Resident 1. Findings: 1. During a review of the facility's policy revised [DATE], titled, Change of Condition Notification, indicated A Licensed Nurse will notify the resident's Attending Physician and legal representative or an appropriate family member when there is an: A significant change in the resident's physical, mental or psychosocial status, deterioration in health, mental or psychosocial status, life-threatening conditions or clinical complications. Any untoward response or reaction by a patient to a medication or treatment. A need to alter…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review, and the facility's policy, the facility failed to ensure timely, accurate, and complete documentation for one of three residents (Resident 1) when there was a change in condition. This failure resulted in an incomplete, and an inaccurate clinical medical record, for Resident 1. Findings: During a review of the facility's policy revised 4/1/2015, titled, Change of Condition Notification, Documentation: A Licensed Nurse will document the following: Date, time, and pertinent details of the incident and the subsequent assessment in the Nursing Notes. The time the Attending Physician was contacted, the method by which he was contacted, the response time, and whether or not orders were received. The time the family/responsible person was contacted. iv. Update the Care Plan to reflect the resident's current status. The incident and brief details in the 24-Hour Report. If the resident is transferred to an acute care hospital, complete an inter-facility transfer form. Complete 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to assure that there was sufficient, qualified nursing staff available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being for 11 of 32 residents sampled for sufficient staffing (Residents 307, 407, 132, 408, 147, 20, 117, 52, and three confidential residents) when call lights were observed and reported to be left on for extended periods of time, and/ or resident(s) could not locate their call bell, resulting in bowel and bladder incontinence, residents being left in bowel movement and urine, or waiting for assistance in bed for a variety of reasons, including attempting to go to the toilet. This failure had the potential to result in skin breakdown, infection, increase of resident accidents and falls due to frustration and attempting self-help, decline in physical health status, humiliation and diminished…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and interview, the facility failed to provide a safe, clean, comfortable homelike environment for all residents when areas throughout the facility were unclean and/or in disrepair. 1. A trash can in the Station One shower room contained trash with no liner and was dirty 2. Resident 28's bed, restroom, bedside table, and walls were in disrepair 3. A wall mounted piece of electronics outside room three was missing from the wall. 4. The built-in wooden cabinet finishes in rooms [ROOM NUMBERS] appeared to be chipped, scratched, gouged and missing areas of finish and appear porous and uncleanable and unhomelike. 5. Resident 92's bathroom ceiling fan had an accumulation of greyish debris on the blades and did not work when it was turned on. This failure had the potential to negatively impact the residents' emotional and physical well-being. Findings: A review of the facility's policy and procedure titled, Resident Rooms and Environment, dated 12/1/12, indicated the facility will provide a safe,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prevent abuse for two of three sampled residents (Residents 16 and 63) when Resident 16 complained to nursing staff about verbal abuse from their roommate, Resident 63, and the residents were not separated. This failure resulted in a physical altercation between the two residents, which had the potential to threaten their health and well-being. Findings: A facility policy, titled, Abuse - Prevention, Screening, & Training Program, revised 7/1/18, was reviewed. The policy's stated purpose was to address the health, safety, welfare, dignity and respect of residents by preventing abuse. The facility did not condone any form of resident abuse. Verbal abuse was defined as any use of oral, written, gestured communication, or sounds that willfully included disparaging and derogatory terms directed to residents withing their hearing distance, regardless of age, ability to comprehend, or disability. Physical abuse was defined as, but not limited to, hitting,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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: 1. Parsley was stored under sanitary conditions when it was not labeled, dated or stored safely in the walk-in refrigerator. 2. The walk-in freezer was free from frost build up. These failures had the potential to result in foodborne illnesses. 1. During a concurrent observation and interview on the initial tour, in the walk-in freezer with Dietary Manager (DM), on 2/3/25 at 9:40 am, frost was noted to multiple areas on the ceiling of the walk-in freezer. DM confirmed frost was on multiple areas of the ceiling and confirmed frost should not be on the ceiling. During a concurrent observation and interview in the walk-in freezer, on 2/6/25 at 8:15 am with Maintenance Supervisor (MS), frost was noted on the ceiling. MS confirmed there was frost on the ceiling. MS stated frost has recently started to build up on the ceiling and the maintenance staff removed the frost but it continues to come back. 2. During a concurrent observation and interview on the initial tour, in the walk-in refrigerator with DM, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to keep complete and accurate records for one of five sampled residents (Resident 16) when documentation about skin assessments and treatments was inconsistent. This failure had the potential to negatively impact Resident 16's skin care and treatment, and to make it difficult to track the history and progress of any skin issues. Findings: A facility policy, titled, Skin Integrity (health) Management, revised 6/27/24, was reviewed. The policy indicated that a Licensed Nurse (LN) would have completed a skin evaluation when there was a change in skin integrity. Treatments to pressure injuries or other skin integrity conditions would have been ordered by the physician. Treatments administered would have been documented in the resident medical record. A facility policy, titled, Skin and Wound Management, revised 1/1/2012, was reviewed. The policy indicated that all Nursing Staff was responsible for the prompt reporting of any skin related…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observation and record review, the facility failed to meet this requirement when a nurse did not sanitize a blood pressure cuff in between using it on two of 32 sampled residents, (Residents 74 and 42). This practice was not supported by the facility's policy and resulted in the potential to spread infection and illness. Findings: Review of the facility's policy titled Cleaning and Disinfection of Resident Care Equipment, last revised 1/1/12, indicated that the purpose of the policy was To ensure that the cleaning and disinfection of environmental surfaces is in accordance with Centers for Disease Control and Prevention (CDC) and Occupational Safety & Health Administration. The policy further indicated, Resident care equipment, including reusable items and durable medical equipment, is cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. The policy indicated, Reusable items are cleaned and disinfected or sterilized between residents (e.g. stethoscopes, durable medical equipment). On 2/4/25…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 protect 1 out 3 residents (Resident 1) from abuse when, Licensed Vocational Nurse 1 (LVN 1) on duty told Resident 1 to mind his own f*ing business. Resident 1 stated he backed off and that the response from LVN 1 surprised him because they had got along prior to this. Resident 1 stated he asked LVN 1 how his Resident 2 was doing after her fall. He had his phone in his hand and asked if she wanted him to call 911. LVN 1 said, If you ' re calling 911, I will f*ing kill you. This had the potential to result in psychosocial harm. Findings: A review of a facility document titled, Abuse- Prevention, Screening, and Training Program, revised July 2018, defined abuse as the willful, deliberate infliction of injury .it includes verbal abuse, sexual abuse, physical abuse, mental abuse . A review of a facility document titled, Abuse Prevention and Management, copyright 2022, stated, The facility does not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation, and /or mistreatment. During…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 nursing staff respond in a timely manner to the resident's requests for assistance for three out of three sampled residents (Resident 3, Resident 4, and Resident 5), when: 1. Resident 3 was soiled, and the nursing staff was not available to assist Family 1 to change Resident 3. 2. Resident 4's call-light was on and was yelling for help for 12 minutes when she was leaning on the bedrail, three staff walked past Resident 4's room, and did not respond to Resident 4's calling for help. 3. Resident 5's call-light was not answer in a timely manner for multiple times. These failures resulted in Resident 3 and Resident 5 soiling their incontinence briefs which had a negative effect on the residents' self-esteem and self-worth and placing Resident 4 at risk of falling from her bed. Findings: During a review of the facility policy titled, Communication – Call System , revised 1/1/2012, indicated, The Facility will provide a call system…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 protect the resident's right to be free from physical abuse when Certified Nursing Assistant (CNA) D insisted on changing Resident 2's brief when Resident 2 refused and asked CNA D to leave. This failure caused a 4.5-centimeter (cm) x 5-centimeter (cm) bruise between Resident 2's thumb and the 1st finger, Resident 2 was angry and humiliated. Findings: During a review of the facility policy titled Abuse – Prevention, Screening, & Training Program , revised 7/2018, indicated: · The Facility does not condone and form of resident abuse, neglect, misappropriation of resident property, exploitation, and /or mistreatment and develops Facility policies, procedures, training programs, and screening and prevention systems to promote an environment free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment. · Abuse is defined as the willful, deliberate infliction of injury · Physical abuse is defined as, but not…

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

Based on interview and record review, the facility failed to provide appropriate staffing necessary to care for 4 out of 5 Residents sampled for nursing services (Residents 1, 2, 3, 4). Residents 1, 2, 3, and 4 had call lights wait times of 40-50 minutes, making them feel like the facility does not care, embarrassed, and concerned for their skin. Licensed Vocational Nurses 1, 2, 3, and Registered Nurse 1 feel overwhelmed, shifts are too hard, and feel they cannot care for their residents appropriately. Findings: Review of a facility document titled, Resident Council Meeting Minutes, dated 08/27/24, noted that call light times were ok but depends who is working. During a review of a policy and procedure titled, Nursing Department- Staffing, Scheduling & Postings, revised January 1, 2012, indicated that each facility will employ sufficient nursing staff. The Director of Nursing (DON- supervises all nursing duties) and the Administrator will establish nursing hours and make adjustments to meet residents' needs. According to the State Operations Manual, issued 08/08/24, the 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 protect one of five sampled residents (Resident 1) from being injured by staff. This resulted in a skin tear to the resident and had the potential to cause psychosocial (mental/socializing) harm. Findings Resident 1 was admitted to the facility with difficulty in walking, falls and a fractured leg, colon cancer, and vascular dementia, a type of memory loss from insufficient blood flow to the brain. Resident 1 was unable to complete a mental assessment conducted on 8/6/24 and was assessed with moderate impairment of her cognitive ability (mental health). A review of the facility ' s policy titled Abuse Prevention and Management, dated 1/1/12, indicated that the facility does not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation, or mistreatment. A review of a nearby hospital ' s admission record indicated that on 8/18/24 at 8:30 AM, Resident 1 was seen in the emergency room for a repair of a skin tear. Review of a report dated 8/19/24, filed by the facility to the California…

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

Based on interview and record review the facility failed to follow physician orders to consistently cover and protect Resident 2 ' s nephrostomy stoma (a hole in a resident ' s back with a tube to drain urine from the kidney into a bag) during showers, and failed to remove the dressings for Resident 2, Resident 3, and Resident 4 following their dialysis treatments as required. This had the potential to contribute to infection, illness, and may have contributed to an interruption to Resident 2, 3 and 4 ' s care. Findings Resident 2 was admitted to the facility for conditions including end stage renal disease (kidney disease worsening), diabetes, history of stroke, dementia, and was dependent on dialysis (using a machine to do the work of the kidney to clean the blood of waste). A review of the facility ' s policy titled, Dialysis Care, dated 10/1/18, indicated that the facility will arrange for dialysis care as ordered by the attending physician. The policy indicated, Facility Staff will educate resident on the importance of complying with the care plan and attending physician…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 2 of 3 residents sampled (Resident 1 and Resident 2), for assistance with activities of daily living (ADLs) received scheduled showers or baths, when twice weekly bathing was not completed scheduled. These failures had the potential to result in residents feeling depressed with poor self-esteem, and had the potential to contribute to skin breakdown, infection, and negatively impact their ability to attain or maintain their highest practicable level of well-being. Findings: A review of the facility ' s policy revised on 1/1/2012, titled, Showering and Bathing, indicated the purpose of a tab bath or shower is given to the residents to provide cleanliness, comfort, and to prevent body odors. This facility ' s policy also indicated to observe the skin during the bath or shower. A review of the facility ' s policy dated 8/31/22, titled Bed Bath, indicated residents are given baths as scheduled to promote cleanliness, comfort, and stimulate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 comply with applicable Federal, State, and local laws, regulations, and with accepted professional standards and principles for one of three sampled residents (Resident 1) when: 1. The administrator (ADMIN) requested Registered Nurse (RN) D to reword her progress note. 2. The administrator directed Licensed Nurse (LN) B to change LN A ' s progress note. 3. The administrator directed LN A to redraft his progress note, because the time on the note was showing the delay of the care. These failures had the potential to inaccurately document the care provided to all the residents, and the inappropriate care services go undetected and unreported to the authorities. Refer to F 678. Findings: During a review of California Penal Code, Section 471.5, indicated, Any person who alters or modifies the medical record of any person, with fraudulent intent, or who, with fraudulent intent, creates any false medical record, is guilty of a misdemeanor.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 immediately initiate Basic Life Support (BLS) including Cardiopulmonary Resuscitation (CPR- an emergency lifesaving procedure performed when the heart stops beating) when one of three sampled full code (as full support which includes cardiopulmonary resuscitation, if the patient has no heartbeat and is not breathing) residents (Resident 1) was found unresponsive and without a pulse in his bed, and staff took 10 minutes to start CPR on Resident 1. These deficient practices had the potential to delay provisions of emergency care for current residents who wish to have full treatments in a life-threatening situation. Findings: During a review of American Heart Association website page titled, What is CPR, indicated that CPR is an emergency lifesaving procedure performed when the heart stops beating. Immediate CPR can double or triple chances of survival after cardiac arrest. During a review of American Heart Association Basic Life Support (BLS) healthcare…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide sufficient nursing staff in the facility to meet the need of the residents' acuity (the level of severity of residents' illnesses, physical, mental, and cognitive limitations and conditions) when: 1. Facility failed to sufficiently staff multiple nursing Stations during the week of 3/30/2024 through 4/5/2024. 2. Residents 14, 2, 3, 4, 5, 6, and 8 did not receive showers as scheduled. This failure resulted in long wait times for call lights to be answered (average 30 minutes) and residents not receiving Activities of Daily Living (ADLs) including hydration and shower assistance. This had the resulted in residents to feel neglected and affected their dignity. Findings: 1. During a concurrent observation on 4/12/2024 at 11:15 am, a call light was initiated in room [ROOM NUMBER]A. Call light was not answered by a direct care staff member until 11:45 am. During a concurrent observation and interview on 4/12/2024 at 11:18 am, Resident 14…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide nursing staff with necessary competencies and skill sets to meet the care and services for residents' need for one of three sampled residents (Resident 1) when a change of condition was not promptly identified and reported to the physician. Resident 1 was experiencing signs and symptoms of stroke (a life-threatening medical emergency, when the blood supply to part of the brain is blocked or reduced) on 4/14/2024, he was transferred to the Acute hospital on 4/16/2024. This failure resulted in a three-day delay in transferring Resident 1 to the hospital for proper treatment, and increased Resident 1's pain and discomfort. Resident 1 suffered significant declines on his functional abilities: slurred speech, left-sided weakness, inability to swallow. Resident 1 died on 5/11/2024, within a month of his initial admission [DATE]). Findings: During a review of the facility's policy titled, Change of Condition , revised 11/18/2021,…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that a direct care staff interacted and communicated in a manner that promoted the mental and psychosocial well-being for one of three sampled residents (Resident 9) when the Certified Nursing Assistant (CNA) G said to Resident 9 Don't be a smartass . This failure resulted in upsetting Resident 9 and Resident was crying. Findings: During a review of Resident 9's clinical record, the record indicated, Resident 9 was originally admitted to the facility on [DATE] with diagnoses which included diabetes (high blood glucose), difficulty in walking, and need for assistance with personal care. Resident 9 was her own health care decision maker. During a review of Resident 9's Minimum Data Set (MDS - an assessment and care screening tool), dated 4/17/2024, the MDS indicated that Resident 9 had a brief interview for mental status (BIMS) score of 15, at section C Cognitive Patterns indicating that her cognition was intact. During a review of the facility'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 observation, interview, and record review the facility failed to develop and implement safe and successful discharge plan for one of 15 residents (Resident 15) when the Interdisciplinary Team (IDT, a team composed of nursing, social work, and therapy who develop resident plan of care) did not ensure she and her family were prepared for returning home. This resulted in Resident 15 to return to the skilled nursing facility with 24 hours of discharging after falling at home. Findings: A review of a facility policy titled Discharge and Transfer of Residents , revised 02/2018, indicated To ensure that discharge planning is complete and appropriate and that necessary information is communicated to the continuing care provider. The Facility may transfer or discharge a resident with an order from the resident's physician if the resident's health has improved significantly and services provided by the facility are no longer required. A review of Resident 15's admission record indicated she was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure equipment in the facility was maintained when: 1. The Central Air Conditioning (AC) system and Packaged Terminal Air Conditioners (PTAC, a standalone AC/heater, self-contained, meaning they do not rely on ducts to operate) on Station 3 and 4 were not working. This resulted in an uncomfortable temperature during the warmer months and resident discomfort. 2. A resident rooms lights did not work. This put two residents at risk for falls. Findings: During an observation on 5/9/2024 at 2 pm, the outside temperature was 83 degrees Fahrenheit (F). During a concurrent observation and interview with Maintenance Tech (MT A) on 5/9/2024 at 2:27 pm, the following room temperatures were observed in resident rooms that did not have working fans and chilling coils: - room [ROOM NUMBER]A: 76.7 F at wall thermometer - room [ROOM NUMBER]A: 76.7 F at wall thermometer -room [ROOM NUMBER]A: 79.3 F at wall thermometer During an interview with Resident 16…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 it ' s abuse policy for one of 3 sampled residents (Resident 1) when it did not identify, investigate, and protect a resident after the facility was informed of an abuse allegation involving Resident 1 and Responsible Party (RP, person legally responsible medical decisions). These failures resulted in Resident 1 to be physically held down by RP when he pushed her head down into her pillow and forced her mouth open during medication administration and put her at risk for further abuse and injuries.Findings: A review of facility policy titled Abuse - Prevention, Screen, & Training Program dated 11/18/2021, indicated the facility will protect the health, safety, and welfare of facility residents by ensuring that all reports of resident abuse, mistreatment, neglect, exploitation, injuries of an unknown source and suspicion of crimes are promptly reported and thoroughly investigated. The facility identifies, corrects, and intervenes in situations…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident ' s rights to be free from physical, mental, and verbal abuse for one of three sampled residents (Resident 1) was free from physical abuse by the Responsible Party (RP, person legally responsible for medical decisions). This resulted in Resident 1 to be physically held down by RP when he pushed her head down into her pillow and forced her mouth open during medication administration.Findings: A review of facility policy titled Abuse - Prevention, Screen, & Training Program dated 11/18/2021, indicated that the facility will protect the health, safety and welfare of Facility Residents by ensuring that all reports of resident abuse, mistreatment, neglect, exploitation, injuries of an unknown source and suspicion of crimes are promptly reported and thoroughly investigated. The facility identifies, corrects, and intervenes in situations in which abuse, neglect, exploitation, misappropriation of resident property and/or mistreatment is more…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of three residents (Resident 2) reviewed for admission and transfer processes was readmitted to the facility after a hospitalization. This failure had the potential to cause Resident 2 further psychosocial decline by not letting her return to the facility she called home. Findings: Resident 2's clinical record was reviewed. Resident 2 was admitted on [DATE] with diagnoses that included suicide attempt, (self-harm to kill themselves), sequela (chronic result or complication of a disease or trauma), suicidal ideations (thoughts of killing yourself with or without a plan), schizoaffective disorder, (a mental health problem with psychosis, loss of reality with mood symptoms), anxiety (feelings of constant worry, tension, and fear), and end stage kidney disease requiring dialysis (a treatment to filter the blood toxins). Review of Resident 2's annual minimum data set (MDS, a resident tool assessment) dated 01/14/24, indicated…

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

Based on interview and record review, the facility failed to protect one of seven sampled residents ' right to be free from verbal abuse by staff when a staff member used profanity directed to a resident. This resulted in the resident's rights being violated. Findings Resident 1 was admitted to the facility with a shoulder fracture, difficulty walking, and the need for assistance with his personal care. A review of the facility ' s policy titled, Abuse Reporting and Investigations, dated 2022, indicated that the facility will report all allegations of resident abuse . A review of the facility ' s record titled Elder Abuse dated 10/12/23 indicated that CNA D had been trained in reporting requirements for abuse and received training, and that verbal abuse was defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families. A review of a facility-provided record from Director of Nursing (DON D) dated 2/14/24 indicated that on February 10 at around 1:40 PM, a CNA E was observed by staff using the profanity…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record reviews, and document review, the facility failed to transmit Minimum Data Set (MDS) assessments within 14 days of the completion date for 5 (Residents #34, #48, #57, #68, and #100) of 5 sampled residents reviewed for resident assessments. Findings included: A review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2023, revealed Transmitting Data: Providers must transmit all sections of the MDS 3.0 required for their State-specific instrument, including the Care Area Assessment Summary and all tracking or correction information Transmission requirements apply to all MDS 3.0 records used to meet both federal and state requirements. Care plans are not required to be transmitted. - Assessment Transmission: Comprehensive assessment must be transmitted electronically within 14 days of the Care Plan Completion Date. All other MDS assessments must be submitted within 14 days of the MDS Completion Date. 1. A review of Resident #34's admission Record, revealed the facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations, interviews, record reviews, and facility policy review, the facility failed to ensure the medication error rate was less than 5 percent (%). There were six errors out of 32 opportunities, which resulted in a medication error rate of 18.75 % for 2 (Resident #103 and Resident #88) of 3 residents observed for medication administration. Findings included: Review of a facility policy titled, Medication - Administration, revised on 01/01/2012, revealed Purpose To ensure the accurate administration of medications for residents in the Facility. The policy specified, 1. Medication will be administered directed by a Licensed Nurse and upon the order of a physician or licensed independent practitioner. 1. A review of Resident #103's admission Record, revealed the facility admitted the resident on 04/07/2023, with diagnoses included type 2 diabetes, seasonal allergic rhinitis, and chronic pain. A review of Resident #103's Order Review History Report, for the time period 12/01/2023 to 12/31/2023, revealed: - An order for fluticasone propionate nasal suspension 50…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review and interviews, the facility failed to ensure a Minimum Data Set (MDS) was accurate for 1 (Resident #2) of 2 sampled residents reviewed for hospice services. Findings included: A review of Resident #2's admission Record revealed the facility readmitted the resident on 07/09/2023, with diagnoses that included hemiplegia and hemiparesis and type 2 diabetes mellitus. A review of Resident #3's significant change in status MDS, with an Assessment Reference Date (ARD) of 10/16/2023, revealed the resident had modified independence with cognitive skills for daily decision making based on the Staff Assessment for Mental Status (SAMS). The MDS revealed Resident #2 received hospice services. A review of Resident #2's comprehensive care plan, with an admission date of 07/09/2023, revealed no evidence to indicate the resident received hospice services. A review of Resident #2's physician orders, revealed an order with a revision date of 10/10/2023 to discontinue hospice services. During an interview on 01/18/2024 at 12:39 PM, MDS nurse #15 stated she knew Resident #2 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.

Based on interviews, record review, and facility policy review, the facility failed to develop and implement a comprehensive care plan to include food allergies for 1 (Resident #97) of 3 sample residents reviewed for food allergies. Findings included: Review of a facility policy titled, Comprehensive Person-Centered Care Planning, revised in November 2018, revealed the Purpose To ensure that a comprehensive person centered care plan is developed for each resident. Policy It is the policy of this Facility to provide person-centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being. Review of Resident #97's admission Record revealed the facility admitted the resident on 05/24/2023 with diagnoses that included acute on chronic systolic congestive heart failure, anxiety disorder, unspecified, chronic pain syndrome, essential primary hypertension, paroxysmal atrial fibrillation,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations, record review, interviews, and facility policy review, the facility failed to ensure physician's orders were followed for 1 (Resident #11) of 26 sampled residents. Findings included: Review of a facility policy titled, Physician Orders, revised on 11/16/2022, revealed The licensed nurse will confirm that physician orders are clear, complete and accurate as needed. A review of Resident #11's admission Record revealed the facility readmitted the resident on 08/25/2022. The admission Record revealed the resident had diagnoses that included hemiplegia and hemiparesis, chronic pain, and hereditary and idiopathic neuropathy. A review of Resident #11's quarterly Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 12/22/2023, revealed the resident had a Staff Assessment for Mental Status (SAMS), which indicated Resident #11 had severely impaired cognitive skills for daily decision making with long and short-term and long-term memory problems. The MDS revealed the resident received scheduled pain medication regime, PRN (pro re nata; as needed) pain…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations, interviews, record review, and facility policy review, the facility failed to implement measures to ensure 1 (Resident #97) of 3 sampled residents reviewed for food allergies did not receive a food they were allergic to. Findings included: Review of a facility policy titled, Diet Record Maintenance, revised on 06/01/2014, revealed Purpose To ensure that the facility provides residents with meals that meet the nutritional and consistency requirements per physician orders. Policy The dietary department will maintain a system to record dietary information necessary to use on the resident's tray card. Procedure 1. The diet record system will contain the following information to be reflected on the resident's tray card: A. Name; B. Room number and bed location; C. Dining location, as applicable; D. Diet order; E. Resident's diet pattern, if different from the dietary policies or therapeutic diet extension sheet; F. Physician ordered supplemental feeding or extra nourishment provided to the resident beyond those listed on the therapeutic diet extension sheet; G.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 direct care staff interacted and communicated in a manner that promoted the mental and psychosocial well-being for one of three sampled residents (Resident 3) when the Nursing Assistant (NA) 3 said to Resident 3 You got a big booty. This failure resulted in upsetting Resident 3. Findings: During a review of Resident 3 ' s clinical record, indicated that she was originally admitted to the facility on [DATE] with diagnoses which included diabetes (high blood glucose), difficulty in walking, and need for assistance with personal care. Resident 3 was her own health care decision maker. During a review of Resident 3 ' s Minimum Data Set (MDS - an assessment and care screening tool), dated 12/04/2023, the MDS indicated that Resident 1 had a brief interview for mental status (BIMS) score of 15, at section C Cognitive Patterns indicating that her cognition was intact. During a review of Resident 3 ' s Interdisciplinary Team (IDT, a group 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 protect the resident ' s right to be free from physical abuse when Resident 2 smacked one of three sampled residents (Resident 1) on the hand. This had the potential to negatively impact Resident 1 emotionally and psychologically. Findings: During a review of the facility policy titled Abuse – Prevention, Screening, & Training Program, revised 7/2018, indicated: 1. The Facility does not condone and form of resident abuse, neglect, misappropriation of resident property, exploitation, and /or mistreatment and develops Facility policies, procedures, training programs, and screening and prevention systems to promote an environment free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment. 2. Physical abuse is defined as, but not limited to, hitting, slapping, punching, and/or kicking. It also includes corporal punishment which is physical punishment used to correct and/or control behavior. 3. Willful, as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 this requirement was not meant when two of four sampled residents heard staff arguing in the hall outside their rooms. This resulted in creating and environment that disturbed the residents ' sense of well-being and had the potential to cause depression or symptoms to worsen in two residents who had a history of psychiatric problems. Findings 1. Resident 1 was admitted to the facility for Parkinson ' s Disease (a disease of the nervous system that causes tremors and weakness), depression, psychotic disorder (mental problem) with delusions. In an interview on 1/15/24 at 1:15 PM, Resident 1 stated that he recently overheard staff arguing in the hallway outside his room. Resident 1 stated that it upset him and that he didn ' t feel safe, adding, How can I feel safe in a place where the staff is hostile to one another? In an interview on 1/15/24 at 1:55 PM, Minimum Data Set Coordinator (MDS 1) (MDS conducts admission and follow up assessments of residents ' capabilities) confirmed that she had a disagreement regarding a medical order with Licensed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review and revise a comprehensive care plan for two of eight sampled residents, (Resident 2 and Resident 6) when: 1-Resident 2 did not have specific interventions listed for staff to provide nectar thickened (a specific type of consistency of liquids needed for problems swallowing, a common problem after a stroke), liquids for safety while drinking fluids per physician ' s orders. 2-Resident 6 did not have specific interventions for staff to provide Foley catheter (a sterile tube placed into the bladder to drian urine), care (cleansing of the tube site with soap and water to prevent infections), and to empty catheter drainage bag. This failure had the potential to have negative clinical outcomes including infection of the lungs, (aspiration pneumonia, a serious health issue, an infection caused by liquids going into the lungs instead of the stomach), Urinary Tract Infection (UTI), dehydration, and possible hospitalizations. Findings:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide activities of daily living, (adls, are activities related to personal care. Adls include bathing, dressing, getting in and out of bed or a chair, walking, toileting, and feeding) assistance. 1-No water was provided for Resident 6 on 11/20/23 and 11/28/23 on the bedside table. 2-Incontinent care was not provided for Resident 2 and Resident 8 on 11/20/23. 3-Foley Catheter (F/C) drainage bag was not emptied for Resident 6, and F/C care was not provided on 11/18/23. 4-Resident 4 did not receive a dinner meal with assistance needed to eat when the meal trays were delivered on 11/21/23. This failure resulted in the potential for physical decline, including the potential for a bladder infection, altered skin integrity, potential for dehydration, and the potential for a decline in psychosocial wellbeing. Findings: 1-The facility ' s policy undated, titled, Residents ' Rights, indicated each and every resident in the facility has the right…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 eight sampled residents (Resident 5) was treated with dignity and respect when Resident 5 was rushed while being fed by the Certified Nursing Assistant (CNA) N, and Resident 5 was spoken to with a demeaning tone and attitude. This failure had the potential to result in emotional stress, embarrassment, feelings of neglect, and the potential for negative clinical outcomes, such as weight loss. Findings: The facility's policy revised 3/2017, titled, Quality of Life-Dignity, indicated that each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. All residents shall be treated with dignity and respect at all times. Demeaning practices and standards of care that compromise dignity is prohibited. The staff shall promote dignity and assist the residents as needed by promptly responding to the residents' request for activities of daily living (adls, are activities related to personal care. Adls include bathing, dressing, getting in and out of bed or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility filed to protect the resident ' s right to be free from verbal abuse by the Certified Nursing Assistant (CNA) 1 who used profanity while providing care for one of three sampled residents (Resident 2). This resulted in Resident 2 tearing up and withdrawing from social interaction. Findings: During a review of the facility policy titled Abuse – Prevention, Screening, & Training Program, revised 7/2018, indicated: 1. The Facility does not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation, and /or mistreatment and develops Facility policies, procedures, training programs, and screening and prevention systems to promote an environment free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment. 2. Verbal abuse is defined as any use of oral, written, gestured communication, or sounds that willfully includes disparaging and derogatory terms directed to residents within their hearing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. update the care plan for one of three sampled residents (Resident 2); 2. hold an Interdisciplinary Team (IDT—a group of professionals from different disciplines who met to discuss the residents' care) meeting to address a new problem added to the Care Plan of another one of three sampled residents (Resident 1). These failures had the potential to negatively impact the residents' quality of life by failing to identify and address unmet needs. Findings: A facility policy, titled, Comprehensive Person-Centered Care Planning, revised 11/1/18, was reviewed. The policy indicated the facility would have provided person-centered, comprehensive and interdisciplinary care that reflected best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being. The comprehensive care plan would have been periodically reviewed 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 provide competent nursing care to 1 of 4 sampled residents (Resident 1) when Certified Nursing Assistant (CNA)1 and Nursing Assistant (NA) 2 did not implement the care plan to safely transfer Resident 1 from her wheelchair to her shower chair. This failure resulted in an avoidable fall for Resident 1 and caused fractures to her right knee, pain, and delay in physical therapy treatments. (Reference F689) Findings: A review of Resident 1's admission Record indicated she was admitted to the facility on [DATE] with diagnoses that included displaced trimalleolar fracture of right lower leg (a fracture of the bones of the ankle), morbid (severe) obesity (severely overweight) and difficulty walking. A review of Resident 1's Lift/ Transfer Evaluation dated 8/18/2023 indicated the resident could bear weight and her current weight was over 200 pounds. A review of Resident 1's Minimum Data Set (a process for clinical assessment of all residents 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's Governing Body (GB), legally responsible for establishing and implementing facility policies, failed to effectively manage the facility when: 1. The facility failed to ensure the Air Conditioning (AC) system on Station 1 and 2 were in operating condition to keep temperatures at a comfortable level for residents. 2. Facility did not ensure building was maintained in safe, secure, clean and homelike manner. This had the potential for accident and hazards when the portable AC units were not used according to manufacturer's instructions. 3. The facility failed to ensure sufficient and competent nursing staff to meet the needs of all residents. This resulted in activity of daily living resident needs not to be met. Refer to F 584, F689, F725 and F 908. Findings: 1. A review of policy titled Governing Body, dated July 22, 2021, indicated the Governing Body has full legal authority and responsibility for the management and operation of the Facility. The Governing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews and record review the facility failed to ensure a clean and comfortable home-like environment when: 1. Facility temperatures made residents on Station 1 and 2 uncomfortable during the summer. 2. Residents 8, 16, 15, 14, 13 and 34 did not have a clean and homelike environment. These failed practices resulted in disturbed sleep patterns, discomfort, skin rashes, and emotional distress. Findings: 1. On 8/16/23, during an observation of Resident Rooms 1-42 on Station 1 and 2, indicated 15 rooms had fans, 3 rooms had portable air conditioning (AC) units and 6 rooms had both fans and portable AC units. There were 7 large portable AC units located throughout the common areas of Station 1 and 2. During record review of document titled Resident Grievance/Complaint Investigation Report dated 7/17/23 the family member of Resident 5 wrote that the room is extremely hot and at times unbearable , and the dining room on Station 1 is also very hot. On 7/25/23 Director of Property Maintenance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safety of all residents when: 1. The main entrance to the facility was observed to be unsecured outside of normal working hours. This failure had the potential to allow 4 of 4 residents at risk for elopement (leaving the facility unsafely or unescorted) to leave the facility and for unrestricted and unsafe access to the facility by unwelcome and unwanted persons after hours. 2. Multiple tripping, falling, and electrical hazards caused by cooling equipment observed in resident rooms. This failure had the potential for all residents, staff and visitors to be a risk for injuries related to falling and electrical fires. Findings: 1. Upon entrance to the facility on 8/15/23 at 5:08 AM, the main entry door was observed to be propped open with a newspaper. During an interview on 8/15/23 at 5:10 AM at Nurses Station 1, Licensed Vocational Nurse (LVN) 1 stated the front door was supposed to be locked after hours to keep the wanderers…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews and record review the facility failed to provide nursing staff to meet the needs of the residents when: 1. There was insufficient nursing staff to assure resident safety, comfort and to attain and maintain the highest practicable physical, mental and psychosocial well-being of each resident. 2. Nursing assistants did not receive orientation and mentoring post graduation from CNA program. These failures resulted in residents having to wait for extended times for assistance, not being provided scheduled baths/showers, and had the potential for unwitnessed falls, skin breakdown, and frustration when resident needs were not met. Findings: 1. On 8/15/23 at 5:08 AM, at Nurses Station 1 during interview with Licensed Vocational Nurse (LVN) 1 she stated that staffing is awful, has worked here for 15 years and there was a lot of staff turnover. During interview at 8/15/23 at 5:34 AM, Resident 1 stated other residents are being neglected at dinner time. Resident 1 stated they need more…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 all equipment in the facility was maintained when: 1. Central air conditioning (AC) system was not maintained. This resulted in an uncomfortable temperature range and caused resident discomfort. 2. Portable AC units were not used according to manufacturer's instructions. 3. Shower room and leaking AC pipes in a resident room ceiling exposed corroded, conduit and electrical wiring. This had the potential to put all residents at risk for building hazards and fires. Findings: 1. On 8/15/23 at 6:40 AM, during a concurrent observation and interview, on Station 4 Certified Nursing Assistant (CNA) 4 stated if she had to work on Station 1 or 2, she would quit as it gets too hot in the summer. Station 1 and 2 was the older hot side and Station 3 and 4 were the newer cool side. On 8/15/23, at 9:25 AM in room [ROOM NUMBER] Resident 5 reported it gets really hot sometimes. During an observation on 8/15/2023 at 4:15 PM, in the activity/dining…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure one out of 3 residents (Resident 1) had an intervention in the care plan directing nursing staff how to safely transfer Resident 1. This failure had the potential for Resident 1 to be transferred incorrectly and cause an injury. Findings: During a review of Resident 1's record titled, admission Record, Resident 1 was admitted to the facility on [DATE]. Resident 1's medical diagnoses included morbid obesity, osteoarthritis to left knee and hip, chronic respiratory failure, and lack of coordination. During a review of Resident 1's record titled, Weights, dated 1/27/2023-9/6/2023, indicated Resident 1 weighed 267 pounds in January 2023 and 290 pounds in September of 2023. During a review of facility record titled, Incidents by Incident Types, dated 1/1/2023 to 8/29/2023 indicated, Resident 1 had falls on 1/3, 2/15,3/8, 5/29 and 6/19/23. During a review of Resident 1's record titled, Care Plan, no records were found in the 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 provide three out of three sampled residents (Resident 1, 2, and 3) with appropriate services to maintain or prevent a decline in range of motion (ROM, the normal movements that a joint should be able to perform, for example bending the head down or raising an arm up) when: 1a. Restorative Nursing Program orders were not followed for Resident 1. 1b. Restorative Nursing Program orders were not followed for Resident 2. 1c. Restorative Nursing Program orders were not followed for Resident 3. This failure had the potential to cause a decline in ROM and mobility which could negatively impact resident health status out-comes and well-being. Findings: During a review of the facility's policy and procedure (P&P) titled, Restorative Nursing Program Guidelines, revised 9/19/19, indicated, This program actively focuses on achieving and maintain optimal physical, mental, and psychosocial functioning unless a decline is unavoidable based on the resident's clinical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide needed care and services for one out three sampled residents (Resident 1) when wound care orders and recommendations were not followed, and documentation was not present that reflected Resident 1's choices regarding care being provided. This failure had the potential to result in wound worsening, a decline in health status, and negatively affect Resident 1's overall well-being. Findings: During a review of the facility's policy and procedure (P&P) titled, Physician Orders, revised 8/21/20, indicated the purpose of the P&P was To have a process to verify that all physician orders are complete and accurate, and Documentation pertaining to physician orders will be maintained the Resident's medical record. During a review of the facility's P&P titled, Skin and Wound Management, revised 1/1/12, indicated facility staff would Update the resident's Care Plan as necessary. The P&P indicated documentation would be included in 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure medical records were complete when: 1. There was no documentation present in the medical record for one out three sampled residents (Resident 1), that indicated the physician had been notified when Resident 1 had a decrease in meal consumption (eating less). 2. Certified Nurse Assistants (CNA) did not consistently document meal percentages (amount of meal eaten), when nourishment (snacks) had been provided, or if meal substitutions (a different meal) had been offered for three out of three sampled residents (Resident 1, 2, and 3). These failures had the potential to negatively impact resident care which could lead to negative clinical outcomes and cause a delay in care for residents with weight loss. Findings: 1. During a review of the facility's policy and procedure (P&P) titled, Completion and Correction, revised 1/1/12, indicated, the purpose of the P&P was To ensure that medical records are complete and accurate , descriptive, and document…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Certified Nursing Assistants (CNAs) had the competency and skills to communicate a change of condition when CNA 1 did not report to a licensed nurse immediately after Resident 1 was injured during repositioning in bed. This failure resulted in a delay in assessments, care and pain for Resident 1. Resident 1 reported the incident to staff two days after the event and a small bruise was noted on her right wrist. Findings: A review of policy titled, Abuse and Neglect indicated all staff will receive training upon hire on elder abuse incidence, signs and symptoms and reporting requirements. A review of policy titled, Abuse-Prevention, Screening & Training Program dated July 2018 indicated the facility conducts mandatory staff training in reporting to whom and when to report without fear of reprisal, and understanding resident behavioral symptoms that may increase the risk of abuse and neglect and how to respond. A review of Resident 1's record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to address and monitor the safe storage and handling of medications and biologicals in accordance with manufacturers' specifications and standards of practice. This failure resulted in medication refrigerators in Med room [ROOM NUMBER] and #2 having temperatures out of range for 20 days without documented interventions or follow-up, and 11 days with no temperatures recorded. This failure had the potential to result in decreased potency or new side effects of the medications administered to residents. Refer to F658. Findings: During an observation of Medication room [ROOM NUMBER], on 08/10/2021 at 1:20 PM, the medication refrigerator thermometer read 34 degrees Fahrenheit. In a concurrent interview with Licensed Vocational Nurse (LN), LN D looked in the medication refrigerator and confirmed the thermometer read 34 degrees Fahrenheit. LN D also stated that the temperature range should be between 36 to 48 degrees Fahrenheit, and if it was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2.a. During an observation in Resident (Resident 11) in room [ROOM NUMBER] C, on 08/09/21 at 7:54 AM, the following was noted a 5 inch by 7 inch hole in a wall behind Resident 11's bed with sheet rock exposed and peeling wallpaper above baseboard with dried light brown, liquid stains. b. During a concurrent observation and interview with Plant Maintenance (PM A) in room [ROOM NUMBER] C, on 08/12/2021 at 8:55 AM, PM A stated he did not know about this damage to the wall and that he was going to patch it up immediately. Using a facility measuring tape, PM A measured the hole in the wall as approximately 5 inches x 7 inches. c. During a concurrent observation and interview with Resident 4 in room [ROOM NUMBER] C, on 08/10/2021 at 7:30 AM, it was noted that dried bright pink nail polish was on floor beside resident bed and on the bottom of the bedside table stand. Resident 11 stated the staff have seen it but they can't clean it up, and It doesn't bother me anymore. d. During a concurrent observation and interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide sufficient nursing services when 1. 7 of 21 sampled residents (Residents 5, 18, 20, 42, 56, 67, 74) 2. four of 8 confidentially interviewed residents reported that their call lights were not answered in a timely manner. As a result, one resident was mad and one felt humiliated. This failure had the potential to affect residents' dignity, quality of care and for the residents not to receive nursing services in a timely matter. Findings: 1.a. A review of the medical record for Resident 56, indicated, she was admitted to the facility on [DATE] with diagnoses included urinary tract infection, malnutrition and anxiety. The admission Minimum Data Set (MDS, a standardized resident assessment), indicated the resident's Brief Interview for Mental Status (BIMS. The BIMS test is used to get a quick snapshot of how well a person is functioning cognitively at the moment) score was 11 (moderately impaired cognition). 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 observation, interview, and record review, the facility failed to ensure medications were administered per manufacturers instructions and physician orders when: 1. Respiratory rate was not assessed prior to administration of a medication as directed. 2. Medication doses were not being delivered as instructed in physician orders or per manufacturer specifications and professional standards. This failure resulted in an error rate of 18.25 percent and had the potential to cause decreased therapeutic effects of medications, and respiratory depression. Findings: 1. a. During an observation of a medication pass with a Licensed Vocational Nurse (LN) on Station 1, on 08/10/2021 at 8:35 AM, it was observed that LN B administered Morphine Sulfate (opiate used for severe pain relief) 30 milligrams (mg) orally to Resident 11. The nurse did not assess the resident's (Resident 11) respiratory rate before giving the medication, as directed in the physician's order. b. A record review of a medication administration record (MAR) for Resident 11, dated 08/2021, stated to hold the medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 kitchen equipment in safe working order when there were ice deposits on the ceiling by the freezer fan, and water leaking from a drainage pipe from the ice machine. These failures had the potential to cause contamination of the food by germs and dirt which could have made residents ill. Findings: Review of the facility policy, titled, Maintenance Service, revised 1/1/2012, indicated its purpose was to protect the health and safety of residents, visitors, and Facility Staff. The Maintenance Department maintained all areas of the building, grounds, and equipment. Functions of the Maintenance Department included maintaining the building in good repair and free from hazards. During an observation, on 8/9/2021, at 7:56 AM, there was a small puddle of water underneath the pipes that drained from the ice machine into the air gap hole in the floor. The Dietary Manager (DM) confirmed there was water on the floor. During a concurrent observation and interview, on 8/11/2021, at 9:27 AM, there was a slow drip…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 nursing staff failed to follow manufacturers' specifications and standards of practice for the safe storage and handling of medications and biologicals. This failure resulted in medications and vaccines being stored in temperatures not in accordance with professional standards of quality, and had the potential to result in decreased potency or new side effects of the medications administered to residents. Refer to tag F761 Findings: During an observation of Medication room [ROOM NUMBER], on 08/10/2021 at 1:20 PM, the medication refrigerator thermometer read 34 degrees Fahrenheit. In a concurrent interview with Licensed Vocational Nurse (LN), LN D looked in the medication refrigerator and confirmed the thermometer read 34 degrees Fahrenheit. LN D also stated that the temperature range should be between 36 to 48 degrees Fahrenheit, and if it was out-of-range she would adjust the thermostat to correct the temperature and re-check after an hour. If the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facilty failed to make sure that two residents (Residents 10 and 46) were kept free of accident hazards when: 1. both residents were left unattended in beds in the high position; 2. Resident 46 was left up in a wheelchair in their room without supervision or access to their call light. Leaving beds in the high position posed a safety hazard to the residents and not having a call light within reach to call for help put the resident at risk for falls and injuries. Findings: 1. A review of Resident 10's clinical record showed an original admission to the facility on 7/11/2018 with diagnoses that included dementia, convulsions, and generalized weakness. Resident 10's Minimum Data Set (MDS--a standardized resident assessment) showed a Brief Interview for Mental Status (BIMS--a screening tool used in nursing homes to assess intellectual function) score of seven, which indicated severe mental impairment. During an observation, on 8/9/2021, at 11:59 AM, Resident 10 was lying 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.