El Encanto Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure bilateral (both sides) side rails pads were free from damaged, wear and tear, for one of one sampled resident (Resident 3). This deficient practice had potential to place Resident 3 at risk for injury from the use of damaged side rail pads. Findings: During a review of Resident 3's admission Record (AR), the AR indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia (a group of conditions, decline in mental ability, that interfere with daily activities)and senile degeneration of the brain (a decline in mental abilities, particularly memory and thinking skills, often associated with old age). During a review of Resident 3's Care Plan (CP), dated 9/26/2022, the CP indicated Resident 3 was on side rail management as enabler (assistive device that aids with mobility). The CP's intervention indicated for nursing staff to check the side rails periodically for safety/security, to refer…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff did not give medications to one of three sampled residents (Resident 1) without a current physician's order as indicated in the facility's policy and procedure (P&P) titled, Medication Administration. This deficient practice had the potential to result in the unnecessary use of medication, medication errors, and adverse side effects for Resident 1. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 10/19/2020, with diagnoses that included non-displaced intertrochanteric fracture of right femur (a type of fracture that occurs in the upper part of the thigh bone), dementia (a group of symptoms affecting memory, thinking and social abilities), and difficulty in walking. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 1/26/2025, the MDS indicated Resident 1 was usually understood by others and had the ability to usually understand others. The MDS indicated Resident 1 was dependent (helper does…

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

Based on interview and record review, the facility failed to follow the facility ' s policy and procedure (P&P) titled, Charting and Documentation, by failing to document a complete assessment (the process of evaluating a patient's condition) for one of three sampled residents ' condition (Resident 1). This deficient practice had the potential to not provide complete information regarding Resident 1 ' s condition. Findings: During a review of Resident 1 ' s admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 10/19/2020 with diagnoses that included non-displaced intertrochanteric fracture of right femur (a type of fracture that occurs in the upper part of the thigh bone), dementia (a group of symptoms affecting memory, thinking and social abilities), and difficulty in walking. During a review of Resident 1 ' s Minimum Data Set (MDS – a resident assessment tool), dated 1/26/2025, the MDS indicated Resident 1 was usually understood by others and had the ability to usually understand others. The MDS indicated Resident 1 was dependent (helper does all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident's call light was within reach for two of two sampled residents (Residents 20 and 27). These deficient practices had the potential for Residents 20 and 27 not to receive necessary care or received delayed services to meet the residents' needs. Findings: a. During a review of Resident 20's admission Records (AR), the AR indicated Resident 20 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (a brain condition caused by a chemical imbalance in the blood) and Parkinson's disease (disease that affects the nerve cells in the brain that produces symptoms that include muscle rigidity, tremors, and changes in speech and gait) During a review of Resident 20's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 5/9/2024, the MDS indicated Resident 20 had severely impaired cognition (ability to understand) and required maximal assistance (helper does more than…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the resident's Advance Directive/Preferred Intensity of Care Documentation form (AD, a written instruction, recognized under State law relating to the provision of health care when the individual becomes incapacitated [lacking the ability to meet essential requirements for physical health, safety, or self-care]) was in the resident's medical record for two of two sampled residents (Resident 35 and 2). These failures had the potential for staff to provide care and services against the resident's will. Findings: a. During a review of Resident 35's admission Record (AR), the AR indicated Resident 35 was admitted to the facility on [DATE] with diagnoses that included dependence of renal dialysis (treatment for kidney failure [loss of kidney function] that removes unwanted toxins, waste products and excess fluids by filtering the blood) and fracture (broken bone) of the lower leg. During a review of Resident 35's AD form dated [DATE], the AD form…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were provided with a communication device in a language that the resident understood for two of three sampled residents (Residents 20 and 34). These deficient practices had the potential to affect Residents 20 and 34's communication with the staff and had the potential for the delay of the provision of care, treatment, and services to the residents. Findings: a. During a review of Resident 20's admission Records (AR), the AR indicated Resident 20 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (a brain condition caused by a chemical imbalance in the blood) and Parkinson's disease (disease that affects the nerve cells in the brain that produces symptoms that include muscle rigidity, tremors, and changes in speech and gait) During a review of Resident 20's untitled Care Plan (CP), dated 8/2/2023, the CP indicated Resident 20 spoke another language/dialect. Resident 20 spoke…

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

Based on observation, interview, and record review, the facility failed to store and prepare food in accordance with the facility's Policy and Procedure (P&P) on dating open food containers, refrigerated food storage labeling and dating and hair net policy, for one of one facility kitchen, by failing to: A. Label one bottle of salad dressing, one carton of milk, one canister of chopped onion seasoning, one canister of garlic herb cayenne pepper, and one canister of chicken flavor base, with the open date. B. Discard one tray of nourishments that contained yogurt, prunes, and cottage cheese from the refrigerator dated 6/12/2024. C. Wear a beard net for two staff members who had facial hair while working in the facility's kitchen area on 6/19/2024. These failures had the potential to result in food contamination and food borne illnesses (illness from ingesting contaminated food). Findings: During an observation on 6/18/2024 at 9:50 am in the kitchen, one bottle of salad dressing, one carton of milk, one canister of chopped onion seasoning, one canister of garlic herb cayenne pepper,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 its binding arbitration agreements included selection of a venue convenient to both facility and resident/resident responsible party for three of three sampled residents (Residents 16, 20 and 35). These deficient practices placed Residents 16, 20 and 35 at risk for unjust arbitration and delayed arbitration hearing in an event of an arbitration dispute. Findings: a. During a review of Resident 16's admission Record (AR), the AR indicated the facility admitted Resident 16 on 5/6/2024 with diagnoses that included dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning), essential hypertension (elevated blood pressure without a known cause) and type 2 diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in elevated levels of glucose/sugar in the blood and urine). During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a quarterly Minimum Data Sets (MDS - a comprehensive standardized assessment and screening tool) was timely completed within the required time frame for one of one sampled resident (Resident 4). This deficient practice had the potential to negatively affect the provision of necessary care for Resident 4. Findings: During a review of Resident 4's admission Record (AR), the AR indicated the facility admitted Resident 4 on 9/16/2022, with diagnoses that included dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) and malnutrition. During a review of Resident 4's MDS dated [DATE], the MDS indicated the MDS was a quarterly MDS assessment and was not yet completed as of 6/8/2024. During a review of the Center for Medicare and Medicaid Services (CMS, a federal agency that administers the Medicare program and works with state governments to administer the Medicaid 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 develop a specific and individualized person-centered care plan to meet the resident's needs for one of one sampled resident (Resident 20) who was assessed with hearing difficulty. This deficient practice had the potential for Resident 20 not to receive the necessary care, treatment, and services. Findings: During a review of Resident 20's admission Records (AR), the AR indicated Resident 20 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (a brain condition caused by a chemical imbalance in the blood) and Parkinson's disease (disease that affects the nerve cells in the brain that produces symptoms that include muscle rigidity, tremors, and changes in speech and gait) During a review of Resident 20's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 5/9/2024, the MDS indicated Resident 20 had severely impaired cognition (ability to understand) and required maximal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 label and date the Intravenous (IV- administered into a vein) site consistent with professional standards of practice for one of one sampled resident (Resident 93). This deficient practice had the potential to result in infection and worsen Resident 93's medical condition. Findings: During a review of Resident 93's admission Record (AR), the AR indicated Resident 93 was admitted to the facility on [DATE], with diagnoses that included dysphagia (difficulty swallowing) and malignant neoplasm of the lung (lung cancer). During a review of Resident 93's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 6/13/2024, the MDS indicated Resident 93 had moderately impaired cognition (ability to understand). The MDS indicated Resident 93 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) for personal hygiene, toileting and rolling left and right. During a review of Resident…

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

Based on observation, interview, and record review, the facility failed to follow the its Policy and Procedure (P&P) on Enhanced Barrier Precaution (EBP, precautions that include the use of a gown and gloves during high contact resident care activities for residents) to prevent the spread of infections for one of five sampled residents (Resident 35) for infection control when Licensed Vocational Nurse 7 (LVN 7) did not don (put on) personal protective equipment (PPE, equipment worn to minimize exposure to hazards ) before taking the blood pressure of Resident 35 in an EBP room. This failure had the potential to result in transmission of multidrug-resistant organisms (MDRO, bacteria that is resistant to antibiotics) to other residents in the facility. Findings: During a concurrent observation and interview on 6/19/2024 at 9:41 am with LVN 7, an EBP sign was noted outside of Resident 35's door. LVN 7 entered Resident 35's EBP room without donning on PPE and took Resident 35's blood pressure. LVN 7 stated LVN 7 did not have a gown on when taking Resident 35's blood pressure and stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to report an injury of unknown origin for one of two sampled residents (Resident 1) to the Ombudsman and local law enforcement. This deficient practice had the potential for delayed investigation of abuse for Resident 1. Findings: During a review of Resident 1's admission Record, the admission record indicated the facility admitted the resident on 8/22/2016, with diagnoses that included dementia (a loss of cognitive functioning such as thinking, remembering, and reasoning that interferes with a person's daily life and activities) and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks. During a review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 11/23/2023, the MDS indicated Resident 1's cognitive (ability to understand) skills for daily decision making was severely impaired. The MDS indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a comfortable and safe temperature in one of two hallways in Station 2 and two of 34 resident's rooms, affecting three of 34 sampled residents (Residents 7, 19 and 33). This deficient practice had the potential to affect the resident's safety and well being. Findings: During an observation on 7/11/23 at 10:48 am, Resident 7 was sitting in the wheelchair (w/c) in the hallway. The resident was fanning her face. During a concurrent interview, Resident 7 stated it was hot in the hallway and complained that the temperature gets very hot at the facility. During an interview on 7/11/23 at 3 pm, Resident 7 was in her room, lying in bed. Resident 7 complained the room felt too hot, and she was not comfortable. During an observation on 7/11/23 at 3:02 pm, Licensed Vocational Nurse 1 (LVN 1) entered Resident 7's room and informed Resident 7 that only the maintenance department could adjust the temperature in the resident's room. Resident 7's…

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

Based on observation, interview and record review, the facility failed to ensure safe serving of food. During a food tray line observation ( system of food preparation in which trays move along) on 7/12/23 , 20 hot food items during the 12 pm tray line were under 145 degrees Fahrenheit (F- unit of temperature measurement) for starch and vegetables, meat or entrees, and soup, according to the facility's Policy and Procedure for Resident Meal Service. This deficient practice had the potential for residents to be exposed to food-borne illness. Findings: During a tray line observation in the kitchen on 7/12/23 at 11:50 am, with Dietary Supervisor (DS), DS checked the temperature of the hot food on the steam tables just before the 12 pm tray line for lunch with the following findings: 1. Regular texture ham: 104 degrees 2. Regular texture yams: 130 degrees F 3. Turkey breast: 130 degrees F 4. Chicken patty: 140 degrees F 5. Ground cauliflower: 140 degrees F 6. Four (4) individual porridge cups: 120 degrees F each 7. Ground chicken: 130 degrees F 8. Puree cauliflower: 140 degrees F 9.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 necessary qualifications were met and in-services (education) were provided, for one of one kitchen staff (Dietary Supervisor, DS) when the DS was hired without having a California Food Handler (CFH, designated to ensure employees who handle food receive reasonable level of training in food safety practices to reduce the potential for food-borne illnesses [caused by contaminated food that can lead to food poisoning) card from the American National Standards Institute (ANSI). In addition, the facility failed to ensure in-services (education) were provided to 14 of 14 kitchen staff and nursing staff, as indicated in the facility's Registered Dietician (RD) and DS job descriptions, when: These failures had the potential to result in food-borne illnesses throughout the facility and compromise the health and nutritional needs of the residents. Findings: During a kitchen tour and interview on 7/11/2023 at 8:36 AM, the DS introduced self and stated they were the Dietary Supervisor. During a concurrent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 food was served at a safe and appetizing temperature for 10 of 10 residents who were served yam for lunch on 7/12/23. The temperature of the yam on the test tray from the tray line was 129.6 degrees Fahrenheit (F- unit of temperature measurement). This failure resulted in Resident 10 complaining about the temperature of food served in the facility. This deficient practice also placed the residents at risk for food-borne illness (illness caused by contaminated food). Findings: During a review of Resident 10's admission Record, dated 4/25/23, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included stage 4 (severe) chronic kidney disease (damage to the kidneys so they cannot filter blood the way they should) and type II diabetes (DM2- a condition that happens because of a problem in the way the body regulates and uses sugar as fuel). During a review of Resident 10's Minimum Data…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to report in a timely manner, a change of condition (COC, a change in the resident's normal physical, mental, or behavioral state) to the physician (MD, medical doctor), for one of 15 sampled residents (Resident 11). Restorative Nursing Aide (RNA 1) reported Resident 11 was unable to walk and reported left hip pain when putting weight on the left leg on 7/5/23. A change of condition report and notification to the MD was not completed until 7/12/23 (7 days after the initial report). This failure had the potential for a delay in intervention and care and cause a decline in function and ambulation (walking) in Resident 11. Findings: During a review of Resident 11's admission Record, the admission record indicated Resident 11 was admitted to the facility on [DATE] with diagnoses including but not limited to nondisplaced intertrochanteric fracture (bone breaks, but stays in place) of left femur (thigh bone), subsequent encounter for closed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Policy and Procedure (P&P) failed to indicate that an alleged resident abuse must be reported within two hours to the Department, Ombudsman (an official appointed to investigate individuals' complaints against maladministration), and to the local law enforcement for one of one resident (Resident 10). This failure resulted in Resident 10 potential for further abuse. Findings: During a review of Resident 10's admission Record, dated 4/24/23, the admission Record indicated, Resident 10 was admitted to the facility on [DATE], with multiple diagnoses including urinary tract infection (UTI, an infection in any part of the urinary system, including the kidneys, bladder, or urethra), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), muscle weakness. During a review of Resident 10's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/2/23, the MDS indicated the resident did not have…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 report an allegation of resident abuse for one of one resident (Resident 10) to the Department, Ombudsman (an official appointed to investigate individuals' complaints against maladministration), and to the local law enforcement, within two hours. This failure had the potential for Resident 10 to be at risk of further abuse. (Cross reference F607 and F943) Findings: During a review of Resident 10's admission Record, dated 4/24/23, the admission Record indicated, Resident 10 was admitted to the facility on [DATE], with multiple diagnoses including urinary tract infection (UTI, an infection in any part of the urinary system, including the kidneys, bladder, or urethra), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), muscle weakness. During a review of Resident 10's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/2/23, the MDS indicated the resident did not have…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a comprehensive care plan for the use of splints (a device that safely stretches tight muscles and joints) to right elbow and left knee as ordered by the physician on 1 of 1 sampled resident, Resident 20. This failure had the potential to cause further decline of Resident 20's contractures (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joint to shorten and become very stiff) to the right elbow and the left knee. Findings: During an observation on 7/11/23 at 10:36 a.m., in Resident 20's room, the resident was lying in bed, asleep, with splints on the right elbow and the left knee. Resident 20 was not able to be interviewed. During a review of Resident 20's admission Record, dated 5/12/23 indicated the resident was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease (a brain disease that causes a decline in memory, thinking, learning and organizing skills…

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

Based on observation, interview, and record review, the facility failed to provide functioning hearing aids for one of four sampled residents (Resident 7) . This deficient practice resulted in Resident 7 not being able to hear and feeling upset not able to hear her daughter during visitation. Findings: During a review of Resident 7's admission Record, the admission record indicated the facility admitted the resident on 5/16/18 with diagnoses including sensorineural (SNHL) hearing loss ( damage to the inner ear and is a permanent hearing loss), high blood pressure and osteoporosis ( a condition in which bones become weak and brittle). During a review of Resident 7's Minimum Data Set (MDS- a standardized assessment tool) dated 5/27/23, the MDS indicated Resident 7's hearing was highly impaired and the resident used hearing aids. Resident 7's cognitive ability (ability to understand and make decisions)was intact . Resident 7 required extensive assistance with one staff physical assist for bed mobility, extensive assistance with one-person physical assist with dressing and supervision…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 24 sampled residents (Resident 10) was served the food preferences listed on Resident 10's lunch tray card. This deficient practice had the potential to result in resident 10's frequent meals refusal, decreased meal satisfaction and consumption and potentially negatively affect Resident 10 nutritional status. Findings: During a review of Resident 10's admission record, dated 5/23/22, indicated, Resident 10 was admitted to the facility on [DATE] with diagnosis included Type 2 Diabetes Mellitus (a group of diseases that result in too much sugar in the blood), hypertension (blood pressure that is higher than normal), and hyperlipidemia (high levels of fat in the blood). During a review of Resident 10's Minimum Data Set (MDS), dated [DATE], indicated, Resident 10 had the ability to express ideas and wants, and ability to understand verbal content. MDS indicated, Resident 10 needs supervision as in oversight, encouragement 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.

Based on observation, interview, and record review, the facility failed to ensure safe food storage, in one of one refrigerator freezer (Ice Cream Freezer 1). The facility failed to monitor and record daily temperatures and ensure Ice Cream Freezer 1's thermometer was in working condition, as indicated in the facility's Policy and Procedures (P&P). In addition, the Dietary Supervisor (DS) did not check refrigerator-freezer temperatures on 7/10/2023 and falsified the facility's Refrigerator-Freezer Temperature Log (RTL) to indicate the temperatures were checked. These failures had the potential to result in harmful organism growth that could lead to food-borne illnesses (caused by contaminated food that can lead to food poisoning) for the residents who had the ability to eat by mouth. Findings: During an interview and initial kitchen tour on 7/11/2023 at 8:50 AM, with the DS, the DS showed the temperature of Ice Cream Freezer 1's external and internal temperatures (external temperatures confirm internal temperatures). The external thermometer indicated a temperature of -14 degrees…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 remain free of pests and did not having an effective pest control for one of four planters (Planter 1) by failing to: a. Eliminate harborage conditions (locations and conditions where the mosquito can live, thrive [grow strong], reproduce, and feed) for mosquitoes to live. b. Eradicate (destroy/kill) mosquitoes (small flying insects that can bite people and spread infectious diseases) observed inside the facility. This failure had the potential to result in vector-borne diseases (diseases that result from an infection transmitted to human by insects such as a mosquitoes) for all residents residing at the facility. Findings: a. During an observation on 7/12/23, at 9:10 am, in the East end of the main dining room, one live mosquito flew and landed on Surveyor 1's right back shoulder. The East end of the main dining room was partitioned off from the rest of the dining room. During a concurrent observation and interview on 7/12/23, at 10:01 am, with the Activities Director (AD), in the main dining room, four…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 train staff to report all allegations of resident abuse to the Department, Ombudsman (an official appointed to investigate individuals' complaints against maladministration), and to the local law enforcement, within 2 hours. Five of seven sampled staff did not know the correct timeframe (within 2 hours) of reporting any allegation of resident abuse. This failure had the potential for residents to be at risk of abuse. (Cross reference F607 and F609) Findings: During an interview on 7/13/23, at 2:07 p.m., the Assistant Director of Nursing (ADON), ADON stated, resident abuse needed to be report within two hours, if there is serious bodily injury, to the Department, Ombudsman, and law enforcement. ADON stated, if the abuse did not cause serious bodily injury, the abuse should be reported within 24 hours. ADON stated, verbal abuse should be reported within 24 hours. During a concurrent interview and record review on 7/13/23 at 2:34 p.m., with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled,…

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