Meadowood Nursing Center

Based on observations, interviews and record reviews, the facility failed to ensure all drugs were in locked compartments for one out of four medication carts, when a medication cart was unlocked when it was unattended.This failure could result in access to medications by unauthorized people leading to medication theft and unauthorized medication ingestion with a risk of overdose, drug interactions, or severe adverse effects.Findings:During a concurrent observation and interview on 2/20/26 at 5:14 p.m., Licensed Nurse (LN) A left the medication cart in hall 1 unlocked while inside a resident's room. There were no other LN or unlicensed staff present to look after hall 1 medication cart. Upon return to the medication cart, LN A verified she left the cart unlocked and unattended. LN A stated it was the facility's policy to ensure medication carts were always locked when unattended by the LN for the safety of the residents.During an interview on 2/20/26 at 5:20 p.m., the assistant Director of Nursing (ADON) stated medication carts should always be locked when unattended per 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 and record reviews, the facility failed to maintain infection control measures for two out of two residents sampled for infection control concerns (Residents 2 and 3) when:1. three pillows that were on the floor were picked up by the Licensed Nurse (LN) and placed back on Resident 2's bed; and2.the mouthpiece of Resident 3's nebulizer (medical device that converts liquid medication into a fine, breathable mist for direct inhalation into the lungs) was not kept in a clean, dry, and sealed container to prevent cross contamination (happens when bacteria or other germs are unintentionally transferred from one object to another).These failures could put the residents at risk for infection transmission, illness, and worsening of chronic conditions.Findings:1. A review of Resident 2's face sheet (front page of the chart that contains a summary of basic information about the residents) indicated an admission to the facility in 1/2026 with diagnoses of Unsteadiness in feet and Dysphagia (difficulty swallowing.During a concurrent observation and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to properly care for one of three residents' (Resident 1) Peripherally Inserted Central Catheter (PICC line, a long, thin, flexible tube inserted into a peripheral vein and threaded into a large central vein near the heart to provide long-term access for administering medications, fluids, or blood products, and for drawing blood, reducing the need for repeated needle sticks) during several shifts by failing to follow flushing and monitoring protocols.This finding could have led to inability to maintain PICC line patency, the formation of blood clots which could have caused a stroke or heart attack, and a potentially life-threatening infection for Resident 1.A review of Resident 1's admission Record (Facility demographic) indicated Resident 1 was admitted to the facility on [DATE] with medical diagnoses which included metabolic encephalopathy (a reversible, acute, or chronic brain dysfunction caused by systemic illness, toxins, or chemical imbalances) and…

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

Based on interview and record review, the facility failed to ensure eight out of eight sampled residents (Resident 7, Resident 25, Resident 53, Resident 59, Resident 69, Resident 90, Resident 94 & Resident 95) were aware of how to file a grievance and had their complaints resolved when the facility had no current grievance process or appointed officer. In addition, complaints brought up during resident council meetings were not being tracked or responded to. This failure resulted in all eight residents feeling frustrated with the lack of facility response to their complaints.During a Resident Council Meeting on 1/07/26 at 11:00 a.m. in the dining hall, all eight residents present could not describe what the current grievance process was. The entire group expressed frustration with the lack of response to various concerns that had been brought up repeatedly. One resident stated that since the last Social Services Director left there had been no follow up on complaints or grievances.A review of resident council notes from 11/25 and 12/25 indicated there were multiple complaints about…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Preadmission Screening and Resident Review Level II evaluation (PASRR-following a Level 1 screening, the Level 2 evaluation determines appropriate placement of an individual with a serious mental illness, considering the least restrictive setting, and whether specialized services are needed) was completed for three of six sampled residents (Resident 23, Resident 41, and Resident 68), based on each Resident's documented psychiatric diagnoses and functional status. This failure had the potential for Resident 23, Resident 41, and Resident 68 to receive inappropriate and ineffective care/treatment, or to be inappropriately placed in a long-term care facility. During a review of the Resident 23's admission Record, it indicated Resident 23 was admitted to the facility on [DATE] with diagnoses including diabetes (a chronic condition where the body has trouble regulating blood sugar (glucose)), major depressive disorder (a serious mood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide face-to-face and in-person physician visits at least once every 60 days for six (6) of 12 sampled residents (Residents 5, 19, 23, 41, 98, and 99). This deficient practice had the potential to result in a decline in medical, health or psychosocial conditions and a delay in necessary care, treatment and services.A review of Resident 19's admission Record indicated Resident 19 was admitted to the facility on [DATE] with diagnoses including cellulitis (a bacterial skin infection causing red, swollen, warm, and painful skin that spreads quickly, often from bacteria entering a cut or wound), essential hypertension (high blood pressure), acute respiratory failure (a condition where there is not enough oxygen or too much carbon dioxide in the body), and spinal stenosis (the narrowing of spaces within the spine, putting pressure on the spinal cord and nerves, causing pain, numbness, weakness, or cramping, often in the lower back, legs,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 food at a palatable temperature for three of eight sampled residents (Resident 90, Resident 7, & Resident 53) at a confidential resident council interview. This failure had the potential to cause loss of appetite and weight loss in a vulnerable population when food is too cold to be appetizing.During a resident council meeting on 1/07/26 at 11:00 a.m. in dining hall, 3 residents who resided in Hall 4 (Resident 90, Resident 7 & Resident 53) complained that the food was always cold because they were served last. A review of the resident council notes indicated that cold food was reported in 08/25, again in 11/25, and in 12/25. During a tray line observation in the kitchen on 1/07/26 at 12:05 p.m., the cook began to plate the food for the residents' lunch. Continuing the tray line observation on 1/07/26 at 1:14 p.m., staff began to pass lunch trays to the residents residing on Hall 4. During a test tray observation and concurrent interview on 1/07/26 at 1:19 p.m., the survey team tested a tray of pureed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safely store residents' food when the two refrigerators used to store residents' personal food from outside the facility were not monitored for proper labeling or outdated items. This failure had the potential to cause food-borne illnesses.During an observation and concurrent interview on 1/06/26 at 2:20 p.m., Licensed Nurse (LN) B stated there was a refrigerator at each nurses' station that was for residents' foods brought in from outside the facility. The refrigerator for residents' foods at Nurses' Station 2 contained several items that were not labeled or were outdated. LN B stated Housekeeping Supervisor (HKS) was responsible for monitoring the foods in the refrigerators and throwing away foods when they needed to be thrown out. LN B stated whoever put items in the refrigerator was responsible for labeling the item, and the label needed to include the resident's name, room number, and the date and time it was put in there. During an observation and concurrent interview on 1/06/26 at 2:27 p.m., HKS…

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

Based on observation, interview, and record review, the facility failed to protect residents' private health information when lunch tray tickets containing residents' names and diet orders were found thrown in the garbage in the dining room. This failure had the potential for residents' private health information to be obtained by persons who did not have a need to know the residents' information.During an observation on 1/05/26 at 12:46 p.m. in the RNA (Name of dining hall) Dining Hall, resident tray tickets were observed in the trash can.During an interview on 1/08/26 at 2:45 p.m., the Assistant Director of Nursing (ADON) stated that no tray tickets should be in the trash as they contain protected health information.A review of the facility policy titled, Confidentiality of Information and Personal Privacy, revised 10/25, indicated, the facility would safeguard the personal privacy and confidentiality of all resident personal and medical records.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the ombudsman's office (a public agency that provides free advocacy services for residents of nursing homes) of a transfer to the hospital for one of three residents sampled for closed record review (Resident 98). This failure had the potential to result in a lack of advocacy services for Resident 98.During a record review on [DATE] at 9:49 a.m., Resident 98's face sheet indicated Resident 98 was admitted to the facility on [DATE] with multiple diagnoses including but not limited to heart failure (condition where the heart can't pump enough blood and oxygen to meet the body's needs), coronary artery disease (cholesterol build-up on the inside of the vessels that bring blood to the heart muscle), end-stage kidney disease (the kidneys can no longer function adequately, requiring dialysis or a kidney transplant for survival), diabetes mellitus (impaired ability to metabolize blood sugar), and an implanted defibrillator (a device implanted in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to coordinate assessments with the Pre-admission Screening and Resident Review (PASRR- a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) program for one of six sampled residents when Resident 5's Level I PASSR did not accurately reflect a serious mental disorder, and Resident 5 was not referred for a Level II PASRR (a level II PASRR screening determines appropriate placement of an individual with a serious mental illness, considering the least restrictive setting, and whether specialized services are needed) screening.This failure had the potential for Resident 5 to receive inappropriate or ineffective care, treatment, and services.During a review of Resident 5's admission Record, it indicated Resident 5 was admitted to the facility on [DATE] with diagnoses including paraplegia (the loss of muscle function in the lower part of the body including both legs), generalized muscle…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 initiate and implement a resident-centered nursing care plan for depression for one of six sampled residents (Resident 32).This failure had the potential to worsen or delay improvement of Resident 32's diagnosed psychiatric condition.A review of Resident 32's admission Record, indicated Resident 32 was admitted to the facility on [DATE] with diagnoses including hemiplegia (paralysis on one side of the body), hemiparesis (one-sided muscle weakness), and major depressive disorder (a serious mood disorder causing persistent sadness, loss of interest, and significant impairment in daily life).A review of Resident 32's Minimum Data Set (MDS, an assessment tool), dated 12/07/25, indicated Resident 32 had a BIMS (Brief Interview for Mental Status-an assessment used in long-term care facilities to quickly screen for cognitive impairment) of 12, indicating moderate cognitive impairment. The MDS also indicated in the past two weeks Resident 32 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 observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 73), received services to maintain functional abilities when staff did not transfer him out of bed and into his wheelchair for an undetermined length of time.This failure had the potential to decrease Resident 73's functional mobility, which could have resulted in skin breakdown, and increased dependency on staff for Activities of Daily Living (ADL's, activities related to self-care such as bathing and toileting). A review of Resident 73's admission record indicated he was admitted on 12/2022 with medical diagnoses which included Rheumatoid Arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility), muscle wasting and atrophy (loss or thinning of muscle tissue), and abnormalities of gait and mobility.A review of Resident 73's Minimum Data Set (MDS-a resident assessment tool) dated 12/24/25, indicated he had a BIMS (Brief interview for Mental Status-an assessment tool used by facilities to screen…

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

Based on interviews and record review, the facility failed to ensure accurate documentation for one of six sampled residents (Resident 1), when Resident 1's Medication Administration Record (MAR) did not indicate the reason, a medication was not administered. This failure had the potential to cause physical discomfort and delayed healing of Resident 1's eye.Findings:A review of Resident 1's admission record indicated admission to the facility on 9/28/25 with diagnoses which included left eye keratitis (inflammation of the cornea (the eye's clear front dome) often caused by infection). A review on 12/17/25 of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 9/25/25, indicated a Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 14 indicating no memory impairment.A review on 12/17/25 of Resident 1's MAR, dated November 2025, indicated Resident 1 did not receive her prescribed Vigamox(R) Ophthalmic Solution 0.5% on 11/9/25 at 5 p.m., 11/11/25 at 5…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 professional standards of nursing practice were followed for a census of 89 residents when:1: One resident's (Resident 1) medication was left by her bedside unattended by staff without a physician order for self-administration of medications,2: An undisclosed number of residents' medications were pre-prepared (a type of workaround, described as a delay between preparation and administration of a medication or the preparation of multiple medications for different residents) prior to administration, and;3: The Director of Nursing (DON) allowed the administration of pre-prepared medications to residents; fully aware they were unlabeled and had been pre-prepared. These failures increased the facility's potential for medication errors and for residents to experience a delay in care and treatment.1. A review of Resident 1's admission record (Facility demographic) indicated she was admitted to the facility in May, 2025, with medical diagnosis which included cellulitis (a skin infection that causes swelling and redness),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 four sampled residents (Resident 1) was protected from neglect when physician notification regarding her change of condition (COC, a significant shift in someone's physical, mental or functional state, requiring attention) was delayed. This failure resulted in Resident 1 to experience delays in care and required hospitalization for an unmanaged fever, altered level of consciousness (sudden changes in condition, awareness or consciousness (your subjective awareness to yourself and the world)) and sepsis (a life-threatening blood infection). Cross reference F761.A review of Resident 1's admission record indicated she was admitted to the facility in May 2025 with medical diagnosis which included cellulitis (a skin infection that causes swelling and redness), and peripheral venous insufficiency (a condition where the valves in the leg veins are damaged causing blood to pool in the lower legs instead of flowing back to the heart). A review of Resident 1's Minimum Data Set (MDS-a federally mandated resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an allegation of abuse within two hours to the DEPARTMENT for one of five (5) sampled residents (Resident 1).This finding had the potential to result in inability for the DEPARTMENT to investigate and advocate for Resident 1's rights, and possible continuous abuse to Resident 1 and other residents of the facility.Record review of the facility Face Sheet (facility demographic) indicated Resident 1 was originally admitted to the facility on [DATE] with medical diagnoses which included post laminectomy syndrome (a condition, where part of the bone (lamina) covering the spinal cord is removed and causes persistent or recurring pain, tingling and numbness in the buttocks and legs) and constipation (a condition characterized by infrequent or difficult bowel movements).Record review of a form titled, SOC-341 (a specific form used in California for Mandated Reporters to document and report suspected Dependent Adult or Elder Abuse), the facility sent and…

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

Based on interview and record review, the facility failed to protect one resident (Resident 1) of seven sampled residents from misappropriation of resident property when Resident 1 ' s debit card was used by Certified Nurse Assistant 1 (CNA 1). This failure resulted in Resident 1 feeling taken advantage of, and stupid. Findings: A review of Resident 1 ' s admission record indicated admission to the facility in June 2023 with diagnosis which included polyneuropathy (a condition where multiple peripheral [outermost] nerves are damaged), intervertebral disc degeneration (a condition where the cushioning discs between the vertebrae [bones that make up the spine] in the spine wear down over time), arthritis (inflammation and damage in the joints), depressive disorder (a mental health condition characterized by symptoms like sadness, loss of interest and low energy), chronic pain syndrome (persistent pain), and adult failure to thrive (decline in overall health and well-being). A review of a Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 3/24/25, 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 record review and interview, the facility failed to ensure a Notice of Medicare Non-Coverage (NOMNC) was issued to 2 (Resident #244 and Resident #245) of 3 sampled residents reviewed for beneficiary notification. Findings included: 1. An admission Record indicated the facility admitted Resident #244 on 06/27/2024. According to the admission Record, the resident had a medical history that included a diagnosis of paraplegia. Per the admission Record, the resident discharged home on [DATE]. A Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/19/2024, revealed Resident #244 had a planned discharge to home/community on 08/19/2024. The SNF [skilled nursing facility] Beneficiary Notification Review, revealed Medicare Part A skilled services for the resident began on 07/11/2024 and the last covered day of Part A service was 08/18/2024. Per the SNF Beneficiary Notification Review, the facility initiated discharge of the resident from Medicare Part A services when benefit were days were 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 observation, interview, record review, and facility policy review, the facility failed to obtain a physician's orders for the use a respiration device for 1 (Resident #140) of 3 sampled residents reviewed for choices. Findings included: A facility policy titled, Acapella Device, indicated, The Acapella device is used to help remove mucus from the lungs by vibrating to loosen the secretions from the airway walls. Per the policy, A licensed nurse or Respiratory Therapist may utilize an Acapella device on a resident in a skilled nursing facility for airway clearance and to help improve respiratory function in various clinical situations, adding the resident's quality of life. All extensions of the Acapella would need to be accompanied by a physician's order. An admission Record revealed the facility admitted Resident #140 on 01/08/2025. According to the admission Record, the resident had a medical history that included diagnoses of acute pulmonary edema and pulmonary hypertension. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/15/2025,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 records review, the facility failed to ensure three of three sampled residents (Resident 6, Resident 5 and Resident 7) were given showers during their scheduled shower days. This failure to maintain Resident 6, Resident 5 and Resident7 ' s personal grooming and hygiene needs had the potential to raise the risk of unidentified skin issues, bacterial and fungal infections. Findings: Resident 5 During a telephone interview with Resident 5 on 5/06/24 at 8:40 a.m., Resident 5 stated she was admitted to the facility to receive Physical Therapy after a left hip replacement (a surgical procedure to replace some or all of a joint). She stated she did not have showers for a few weeks during her stay at the facility. A review of the admission Record indicated Resident 5 was admitted on [DATE] with diagnosis including but not limited to Joint Replacement and Chronic Pain Syndrome (pain that lasts for longer than 3 months). A review of the Minimum Data Set (MDS -health status screening…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 records review, the facility failed to ensure call lights (an alerting device for nurses or other nursing personnel to assist a patient when in need) were answered within five minutes per facility policy for two of three sampled residents (Resident 1 and Resident 3). This failure resulted in 1) Resident 1 to fall on the floor twice while attempting to go to the toilet without staff assistance causing Resident 1 to sustain right arm fracture; and 2) Resident 3 developed Moisture-associated skin damage (MASD - caused by prolonged exposure to various sources of moisture, including urine or stool) to his perirectal area from sitting on his poop for a long time. (Cross Reference F689) Findings: Resident 1 A review of the admission Record indicated Resident 1 was admitted on [DATE] with diagnosis including but not limited to Unsteadiness on Feet and Other Abnormalities of Gait (a manner of walking or moving on foot) and Mobility. A review of the ADL (Activities of Daily Living -…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations, interviews and records review, the facility failed to ensure call light was in good working condition for one of three sampled residents (Resident 8). This failure had the potential risk for Resident 8 ' s needs uncommunicated to the staff placing her at risk for neglect and harm. Findings: A review of the admission Record indicated Resident 8 was admitted on [DATE] with diagnosis including but not limited to Age related cognitive [relating to the mental process involved in knowing, learning, and understanding things] decline, Chronic Obstructive Pulmonary Disease (COPD - diseases that cause airflow blockage and breathing-related problems), and Muscle Weakness. A review of the Minimum Data Set (MDS -health status screening and assessment tool used for all residents) dated 1/18/24 indicated Resident 8 had a BIMS score of 15 out of 15 (Brief Interview for Mental Status - a 15-point cognitive screening measure that evaluates memory and orientation. A score of 13 to 15 is cognitively intact).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and records review, the facility failed to ensure the Minimum Data Set (MDS - health status screening and assessment tool) was accurately completed for 1 of 3 sampled residents (Resident 1). This failure resulted in lack of complete information necessary to develop a resident centered care plan to meet Resident1 ' s health care needs. Findings: A review of the admission Record indicated Resident 1 was admitted on [DATE] with diagnosis including but not limited to Unsteadiness on Feet and Other Abnormalities of Gait (a manner of walking or moving on foot) and Mobility. A review of the MDS dated [DATE] indicated Resident 1 had a BIMS score of 14 out of 15 (Brief Interview for Mental Status - a 15-point cognitive [relating to the mental process involved in knowing, learning, and understanding things] screening measure that evaluates memory and orientation. A score of 13 to 15 is cognitively intact). During an interview and concurrent record review with the MDS Coordinator (MDSC - a nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident (Resident 1) was free from abuse by another resident (Resident 2) of the facility. This failure had the potential to cause physical harm, pain or mental anguish. Findings: During an interview on 2/12/24, at 11:03 AM, in the Administrator ' s office, the Director of Nursing (DON) stated they were encouraging Resident 2 to get out of bed, but Resident 2 also wanted her roommate, Resident 1, to also get up, and pulled the blanket off Resident 1. During review of record, the Progress Note (PN), dated 1/26/24, written by the DON, indicated Resident 2 removed Resident 1 ' s blanket stating: If I have to get up, so does she. During an interview in room [ROOM NUMBER] on 2/12/24, at 2:01 PM, Resident 2 stated she remembered the incident with Resident 1. When asked why she pulled the blanket off Resident 1, Resident 2 stated the staff made her get up to clean the room, she wanted Resident 1 to get up too. During an interview on 2/15/24, at 4:30…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 report immediately or within two hours, an alleged resident-to-resident incident between Resident 1 and Resident 2. This failure had the likelihood for incidents of potential abuse between residents to not get reported, prevented, corrected, or investigated, and could result in physical, mental, or psychosocial harm to residents. Findings: On 1/26/24, the Department received the facility report of an incident between Resident 1 and Resident 2. During an interview on 2/12/24, at 11:03 AM, in the Administrator's office, the Director of Nursing (DON) stated they were encouraging Resident 2 to get out of bed, but Resident 2 also wanted her roommate, Resident 1, to also get up, and pulled the blanket off Resident 1. During review of record, the Progress Note (PN), dated 1/26/24, written by the DON, indicated Resident 2 removed Resident 1's blanket stating: If I have to get up, so does she. During an interview in the residents' room, on 2/12/24, at 2:01 PM, Resident 2 stated she remembered the incident between her and Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide pharmaceutical services to one of two residents (Resident 1), when the facility did not administer three ordered medications to Resident 1. This failure prevented Resident 1 from receiving medications to treat her medical conditions. Findings: A review of Resident 1 ' s admission Record and admission Progress Notes indicated she was admitted to the facility on [DATE] at 5:30 p.m. A review of Resident 1 ' s Physician Orders indicated the following three medications to be administered in the evening or night of 1/30/24: Carvedilol [to treat blood pressure] Tablet 25 MG [milligrams] two times a day at 8 a.m. and 5 p.m.; Combivent Aerosol Solution [to improve respiratory function] 20-100 MCG/ACT [micrograms] four times a day at 8 a.m., 12 noon, 5 p.m. and 9 p.m.; and Flonase [for allergy] 50 MCG/ACT at 8 a.m. and 8 p.m. A review of Resident 1 ' s Medication Administration Record (MAR) (where the administration of medications is recorded) for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain complete and accurate medical records for one of two residents (Resident 1), when Resident 1 ' s Medication Administration Record (MAR) (where nurses document the administration of medications) for August 2023, lacked documentation of blood glucose monitoring and administration of insulin during four of 19 days. This failure resulted in Resident 1 having an incomplete and inaccurate MAR. Findings: A review of Resident 1 ' s facesheet indicated she was admitted to the facility on [DATE], with diagnoses including Type 2 Diabetes Mellitus (impaired ability to regulate blood sugar levels). A review of Resident 1 ' s Physician Orders indicated orders, dated 8/10/23, for blood glucose (sugar) monitoring and administration of insulin (a medication used to control blood sugar) three times a day: 7:30 a.m., 11:30 a.m., and 4:30 p.m. A review of Resident 1 ' s MAR for August 2023, on 8/29/23, indicated no documentation of blood glucose monitoring on…

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

Based on interview and record review, the facility failed to include the necessary information, such as Facility name, Total number of actual hours worked by Registered Nurse (RN), Licensed Vocational Nurse (LVN), and Resident census, on the Nursing Staff Data daily, for the month of November and December 2022. These failures had the potential to result in poor quality of care to residents, due to inaccuracy of total numbers of hours worked by the nursing staff. Findings: A review of the Nursing Staff Data daily staffing for the month of November 2022 and December 2022, revealed the data sheet did not have the name of the Facility, each Licensed Nurses and Unlicensed nurses did not have the actual total hours worked documented by each shift, and the resident census information. There were several erasure noted, of staff names in each data sheet, due to call offs. The data staffing sheet was difficult to understand who would work and how many hours were worked, due to the erasures and changes of different hours of staff arrival to work. During a concurrent interview and record review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the call light system, installed in the bathrooms used by residents, in 38 of 40 resident rooms (Rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 12, 14, 15, 16, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40 and 41), were accessible to residents lying on the floor of the bathroom. This failure created the potential for residents who fell in the bathroom, not to be able to alert staff and summon help. Findings: During an observation and interview on 12/2/22, at 3:15 p.m., with the Director of Maintenance (DM), the call light system in the bathrooms used by residents in all resident rooms (Rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40 and 41), was inspected. The call light system in the resident bathrooms consisted of a button on the wall next to the toilet at elbow-height level of a resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and records review, the facility failed to provide an Activities program designed to meet the needs and interests of seven sampled residents (Resident 8, 21, 25, 33, 36, 53, and 59), who received 1:1 activity visits. This failure had the potential to result in deterioration of the residents' mental and physical health and decreased quality of life. Findings: During an interview on 12/6/22, at 9:30 a.m., with the Infection Preventionist (IP), he stated the facility had been on a quarantine status due to positive flu cases. The IP stated the changes took place over three weeks ago. The IP stated social dining and group activities had been stopped as part of the quarantine process. During an observation, on 12/7/22, at 10:01 a.m., Resident 33 was in bed. Resident 33 had his eyes open and was staring at the wall. During an observation, on 12/8/22, at 11:09 a.m., Resident 36 was in bed. During an observation, on 12/12/22, at 3 p.m., Resident 36 was in bed. Resident 36 had a blanket…

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

Based on observation, interview and record review, the facility failed to provide care and services to maintain acceptable parameters of nutritional status for two of two sampled residents, when it: a. Failed to monitor and revise interventions to provide adequate hydration to Resident 21 as recommended by the RD, and; b. Failed to accurately record two of Resident 6's meal intakes. These failures had the potential for: a. Resident 21 to continue losing weight and increased her risk to develop dehydration (a condition where the amount of water in your body is too low) which may lead to dry skin and mucosa, sleepiness or tiredness, headaches, constipation, minimal urine output, dizziness and, in severe cases, delirium, unconsciousness or even death. b. Resident 6 to have inadequate monitoring of nutritional status due to false data, which may lead to significant weight loss and a decline in health. Findings: Resident 21 Record review indicated Resident 21 was admitted to the facility with diagnoses including dementia (a general term for loss of memory, language, problem-solving and…

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

Based on interviews and records review, the facility failed to ensure sufficient nursing staff to provide safe and quality of care to all residents during night shift, when: 1) The Nursing Staff Data sheet, dated 11/25/22, from 10 p.m. - 6:30 a.m., revealed two (2) Licensed Nurse CNAs were providing care. A review of the Facility census was 86 residents; 2) The Nursing Staff Data sheet, dated 11/27/22, from 10 p.m. - 6:30 a.m., revealed (1) Licensed Nurse (LN) and three (3) Certified Nursing Assistants (CNAs) were providing care. A review of the Facility census was 83; and, 3) The Nursing Staff Data sheet, dated 11/28/22, from 10 p.m. - 6:30 a.m., revealed, one (1) Licensed Nurse (LN) and one (1) CNA were providing care to residents. A review of the facility census was 82. These failures had the potential to result in falls and skin breakdown to vulnerable residents, when adequate staff was not present to attend to their toileting and turning needs. Findings: During a concurrent interview and record review on 12/9/22 at 10 a.m., with Staff R (CNA) staffer (ensures staff were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility: (1) failed to properly dispose of controlled drugs (medications with a high potential for abuse and dependency), when controlled drugs documented as disposed were not destroyed and were kept unsecured. These failures created the potential for diversion of controlled substances and for staff to work impaired, placing residents at risk of improper care. The facility further: (2) failed to ensure proper handling and administration of medications for one resident (Resident 185), when Resident 185's medications were left unattended at her bedside table. This failure placed Resident 185 at risk of not receiving her medications. Findings: (1) During a concurrent observation, interview, and record review on [DATE], at 11:45 a.m., with the Assistant Director of Nursing (ADON), in her office, centrally located at the facility and with an unlocked door facing the entrance to Hallway 1, where Resident rooms 1-10 were located, the ADON explained 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 interview and record review, the facility failed ensure medications were administered as prescribed, to one of 20 sampled residents (Resident 58), when facility staff administered Isosorbide Dinitrate and Carvedilol (medications to treat high blood pressure and heart failure) and Insulin Glargine (a medication to treat high blood sugar) to Resident 58 outside of the parameters indicated by Resident 58's physician. These failures resulted in Resident 58 receiving 28 doses of unnecessary medications (7 doses of Isosorbide Dinitrate, 17 doses of Carvedilol and 4 doses of Insulin Glargine) over a period of 40 days. Findings: A review of Resident 58's Facesheet indicated she was admitted to the facility on [DATE], with diagnoses including myocardial infarction, chronic kidney disease, and diabetes (uncontrolled blood sugar). A review of Resident 58's physician orders indicated the following medication orders: Isosorbide Dinitrate Tablet 30 MG [milligrams] Give 1 tablet by mouth one time a day . Hold for SBP…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews, and record review, the facility failed to ensure the menu was followed for one day, when an incorrect portion of the seasoned sauce was served for lunch, and 42 of 42 residents on pureed/dysphagia mechanical diets (food altered in consistency for those with swallowing difficulties) did not receive the correct food items. These failures had the potential for residents to receive the wrong and/or inappropriate allocation of caloric intakes, which could further compromise their medical status. Findings: Review of, Winter Menus, dated, 12/08/22, indicated, Roast Turkey, Seasoned Sauce, Tuscan Roasted Potatoes, [NAME] Beans with Red Peppers, Wheat Roll, Apple Streusel Pie. During an observation on 12/8/22 at 11:40 a.m., Staff L was whisking mashed potatoes on a steam pan. During a concurrent interview, Staff L stated those on a pureed/dysphagia mechanical diet would have the mashed potatoes instead of the roasted potatoes. During an observation of the tray line 12/8/22 at 12 p.m., Staff I poured a pan of sauce over the slices of roast turkey. The middle…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prepare and store food in a sanitary manner, when a kitchen staff was not wearing appropriate hair restraints, and the kitchen pantry shelves contained multiple dented cans of food, and packages of English muffin kept past their storage date. These failures had the potential to place residents at risk for food-borne illness and the growth of microorganisms. Findings: During an observation on 12/6/22 at 9:10 a.m., Staff J was walking inside the kitchen without wearing a hairnet. During an observation of the pantry on 11/6/22 at 9:20 a.m., four 102-oz size cans of enchilada sauce, with dented sides, were located on the shelves. Two packages of English muffins, dated, 11/22/22, were on another shelf. A concurrent review of the manufacturer guideline on the rear of the muffin packaging indicated, Storage Information: Room temperature = 6-7 Days. During a concurrent interview, the DS (Dietary Supevisor) confirmed the cans were dented and should have been separated from the food supply shelves so they would not be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 submit an accurate staffing information based on Payroll Based Journal (PBJ) to Federal Agency for the month of May, June, July, August, September, October, and November 2022. This failure had the potential to result in inaccuracy of numbers of Direct Care Staff needed to provide care to residents, based on PBJ report to the Federal Agency. Findings: During an interview on 12/9/22 at 12:19 p.m., the Administrator (ADM) stated, since May 2022, when a new Payroll system started, she identified the concern regarding incorrect information on the PBJ reported to Federal Agency. The ADM stated she had been working with the new Payroll Company to correct the information, and the Company was working on correcting the problem. The ADM stated, because of the inaccuracy of the report from the Payroll Company, the Federal Agency did not get the accurate staffing information from the PBJ. The ADM stated she paid the Payroll company monthly to correct the identified concerns. The ADM stated she would give the Payroll Company one 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.

Based on interview and record review, the facility failed to ensure one of three licensed nurses (Licensed Nurse D) knew the minimum contact time (how long the product needs to stay wet on a surface to be effective) of the disinfectant used to sanitize the facility's reusable glucometers (portable devices which analyze resident blood samples for glucose levels). This failure created the potential for the use of contaminated glucometers, exposing residents to blood-borne diseases. Findings: During an interview on 12/12/22, at 12:19 p.m., Licensed Nurse D stated she had six residents who needed daily blood sugar monitoring. Licensed Nurse D stated she used wipes called, Sani-Cloth Germicidal Disposable Wipes, (Sani-Cloth) to disinfect the glucometers in between resident use. Licensed Nurse D stated the contact time of the Sani-Cloth was 60 seconds. A review of the packaging of Sani-Cloths used by the facility, indicated, Allow treated surface to remain wet for a full two (2) minutes. During an interview on 12/13/22, at 12:19 p.m., the facility's Infection Preventionist (IP) confirmed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide care and services to prevent pressure ulcers to one of three residents (Resident 37) at risk for pressure ulcers. For Resident 37, after an assessment indicated Resident 37 was at risk for pressure ulcers and needed extensive staff assistance with bed mobility, the facility failed to create an individualized plan to frequently turn and reposition Resident 37 in bed in order to relieve pressure on bony prominences (a risk factor for the development of pressure ulcers). The facility also failed to have a system of accurately and comprehensively documenting the turning and repositioning of immobile residents at risk for developing pressure ulcers. These failures placed Resident 37 at risk for pressure ulcers. Resident 37 developed a pressure injury on his sacrum/coccyx area (bottom of spine area). Findings: A review of Resident 37's Face Sheet indicated he was originally admitted to the facility on [DATE], and had diagnoses including…

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