Corona Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure, for one of one resident (Resident 7):- Post dialysis (a medical procedure that acts as an artificial kidney, used when a person's kidneys fail to remove waste and excess fluid from the blood) complications were appropriately monitored on July 21, 2025;- The physician was notified of Resident 7's low blood pressure after dialysis treatment; and- Resident 7 's low blood pressure was not monitored. These failures had the potential to result in the untimely reporting of adverse effects and symptoms post dialysis, which could also result in a decline in health condition.Findings: On July 22, 2025, at 1:45 p.m., a concurrent interview and record review was conducted with Licensed Vocational Nurse (LVN 2). LVN 2 stated a progress note were to be written when a resident would go out for dialysis treatment and another progress note to be documented when the resident would get back from the dialysis treatment. LVN 2 further stated upon a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free from unnecessary medications for one of five residents (Resident 69), when the nursing staff failed to clarify Resident 69's physician's order for lidocaine (medication for pain) 4% (percent, a unit of measurement for concentration) transdermal (topical) patches that directed application twice daily and failed to apply and remove the patch in accordance with both the physician's order and the manufacturer's instructions.This deficient practice had the potential to result in ineffective pain management, medication administration errors and compromised treatment outcomes as well as excessive lidocaine exposure and avoidable side effects such as skin irritation.Findings:On July 23, 2025, during a review of Resident 69's medical record, the admission Record indicated Resident was admitted to the facility on [DATE], with diagnoses which included dementia (loss of memory), major depressive disorder (depression), anxiety,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, for one of three resident (Resident 1) was free from misappropriation of property when the Social Service Designee (SSD) used Resident 1's bank card to purchase items for her personal use, without consent from Resident 1. This failure had the potential to affect Resident 1's psychosocial wellbeing. Findings:On June 19, 2025, at 1:45 p.m., an unannounced visit was conducted at the facility to conduct two complaints and one Facility Reported Incident regarding allegation of abuse.On June 19, 2025, at 2 p.m., during an interview with the Director of Nursing (DON) and the ADM (Administrator), the DON stated the following information gathered through their investigation:-A Certified Nursing Assistant (CNA) notified him that Resident 1 had a concern regarding his Social Security Income (SSI);-Resident 1 reported he checked his bank account and noticed that there was not much money as he expected to be in there;-Resident 1 informed the SSD about the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the ice machine and its components were properly cleaned and sanitized, for 87 of 90 residents who received ice from the the facility's ice machine. This failure had the potential to result in contamination of the ice being served to all residents and could lead to waterborne illness. Findings: On April 18, 2025, at 9:45 a.m., an unannounced visit was conducted at the facility, for the investigation of a complaint regarding dietary services. On April 18, 2025, at 10:15 a.m., an observation and inspection of the facility's Food Service's ice machine was conducted. A dry and clean paper towels were swiped along the top inside bin of the ice machine. The paper towels were noted to have multiple black and brown flakes present on them. The outside, top and sides of the ice machine, were noted to have a layer of dust, brown stain marks, and various pest legs, accumulating on the equipment. A dry clean paper towel was run along the top…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 devices used for the residents, were sanitary, clean, and disinfected properly, when: 1. The pill crusher was observed with brown sticky substance, for 15 of 27 residents which required medications to be crushed; and 2. The stand lift machine (a non-electric standing aid designed to assist seniors in safely rising from a seated position in chairs, couches, or recliners) was observed to be dirty, for one of one resident who uses the stand lift machine. These failures had the potential to result in the residents being exposed to unsanitary shared devices which could lead to spread of infections. Findings: On April 18, 2025, at 9:45 a.m., an unannounced visit was conducted at the facility for the investigation of a complaint. On April 18, 2025, at 11:10 a.m., an observation of Nurse Station 3 (three) and hallway 300 was conducted. The Medication Cart 3 (three) was noted to have a pill crusher on top of the cart and was coated in a brown, semi soft, sticky substance, covering the area the pills were being…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe and functional environment, for two of two residents who independently uses the smoking patio (Resident A and Resident B), when the fire door closed was dismantled. In addition, the ceiling above the fire door closer was observed to have water damage. These failures had the potential to cause injury to Residents A and B while entering or exiting through the fire door. In addition, the stained ceiling had the potential for it to collapse and could injure residents and staff. Findings: On April 18, 2025, at 9:45 a.m., an unannounced visit was conducted at the facility for the investigation of a complaint. On April 18, 2025, at 11:50 a.m., an observation and concurrent interview was conducted with Resident A. Resident A was observed to wheel himself to the smoking area. Resident A was observed to go outside through the exit door, at the end of hallway 100. The fire door closer was observed to be dismantled, and the door did…

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

Based on observation, interview, and record review, the facility failed to implement the system of identifying and monitoring fall risk residents for one of three sampled residents (Resident 1). This failure has the potential for the staff not to provide interventions to residents, resulting to recurrent falls. Findings: On August 12, 2024, at 9:30 a.m., during observation with Resident 1 sitting in a wheelchair in the activity room. He was observed wearing a neck brace (neck support), with black purplish discoloration on the right periorbital (surrounding the eye) area and a band aid on the right eyebrow. Resident 1 ' s record was reviewed. Resident 1 was admitted to facility on July 7, 2024, with diagnoses which included muscle weakness, difficulty in walking, dementia (forgetful). A review of the History and Physical Examination, dated July 9, 2024, indicated, Resident 1 did not have the capacity to understand and make decisions. A review of the Fall Risk Assessment, dated July 7, 2024, indicated a score of 70 (score of 45 and higher indicates resident as high risk for fall)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 consistent and accurate reconciliation of controlled medications (drugs or medications that possess the potential for being misused) for two sampled residents (Resident 1 and Resident 2). This failure resulted in loss of medications and the potential for Resident 1 and Resident 2 to experience preventable suffering and inadequate pain management. In addition, this failure increased the risk for drug diversion (unauthorized/illicit use). Findings: A review of Resident 1 ' s clinical records, the face sheet (contains demographic information) indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included acute respiratory failure with hypoxia, difficulty walking, and idiopathic peripheral neuropathy. A review of Resident 1 ' s physician ' s orders, dated February 1, 2024, indicated a physician order for, Norco 5/325 mg (Hydrocodone acetaminophen) 1 tablet by mouth every 6 hours as needed for moderate to severe pain. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, for three of eight residents reviewed for Advance Directive (AD - written instruction related to the provision of health care when the resident is no longer able to make decisions), the facility failed to ensure: 1. For Resident 38 and 76, a copy of their formulated AD was available for review in the resident's medical records. This failure had the potential for Residents 38 and 76's treatment wishes to not be honored; and 2. For Resident 37, the POLST (Physician Orders for Life-Sustaining Treatment - a portable medical order form that records the resident's treatment wishes for emergency personnel reference) was completed by the resident's representative to indicate the resident's care treatment. This failure had the potential for the facility staff to be not aware of Resident 37's treatment wishes and unable to implement the plan of care for the resident's medical condition. Findings: 1a. On June 27, 2024, Resident 38's record was reviewed. Resident 38 was admitted on…

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

Based on observation, interview, and record review, the facility failed to ensure controlled medications (narcotic medications - used to treat moderate to severe pain) were accounted for, for five of five residents reviewed (Residents 26, 32, 21, 6, and 39) when the narcotic medications were not documented on the Medication Administration Record (MAR) as administered to the residents. In addition, Resident 26 and 39's narcotic pain medication was not given as ordered by the physician. These failures had the potential to result in possible diversion of controlled medications. Findings: On June 28, 2024, at 11:43 a.m., during a concurrent inspection the narcotic box of medication cart 3, interview, and record review with Licensed Vocational Nurse (LVN) 3, the following were observed: 1. Resident 26's narcotic count sheet indicated Norco (narcotic pain medication) 10/325 mg (milligram - unit of measurement) one tablet for moderate pain (pain rate scale of 4 to 6) every four (4) hours as needed and two (2) tabs every four (4) hours as needed for severe pain (pain rate scale of 7 to 10).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medications were stored and labeled according to the facility's policy and procedure when: 1. Multiple over the counter and treatment medications were not identifiable to be discarded or disposed of, were readily available for use in medication storage room at Station 1; 2. Three (3) Luer Lock (brand of syringe) IV (intravenous - through the vein) kits were found expired in the IV Cart; 3. Two (2) bags of 250 ml (milliliter - unit of measurement) normal saline IV were unlabeled and readily available for use in the IV cart; 4. For Residents 68 and 49, multiple medications of different forms and route were stored together in an area in the med cart of station three (3); 5. For Residents 85, 58, and 53, the discontinued meds were found stored in the med cart station three (3) readily available for use; and 6. For Resident 68, the label on the medication bottle found in the narcotic box containing 10 pills in station three (3) was 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, and record review, the facility failed to ensure safe, sanitary food preparation and storage practices were followed in the kitchen when: 1. Food preparation and cooking pans (19 sheet pans, 3 baking pans, 1 steamer pan, 4 small deep container pans, 5 small shallow containers) were stacked wet one on top of another; 2. Dust was observed in several kitchen storage shelves, equipment, and ventilation vents; 3. Observed rust on the metal storage shelves, back stove hood, and fire suppression water pipes; 4. Wooden shelves in storage room were found with chipped paint and dust; 5. Dietary Aide (DA) 3 was observed not removing gloves and washing hands, after handling trash; 6. Observed broken and missing floor tiles in the walk-in-refrigerator, walk-in-freezer, back stove area, and dishwashing machine area; and 7. There was water pooling and unable to drain into the floor drain in the dishwasher area. These failures had the potential to cause food-borne illnesses in a highly susceptible resident population. Findings: On June 25, 2024, starting at 9:05…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 their own policy and procedure to provide an environment free of pests, when black flies were observed flying and landing in the kitchen. This failure had the potential to lead to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) in the facility residents who eat food prepared in the kitchen. Findings: On June 25, 2024, at 10:16 a.m., a concurrent observation and interview was conducted with the the Dietary Services Supervisor (DSS) in the back stove area of the kitchen. One black fly was observed flying over the back stove area several times. The DSS confirmed the fly was present and it should not have been there, as could cause cross-contamination of the residents' food. On June 25, 2024, at 2:55 p.m., a concurrent interview and record review with the Registered Dietitian (RD). The RD confirmed this facility had a pest control issue with house flies. The RD stated her expectation was that the kitchen was not supposed to have any pests as they could…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 eligible residents were provided with a Skilled Nursing Facility (SNF) Advanced Beneficiary Notice of Non-Coverage (ABN- a notice a provider gives after receiving services based on Medicare, federal funded program that covers skilled nursing facility in writing), for two of three residents reviewed for beneficiary notice (Residents 75 and 52). This deficient practice had the potential for the residents not to be informed of services should they decide to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility. Findings: 1. On June 28, 2024, at 09:45 a.m., a concurrent interview and record review was conducted with the Business Office Manager (BOM). The BOM stated Resident 75 was readmitted from the general acute hospital (GACH) on February 28, 2024. The BOM stated Resident 75 was provided skilled services under Medicare Part A from February 28, 2024, to April 12, 2024. The BOM stated Resident 75 was transferred from skilled care to custodial care effective…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurately code the Minimum Data Set Assessment (MDS - a resident assessment instrument), for one of one resident reviewed for hospitalization (Resident 88). This failure had the potential to cause inaccuracy in identifying Resident 88's care and support needs, and cause delay in these needs being met. Findings: On June 27, 2024, at 10:10 a.m., during a concurrent interview and record review with the MDS Coordinator, she stated the Resident 88's Discharge MDS Section A - Identification Information, dated March 29, 2024, indicated the resident was entered as discharged to short term general hospital. She stated Resident 88 was discharged to home. The MDS coordinator stated Resident 88's MDS was not coded accurately. A review of CMS (Centers for Medicare and Medicaid Services) Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, dated October 2023, indicated, .this item documents the location to which the resident is being discharged at the time of discharge. Knowing the setting to which individual…

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

Based on observation, interview, and record review, the facility failed to ensure medications were administered according to the physician's order and the facility's policy and procedure, for two of two residents reviewed during medication storage inspection (Residents 192 and 51). This failure had the potential for Residents 192 and 51 to not receive the full efficacy of the medication and had the potential to place Residents 192 and 51 at risk to affect their health condition. Findings: 1. On June 27, 2024, at 10:50 a.m., Station 3 medication cart was inspected with Licensed Vocational Nurse (LVN) 2. The following bubble pack medications for Resident 192 were observed to contain medications/pills on the following bubble number (#): - Levothyroxin (medication to treat hypothyroidism [a condition in which the thyroid gland doesn't produce enough thyroid hormone which could disrupt heart rate, body temperature, and all aspects of metabolism.]) 75MCG (microgram - unit of measurement) take half tablet = 37.5 mcg once daily, give on an empty stomach; bubble # 26 and 27 contained one…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 respiratory care was provided, for one of five residents reviewed for oxygen (Resident 77), when a humidifier bottle (a medical device used to increase moisture and decrease dryness from oxygen) was found undated. This failure had the potential to place Resident 77 at risk for infection and respiratory failure. Findings: On June 26, 2024, at 11:16 a.m., Resident 77 was observed sitting upright in her bed, the resident had an oxygen concentrator next to her bed with a tubing connected to the oxygen concentrator with the flow of oxygen at the rate of 2 liters per minute via nasal cannula (a device that give you additional oxygen). An undated humidifier bottle was connected to the oxygen concentrator. On June 26, 2024, at 11:20 a.m., an interview was conducted with the Infection Preventionist (IP). The IP stated the humidifier bottle was not dated on the oxygen concentrator for Resident 77. The IP further stated the humidifier bottle…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 psychotropic medications (medication to manage mental and mood disorders) were necessary in managing mental illness, for one of five residents reviewed for unnecessary medications (Resident 55), when there was no evaluation or assessment by the IDT (Interdisciplinary team - a group of healthcare professionals) and psychiatrist prior to the use of risperidone (medication to treat mental illness). This failure had the potential for Resident 55 to receive unnecessary psychotropic medication and placed the resident at risk for adverse reactions. Findings: On June 27, 2024, Resident 55's record was reviewed. Resident 55 was readmitted to the facility on [DATE], and initial admission date of September 1, 2022, with diagnoses which included depression (feeling of sadness) and schizophrenia (a mental illness). A review of Resident 55's physician orders, dated November 19, 2023, included an order for risperidone 1 (one) mg (milligram - unit…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 laboratory order for hemoglobin A1C (HgbA1C - blood test that shows what your average blood sugar (glucose) level was over the past two to three months) was completed as ordered, for one of five residents reviewed for unnecessary medications (Resident 53). This failure had the potential for Resident 53's blood sugar level to be uncontrolled and not be managed. Findings: On June 28, 2024, Resident 53's record was reviewed. Resident 53 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (DM - abnormal blood sugar). A review of Resident 53's physician order included the following medications to treat DM: - Humalog injection (insulin medication) per sliding scale (amount of units to be given according to the blood sugar level) before meals and at bedtime; and - Insulin Detemir solution (insulin medication) give 40 units twice a day. A review of Resident 53's physician order included the following laboratory…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 failed to ensure infection control measures were implemented according to the facility's policy and procedure, when: 1. The facility staff did not assess and change Resident 85's intravenous (IV- soft flexible tube placed inside a vein to give fluids or medicine) site when re-admitted to the facility. This failure had the potential to cause a life threatening infection for the resident; and 2. The facility did not report in a timely manner to the California Department of Public Health (CDPH) when the facility had a COVID-19 (coronavirus - a contagious respiratory infection) outbreak on June 8, 2024. This failure had the potential to prevent effective outbreak management that could have potentially prevented further Covid cases. Findings: 1. On June 25, 2024, at 12:36 p.m., Resident 85 was observed with an IV dressing placed to the top of right hand, undated, and unlabeled with transparent dressing lifting. In a concurrent interview with Resident 85, she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 appropriate interventions were developed and implemented to address high risk for fractures (broken bones) secondary to osteoporosis (brittle bones) and history of fracture, for one of three residents (Resident A), when: 1. Further assessment and evaluation were not conducted to determine if Resident A was still a candidate for transfer using Hoyer lift (is a mobility tool for a person to be transferred between a bed and a chair or other similar resting places, by the use of electrical or hydraulic power) after Resident A sustained a leg fracture on September 8, 2023 during transfer to the gerichair (a large, padded chair that is designed to help someone with limited mobility) using the Hoyer lift; and 2. An individualized care plan to prevent fracture of the right leg using the use of Hoyer lift during transfer was not developed for Resident A. These failures had the resulted in Resident A to sustain a second fracture on February…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care plan was developed to include hip precautions following a right hip arthroplasty (hip replacement surgery, a type of joint replacement surgery), for one of three residents reviewed (Resident 1). This failure had the potential for the staff to not be aware of the interventions to be implemented to prevent complications related to the hip surgery of Resident 1. This failure had the potential for Resident 1 to experience post hip surgery complications (i.e. dislocation of the right hip, fracture [broken bone]). Findings: On November 30, 2023, at 10:40 a.m., an unannounced visit was conducted at the facility to investigate a facility reported incident and a complaint intake. On November 30, 2023, at 2:28 p.m., Resident 1' s record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included aftercare following joint replacement surgery, acute hematogenous osteomyelitis (bone infection in regions of the bone…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 adequate supervision was provided to prevent incident of altercation between residents when the facility failed to provide one-on-one (1:1) monitoring (staff always remain with resident), for one of three residents reviewed (Resident 1). This failure had the potential to result in further incidents of altercation with other residents involving Resident 1. Findings: On November 8, 2023, at 9:30 a.m. an unannounced visit was conducted at the facility for the investigation of a facility reported incident. On November 8, 2023, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included dementia (loss of memory), bipolar disorder (mood disorder), and major depressive disorder (decreased interest in activities). Resident 1's Minimum Data Set (MDS – an assessment tool), dated September 18, 2023, indicated a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and sanitary food preparation and storage practices were implemented in the kitchen when: 1. Food items were stored in the refrigerator past the used-by date and were readily available for use; 2. One container of sugar stored in inside a plastic bag stored in the dry storage area was left open; and 3. The air gap (space between the water outlet and the flood level of a fixture) had a thick build-up of a dark black substance from the drain to the refrigerator. These failures had the potential for the growth of harmful bacteria and cross contamination that could lead to food borne illnesses for a medically compromised population of 62 residents who ate orally and received food from the kitchen out of a facility census of 65 residents. Findings: 1. On March 7, 2022, at 9:21 a.m., an initial tour of the kitchen was conducted with the Dietary Supervisor (DS). One container of vanilla yogurt was observed stored in the refrigerator with an open date of February 27, 2022. One container of tomato juice…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 necessary care and treatment services were provided, for two of five residents reviewed for unnecessary medications (Residents 54 and 12), when the uncontrolled blood sugar levels were not evaluated and referred to the physician for appropriate management. This failure had the potential for Residents 54 and Resident 12 to be at risk for complications related to diabetes mellitus (abnormal blood sugar). Findings: 1. On March 7, 2022, Resident 54's record was reviewed. Resident 54 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus. The Order Summary Report, for February 2022, included a physician's order, dated February 5, 2022, which indicated, .Novolog Solution 100 UNIT/ML (milliliter - unit of measurement) (Insulin Aspart - type of insulin to treat diabetes mellitus) Inject as per sliding scale .BS (blood sugar) < (less than) 70 give juice and notify MD (physician) .before meals ., The plan of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure nutritional care and services were provided, for one of seven residents reviewed for nutrition (Resident 56), when, there was no assessment and further interventions to address Resident 56's continued poor food intake, including referral to the Registered Dietician (RD) and the physician. This failure resulted in Resident 56 to have a weight loss of 23 pounds (lbs)/14.02 % (percent) from February 5, 2022, to March 6, 2022 (29 days), which could subsequently cause further decline in the overall health status of Resident 56. Findings: On March 7, 2022, at 12:45 p.m., a concurrent observation and interview with Resident 56 was conducted. Resident 56 was observed sitting in the wheelchair and refused his lunch meal. In a concurrent interview with Resident 56, he stated I don't want the food. On March 7, 2022, at 1:02 p.m., Certified Nursing Assistant (CNA) 1 was interviewed. CNA 1 stated Resident 56 had been refusing his meals. 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.