The Rowland

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure medications were kept secure with limited access by failing to: 1. Ensure to lock the medication cart (Med Cart) that contained residents' medications on North Station when not attended and outside of view. 2. Ensure the Wixela Inhub Inhalation Aerosol Powder Breath (used to control and prevent symptoms (wheezing and shortness of breath) caused by asthma or ongoing lung disease) was in Resident 34's possession. These deficient practices had the potential to result in residents' medications to be accessible to others not authorized to have access to drugs (medications) and biologicals (drugs derived from natural sources) and increased the risk for loss of control, safety, and security of all medications necessary to meet the health care needs of residents. Findings: 1. During a medication Pass Observation on 5/15/2025 at 8:03 a.m. with a Licensed Vocational Nurse 1 (LVN 1) on the North Station, LVN 1 left the medication cart (Med Cart) 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.

Based on observation, interview, and record review, the facility failed to maintain safe food handling practices by failing to ensure: a. Two of four red sanitization buckets with chemical that used in the kitchen to sanitize kitchen surfaces was maintained at the correct chemical concentration to maintain effectiveness of the disinfectant. b. One of one plastic container of expired red tomato salsa, with an open date of 5/4/25, and one plastic container of green salsa, with an open date of 5/2/25, were inside the walk-in refrigerator. c. One of one bag of open penne pasta noodles and one bag of open spaghetti pasta noodles was in dry storage area and was not labeled with an open date and use by date. These deficient practices had the potential to result in food surfaces not being properly sanitized and foodborne illness (illness caused by contaminated food) due to expired food. Findings: During an observation, on 5/13/25, at 8:33 a.m., with the Dietary Supervisor (DS), one pack of penne pasta noodles and one pack of spaghetti pasta noodles was observed in the dry storage…

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 b. During a review of Resident 16's AR, the AR indicated Resident 16 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included malignant neoplasm (cancerous tumor) of the lung, pneumonia (an infection/inflammation in the lungs) and chronic kidney disease (gradual loss of kidney function). During a review of Resident 16's MDS, dated [DATE], the MDS indicated Resident 16 had moderately impaired cognition (ability to understand and process information). The MDS indicated Resident 16 required substantial/maximal assistance (helper did more than half the effort) with eating, upper and lower body dressing and dependent (helper did all the effort, resident did none of the effort to complete the activity) with oral hygiene, toileting, shower and personal hygiene. During a review of Resident 16's Order Summary Report (OSR), dated 5/12/2025, the OSR indicated Resident 16 had an order for Enhanced Barrier Precautions due to Stage 3 pressure injury (full-thickness loss of skin.…

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 staff promoted dignity while assisting one of one sampled resident (Resident 64) during meals by feeding the resident at eye level to maintain face-to-face contact with the resident. This deficient practice had the potential to affect Resident 64's self-worth, dignity, and safety. Findings: During a review of Resident 64's admission Record (AR), the admission Record indicated Resident 64 was admitted on [DATE] with diagnoses that included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), dementia (a progressive state of decline in mental abilities), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 64's Order Summary Report, dated 1/10/2025, the Order Summary indicated Resident 64 had a diet order started on 7/8/2024 for a puree diet with pureed texture.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 47) call light was within reach. This failure had the potential to result in Resident 47 not receiving the necessary care or delayed services. Findings: During a review of Resident 47's admission Record (AR), the AR indicated Resident 47 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) affecting the right dominant side, muscle weakness (lack of muscle strength), and anxiety (intense, excessive, and persistent worry and fear about everyday situations). During a review of Resident 47's Care Plan (CP), dated 8/14/2023, the CP indicated Resident 47 required assistance with activities of daily living (ADLs). The CP interventions included keeping the call light within the resident's reach. During a review of Resident 47's Minimum Data Set (MDS, a resident assessment tool), dated 2/27/2025, the MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the resident's Advance Directive (AD, a legal document indicating a resident's preference for end-of-life treatment decisions) and AD Acknowledgement Form was in the resident's medical record for one of three sampled residents (Resident 16). This failure had the potential to result in the staff providing care and services against the will of Resident 16. Findings: During a review of Resident 16's admission Record (AR), the AR indicated Resident 16 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included malignant neoplasm (cancerous tumor) of the lung, pneumonia (an infection/inflammation in the lungs) and chronic kidney disease (gradual loss of kidney function). During a review of Resident 16's Minimum Data Set (MDS, a resident assessment tool), dated 3/23/2025, the MDS indicated Resident 16 had moderately impaired cognition (ability to understand and process information). The MDS indicated Resident…

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

Based on interview and record review, the facility failed to screen one of two randomly selected employees (Certified Nurse Assistant 2 [CNA 2]) with the Office of Inspector General (OIG - investigates alleged violations of criminal and civil laws) data base prior to hire in accordance with the facility's Policy and Procedure (P&P) titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program. This deficient practice had the potential for employees with a history of abuse get hired, which could lead to possible harm and abuse of the residents. Findings: During a concurrent interview and record review of CNA 2's employee file on 5/15/2025 at 2:08 pm with the Director of Staff and Development (DSD), the DSD stated CNA 2 was hired on 8/1/2024. The DSD stated there was no documented evidence that CNA 2's background check was done prior to hire or recently. The DSD stated that the administrator did the staff background check before hire. The DSD stated it was important to do a background check to ensure employees were safe to work, with no criminal records and residents'…

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 necessary care and services for a resident with Foley catheter (FC, a medical device that helps drain urine from the bladder) in accordance with the facility's Policy and Procedure (P&P) on catheter care for one of one sampled resident (Resident 257). This failure had the potential to result in catheter-related complications for Resident 257. Findings: During a review of Resident 257's admission Record (AR), the AR indicated Resident 257 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control), hypertension (HTN, high blood pressure) and chronic kidney disease (CKD- a progressive condition where the kidneys gradually lose their ability to filter waste and excess fluid from the blood.) During a review of Resident 257's Order Summary Report (OSR) dated 5/2/2025, the OSR indicated for licensed staff to check every shift to ensure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 307), who had a biliary drain (biliary drain- allows bile to flow out from a blocked bile duct from the liver into a collection bag outside the body) did not have biliary drainage on the resident's floor. This failure had the potential to result in the transmission of infection from bodily fluids. Findings: During a review of Resident 307's admission Record (AR), the admission Record indicated Resident 307 was readmitted on [DATE] with diagnoses that included bladder cancer and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 307's Minimum Data Set (MDS - a federally mandated resident assessment tool) assessment, dated 2/13/2025, the MDS indicated Resident 307 had intact cognition (ability to understand) and needed substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides…

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 act upon the pharmacist's medication regimen review (MRR, a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication) recommendation for one of five sampled residents (Resident 72). This failure had the potential for Resident 72 to receive unnecessary medications and result in undesirable or non-therapeutic effect of the medication to the resident. Findings: During a review of Resident 72's admission Record (AR), the AR indicated Resident 72 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included osteomyelitis (inflammation of bone or bone marrow, usually due to infection), diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), and chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing). During 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 implement their policy on the use of an antibiotic and a change in condition for one of five sampled residents (Resident 84) for a urinary tract infection (UTI- an infection in the bladder/urinary tract). This failure resulted in Resident 84 receiving antibiotics without meeting facility criteria and had the potential to result in Resident 84 developing antibiotic resistance. Findings: During a review of Resident 84's admission Record (AR), the admission Record indicated Resident 84 was admitted on [DATE] with diagnoses that included Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities), and depression (a mood disorder that may cause persistent sadness or loss of interest in activities). During a review of Resident 84's Minimum Data Set (MDS - a federally mandated resident assessment tool) assessment, dated 4/11/2025, the MDS indicated Resident 84 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement their Policy and Procedure (P&P) titled, Handwashing and Hand Hygiene for one of eight sampled residents (Resident 3), when Certified Nursing Assistant 1 (CNA 1) did not wash CNA 1's hands after touching the overbed table and bed linens of a resident who tested positive for clostridium difficile (C. diff; bacteria that can cause diarrhea, enterocolitis [inflammation of the small and large intestines], and other intestinal conditions) infection. This failure had the potential to spread infection to other residents, staff, and visitors in the facility. Findings: 1. During a review of Resident 3's admission Record (AR), the AR indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease (ESRD; irreversible kidney failure) and enterocolitis due to C. diff. During a review of Resident 3's History and Physical (H&P; a physician's clinical evaluation and examination of the resident),…

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

Based on interview and record review, the facility failed to transmit assessments within 14 days of completion for 23 of 23 sampled residents (Residents 1, 4, 17, 21, 22, 26, 28, 29, 31, 33, 35, 41, 49, 52, 56, 61, 62, 70, 71, 72, 78, 79, and 80). This failure had the potential to result in inaccurate facility information submitted to the Centers for Medicare and Medicaid Services (CMS, federal agency that works with the health care community to improve quality, equity, and outcomes in the health care system) and would affect the quality of care to the residents. Findings: During record review of the Minimum Data Set (MDS, a standardized assessment and care planning tool) 3.0 Final Validation Report, the MDS 3.0 Final Validation Report indicated it was submitted on 6/6/2024 for Residents 1, 4, 17, 21, 22, 26, 28, 29, 31, 33, 35, 41, 49, 52, 56, 61, 62, 70, 71, 72, 78, 79, and 80. During an interview on 6/6/2024 at 8:46 AM with the MDS Nurse, the MDS Nurse stated the Assistant Administrator (AADM) was responsible for transmitting the MDS assessments to CMS. During an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide necessary care and services for gastrostomy tube (GT, a tube inserted through the abdomen that delivers nutrition directly to the stomach) tubing and site as ordered by the physician and as indicated in the plan of care for two of three sampled residents (Residents 193 and 195). These failures had the potential for infection and adverse consequences related to tube feedings for Residents 193 and 195. Findings: a. During a review of Resident 193's admission Records (AR), the AR indicated Resident 193 was admitted to the facility on [DATE] with diagnoses that included subdural hemorrhage (a pool of blood between the brain and its outermost covering) and epilepsy (a seizure disorder) During a review of Resident 193's untitled Care Plan (CP), dated 5/1/2024, the CP indicated Resident 193 had a feeding tube related to dysphagia (difficulty swallowing). The CP goal was for Resident 193 to tolerate tube feeding without complications.…

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 necessary care and services for residents on oxygen therapy (a treatment that provides with extra oxygen to breathe in) as ordered by the physician, as indicated in the residents' plan of care and in accordance with the facility's Policy and Procedure (P&P) on Oxygen Administration for four of seven sampled residents (Residents 2, 31, 64 and 189). These failures had the potential to result in respiratory complications and infection for Residents 2, 31, 64 and 189. Findings: a. During a review of Resident 189's admission Record (AR), the AR indicated the facility admitted Resident 189 on 4/7/2024 with diagnoses that included hypertension (high blood pressure), morbid obesity (a disorder that involves having too much body fat) and atherosclerosis of the aorta (a condition that occurs when plaque builds up on the inner walls of the aorta). During a review of Resident 189's Minimum Data Set (MDS, a standardized assessment and care…

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 dialysis emergency kit was readily available for staff use in case of bleeding in resident's dialysis (a type of treatment that helps the body remove extra fluid and waste products from the blood when the kidneys are not able to) access site for two of two sampled residents on dialysis (Residents 44 and 85). This deficient practice placed Residents 44 and 85 at risk for excessive bleeding from dialysis access site. Findings: a. During a review of Resident 85's admission Record (AR), the AR indicated the facility admitted Resident 85 on 4/6/2024, with diagnoses that included diabetes mellitus (a condition that happens when the blood sugar [glucose] is too high) and dependence on renal dialysis. During an observation on 6/4/2024 at 11:09 a.m., Resident 85 was lying on his back in bed, alert and coherent. Resident 85's left upper arm dialysis access site was intact. During a concurrent observation and interview with the Treatment Nurse (TN) in Resident 85's room on 6/4/2024 at 11:17 a.m., the TN stated…

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

Based on observation, interview, and record review, the facility failed to post accurate nurse staffing information of actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift daily. The staffing information was not posted in a prominent location for two of four days during the recertification survey. This deficient practice had the potential to mislead the residents and visitors of the actual hours worked by licensed and unlicensed nursing staff directly providing resident care and had the potential to affect the quality of nursing care provided to the residents. Findings: During a concurrent observation and interview on 6/4/2024 at 9:30 a.m. and 6/5/2024 at 9 a.m., the facility's staffing information was posted inside the North Nurses' Station and no staffing information was posted in the South Nurse's Station of the facility. The staffing information indicated actual hours worked by the nursing staff on all shifts (7 am-3 pm, 3pm-11 pm and 11 pm-7 am). During a concurrent interview and review on 6/5/2024 at 10 a.m., 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 five of five sampled residents (Residents 13, 25, 41, 47 and 77) on psychotropic drugs (any drug capable of affecting the mood, emotions, and behavior) were free from unnecessary medication by failing to: A. Attempt a Gradual Dose Reduction (GDR- tapering of a dose) for Residents 25 and 47 B. Ensure PRN (as needed) orders for psychotropic medications were limited to 14 days use for Residents 13, 41, and Resident 77. These deficient practices had the potential for the facility to use psychotropic drugs inappropriately and had the potential to affect residents' physical, emotional and psychosocial wellbeing. Findings: A.1. During a review of Resident 25's admission Record (AR), the AR indicated the facility admitted Resident 25 on 4/28/2023, under Hospice Care (a program that gives special care to people who are near the end of life and have stopped treatment to cure or control their disease) due to diagnosis of end stage Alzheimer's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of disease and infection by failing to: a. Establish facility wide systems and water safety management based on national standards of practice and the facility assessment for the prevention, identification, investigation, and control to prevent the growth of Legionella (bacteria that causes Legionnaires [severe form of pneumonia [lung infection caused by bacteria] and other opportunistic waterborne pathogens [any organisms or agent that can cause disease]) in the building water systems. b. Ensure signage was posted and personal protective equipment (PPE, specialized equipment or clothing that protects against infectious materials) cart was provided to one of one sampled resident (Resident 189) with Foley catheter (FC, thin, sterile tube inserted into the bladder to drain urine into a bag outside the body) who was on Enhanced Barrier Precaution (EBP, an approach 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 follow the facility's policy on Advance Directives (AD, a legal document that informs healthcare providers what kind of care a person would want to receive if the individual was unable to speak for self) to ensure a current copy of a resident's AD was in the medical chart for one of three sampled resident (Resident 288). This failure had the potential for Resident 288's AD to not be followed by the facility staff. Findings: During a review of Resident 288's admission Record (AR), the AR indicated Resident 288 was admitted to the facility on [DATE] with diagnoses that included urinary tract infection (UTI, occurs when bacteria enters the urethra [tube through which urine leaves the body] and multiply), hyperlipidemia (high levels of cholesterol in the blood), and constipation (stool becomes hard and difficult to pass). During a review of Resident 288's History and Physical (H&P, formal document of a medical provider's examination of a patient) dated…

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

Based on observation, interview, and record review, the facility failed to provide privacy during a bed bath to one of one sampled resident (Resident 28.) This deficient practice had the potential to cause embarrassment and lowered self-esteem for Resident 28. Findings: During a review of Resident 28's admission Record (AR), the AR indicated the facility admitted the resident on 12/10/2023, with diagnoses that included dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) and epilepsy (brain disorder in which a person has repeated seizures (convulsions) over time). During a review of Resident 28's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 1/24/2024, the MDS indicated the resident had moderately impaired cognition (ability to understand). The MDS indicated Resident 28 was dependent with showers, self-bathing and toileting and required moderate (helper does less than half the effort) assistance with bed mobility. During an observation on 6/4/2024 at 10:03 am to…

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

Based on observation, interview, and record review, the facility failed implement its policy and procedure (P&P) on Translation and Interpretation services to ensure needs and questions from the resident with limited English proficiency (LEP) were addressed by staff for one of one sampled resident (Resident 289). This failure had the potential to not meet Resident 289's needs. Findings: During a review of Resident's 289 admission Record (AR) the AR indicated the facility admitted Resident 289 on 5/10/2024 with diagnoses that included wedge compression fracture (bone in front of the spine collapsing forming a wedge shape) of first lumbar vertebra (bones in spine to provide support to the body), unspecified hearing loss, and a history of falling. During a review of Resident 289's History and Physical (H&P, a formal document of a medical provider's examination of a patient) dated 5/11/2024, the H&P indicated Resident 289 had the capacity to understand and make decisions. During a review of Resident 289's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated…

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

Based on observation, interview, and record review, the facility failed to answer the call light and provide assistance to a resident in a timely manner in accordance with the resident's care plan (CP) and the facility's Policy and Procedure (P&P) on answering call lights, for one of one sampled resident (Resident 289). This failure had the potential to result in fall or injury to Resident 289 who had a history of falling. Findings: During a review of Resident's 289 admission Record (AR) the AR indicated the facility admitted Resident 289 on 5/10/2024 with diagnoses that included wedge compression fracture (bone in front of the spine collapsing forming a wedge shape) of first lumbar vertebra (bones in spine to provide support to the body), unspecified hearing loss, and a history of falling. During a review of Resident 289's History and Physical (H&P, a formal document of a medical provider's examination of a patient) dated 5/11/2024, the H&P indicated Resident 289 had the capacity to understand and make decisions. During a review of Resident 289s untitled CP, dated 5/11/2024, the CP…

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 interventions were developed and implemented to address the resident's positioning preference for one of one sampled resident (Resident 16.) Resident 16 had a non-healing wound to the left lateral (side) ankle and left medial (middle) ankle and Resident 16 preferred to lie on the left side. This deficient practice had the potential to delay wound healing for Resident 16. Findings: During a review of Resident 16's admission Record (AR), the AR indicated the facility admitted the resident on 7/27/2021 and readmitted on [DATE], with diagnoses that included benign neoplasm of endocrine pancreas (non-cancerous tumors of the pancreas) and infection and inflammatory reaction (pain, swelling, and discomfort) due to internal orthopedic prosthetic devices, implants, and grafts (medical devices or tissues placed inside or on the surface of the body). During a review of Resident 16's Minimum Data Set (MDS - a standardized assessment and care…

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 care and services was provided to prevent pressure ulcer (lesion/wound caused by unrelieved pressure that results in damage of underlying tissue) for one of five sampled residents (Resident 16.) Resident 16 developed redness at the base of the left lateral toe and redness at the base of the right big toe. This deficient practice had the potential for the development of pressure ulcer. Cross Reference: F684 Findings: During a review of Resident 16's admission Record (AR), the AR indicated the facility admitted the resident on 7/27/2021 and readmitted on [DATE], with diagnoses that included benign neoplasm of endocrine pancreas (non-cancerous tumors of the pancreas) and infection and inflammatory reaction (pain, swelling, and discomfort) due to internal orthopedic prosthetic devices, implants, and grafts (medical devices or tissues placed inside or on the surface of the body). During a review of Resident 16's Minimum Data Set (MDS -…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow its policy and procedure (P&P) on Restorative Services (care designed to improve or maintain the functional ability of residents) to provide restorative services in accordance with Medical Doctor's (MD-physician) order for one of four sampled residents (Resident 2). This failure had the potential to result in a decrease in range of motion (ROM, full movement potential of a joint [where two bones meet]) in Resident 2's bilateral (both) legs. Findings: During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included spinal stenosis (narrowing of spinal canal in lower part of the back) of the lumbar region (lower part of the back) and bilateral artificial knee joints. During a review of Resident 2's untitled Care Plan (CP) dated 8/6/2021, the CP indicated Resident 2 required variable assistance with activities of daily living (ADL, basic…

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 necessary care and services for a resident with foley catheter (FC, thin, sterile tube inserted into the bladder to drain urine into a bag outside the body) as indicated in the resident's plan of care for one of two sampled residents (Resident 189). This failure had the potential to result in catheter-related complications for Resident 189. Findings: During a review of Resident 189's admission Records (AR), the AR indicated Resident 189 was admitted to the facility on [DATE] with diagnoses that included urinary tract infection (UTI, an illness in any part of the urinary tract, the system of organs that makes urine) and benign prostatic hyperplasia (BPH, prostate gland enlargement that can cause urination difficulty). During a review of Resident 189's Minimum Data Set (MDS) dated [DATE], the MDS indicated Resident 189 had intact cognition. Resident 189 was dependent (helper does all of the effort, resident does none of the effort…

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 accurately monitor the resident's fluid intake (measurement of the fluids that enter the body) for one of one sampled resident (Resident 30) as ordered by the physician. This failure had the potential for complications related to electrolyte imbalance for Resident 30. Findings: During a review of Resident 30's admission Records (AR), the AR indicated Resident 30 was admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure), anemia (a condition that occurs when the body doesn't have enough red blood cells to carry oxygen to the body's tissues) and atrial fibrillation (irregular, often rapid heart rate that commonly causes poor blood flow). During a review of Resident 30's untitled Care Plan (CP), dated 8/5/2021, the CP indicated Resident 30 had hypertension. The CP interventions included for staff to implement diet restrictions as ordered, monitor for compliance, monitor laboratory work and notify…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, Licensed Vocational Nurse 2 (LVN 2) failed to ensure enteric coated (barrier to prevent gastric acids in the stomach from dissolving or degrading medications after being swallowed) Aspirin (medication to prevent blood clot) was not crushed for one of four sampled residents (Resident 7) during medication administration. This deficient practice had the potential to affect Resident 7's medication efficacy and placed the resident at risk for adverse complications. Findings: During a review of Resident 7's admission Record (AR), the AR indicated the facility admitted the resident on 5/2/2016 and readmitted on [DATE] with diagnoses that included gastroesophageal reflux disease with esophagitis (a condition in which stomach acid repeatedly flows back up into the tube connecting the mouth and stomach) dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) and atherosclerotic heart…

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 follow its policy and procedure (P&P) on Storage of Medications to ensure drugs and biologicals (class of medicines which were grown and purified) were stored in the Medication Refrigerator (MR) at required temperature for one of one sampled Medication Storage room [ROOM NUMBER] (MSR 1). This failure had the potential to result in medications to become unstable and ineffective. Findings: During a concurrent observation and interview on 6/7/2024 at 9:27 AM with Licensed Vocational Nurse 4 (LVN 4) in MSR 1, the MR thermometer inside MR indicated a temperature of 62 degrees Fahrenheit (F, unit to measure temperature). LVN 4 stated the temperature reading inside the MR was 62 degrees F. LVN 4 stated the thermometer was unsure if the thermometer was broken. LVN 4 stated the temperature in the MR was rechecked and indicated a temperature of 56 degrees F. LVN 4 stated the required MR temperature needed to be between 36 degrees F and 46 degrees F…

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 sanitary environment to prevent the spread of infection during a Coronavirus (COVID-19 an illness caused by a virus that can spread from person to person) outbreak (a sudden increase in occurrences of a disease when cases are in excess of normal expectancy for the location or season), as evidenced by failing to: a. Ensure the Activities Director (AD) performed hand hygiene after contact with objects in the immediate vicinity of two of two residents (Residents 4 and 5). b. Ensure Certified Nursing Assistant 1 (CNA 1) changed gloves and performed hand hygiene before and after providing care to two of two residents (Residents 6 and 7). c. Ensure one of one shower chair was disinfected with EPA( Environmental Protection Agency- an agency that develops and enforces environmental regulation to protect people and environment from significant health risk) approved disinfectant (chemical that destroys bacteria). These deficient…

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

Based on observation, interview, and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency related to their duties when: a. Diet Aide 1 (DA 1) and [NAME] 1 did not know sanitary food storage policy related to storing scoop inside the bulk container(cross reference F812). b. Dishwasher 1 (DW 1) and DA 1 did not know the proper sanitizer test strip to use for the dish machine sanitizer and quaternary ammonium (QUAT, a type of sanitizing solution) sanitizer. DA 1 and dietary supervisor (DS) did not know the concentration strength of the quaternary ammonium sanitizer. c. [NAME] 2 did not follow standardized recipes when preparing pureed diet and was not evaluated for competency related to puree preparation (cross reference F803). d. Dietary manager (DM) and dietary supervisor (DS) did not have documented routine staff competency evaluation to ensure all kitchen staff were competent in their job related duties. These deficient practices had the potential to result in unsafe and unsanitary food production that could place 59 out 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 safe and sanitary food storage and food preparation practices in the kitchen when: a. One Diet Aide 1 (DA 1) and one cook (Cook 3) did not wear hair covering that covered hair completely in the food preparation area. b. Equipment, floor, drains and shelving in the food storage and food preparation area were dirty. Chemicals were stored directly on the dirty floor and one detergent without covering. c. Several food items were not dated, labeled, and sealed after opened in the food preparation area, walk-in freezer, and dry storage area. Grape Jelly were stored at room temperature after opened. Some breads in the dry storage area were past best by dates and two can goods were dented. d. Scoops stored inside bulk thickener container and salt container. e. DA 2 did not wash hands after discarding trash when returning to the kitchen and entered walk-in refrigerator to put away delivery. f. Resident meal trays, muffin tins and cooking…

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 two of two sampled residents (Resident 7 and 162) with a urinary indwelling catheter (tube inserted into the bladder to drain urine to a collection bag) receive appropriate care, as indicated in the facility policy. Residents 7 and 162 were not assessed and monitored for signs and symptoms of urinary tract infection (UTI, condition in which bacteria invade and grow in any part the urinary system which includes the kidneys, bladder, ureters [tube that carries urine from the kidney to the urinary bladder], and urethra [canal from the bladder]). This deficient practice had the potential to result in delayed or no treatment for UTI, which could lead to sepsis (severe life threatening infection). Findings: a. A review of the admission Record indicated Resident 7 was readmitted to the facility on [DATE]. Resident 7's diagnosis included chronic kidney disease (CKD, failure of the kidney to filter extra fluids and toxins) and history 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.

Based on observation, interview, and record review, the facility failed to ensure puree diet (composed of food of a pasty consistency: smooth, with no lumps or pips), was prepared according to the menus and standardized recipes when: a. [NAME] 2 prepared pureed ground pork and pureed green beans prior to regular lunch entrées were made and without following puree recipes. b. Puree vegetables texture on the test tray tasted gritty with small chunks and not smooth. These deficient practices had the potential to result in decreased puree food quality, different tastes from the regular menu entrée and had the potential to result in decreased food intakes for residents who were on a pureed diet. Findings: a. During an observation and concurrent interview with the [NAME] 2 on 6/9/2021 at 8:40 am, observed two pans of puree-like food products with a layer of water floating on top of the pan on the stove. [NAME] 2 stated the pans were pureed pork and pureed green beans for lunch. [NAME] 2 stated he usually made puree early in the morning then reheat it later closer to lunch time. [NAME] 2…

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

Based on observation, interview, and record review, the facility failed to ensure the trash stored in the dumpster area was maintained in a sanitary manner. Two of two garbage dumpsters were overfilled, uncovered, and cardboard boxes were scatter on the floor. This deficient practice had the potential for harborage and feeding of pests. Findings: During an observation on 6/9/2021 at 7:34 am, two garbage dumpsters outside in the parking lot were both overfilled. One dumpster lid was opened and another one was unable to close tightly due to overfilling trash. There were five empty cardboard boxes scattered outside of the kitchen door by the parking lot. During an interview with the Maintenance Supervisor (MS) on 6/9/2021 at 8:24 am, MS stated it would be everyone's responsibility to keep dumpster lids closed, and stated the facility did not have a designated staff to routinely inspect the cleanliness and environment of the dumpster area. MS stated whoever took out the trash should close the lids after trash disposal. MS stated the cardboard boxes were trash after the kitchen staff put…

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: a. Ensure the quality assessment and assurance committee (the specification of standards for quality of care, service and outcomes, and systems throughout the facility for assuring that care is maintained at acceptable levels in relation to those standards), reported to the facility's governing body (refers to individuals such as facility owner(s), Chief Executive Officer(s), or other individuals who are legally responsible to establish and implement policies regarding the management and operations of the facility), at least quarterly as indicated in the facility's policy and procedure. This deficient practice had the potential for the facility not to identify quality deficiencies and appropriate plans of action that could affect the residents' wellbeing. b. Develop and implement an appropriate plan of action to correct identified quality deficiencies regarding the medication regimen review (MRR, is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing…

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 appropriate infection control practices, by failing to: a. Ensure Restorative Nursing Assistant 1 (RNA 1) donned (put on) protective personal equipment (PPE, protective clothing, gloves, face shields, goggles, facemasks and/or respirators or other equipment designed to protect the wearer from the spread of infection or illness), when he (RNA 1), repositioned Resident 462 in bed in the facility's yellow zone (area where patients under investigation are allocated). b. Screen five visitors from the Department of Public Health (DPH) for signs and symptoms of Corona Virus Disease 2019 (COVID - 19, a respiratory illness that can spread from person to person). c. Ensure Resident 33's oxygen plastic tubing did not touch the floor. d. Ensure to follow safe/clean handling of the resident's liquid beverages. These deficient practices had the potential to spread infections, including but not limited to COVID-19 to residents, staff, and visitors. Findings: a. During an observation on 6/9/2021, at 4:25 pm, RNA 1…

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 maintain a clean and homelike environment in three of 44 residents rooms (Rooms 313, 314 and 315). The privacy curtains in the rooms had brown and black stains. This deficient practice had the potential to result in an unsanitary environment, which may lead to wide spread infection in the facility and promote a non-homelike environment to the residents. Findings: During a concurrent facility tour with the Licensed Vocational Nurse (LVN 1) on 6/10/21 at 11:37 AM, the privacy curtain in room [ROOM NUMBER] was observed stained with a grey brown substance. During a concurrent observation and interview with the Registered Nurse Supervisor 2 (RN 2) on 6/10/21 at 12:10 PM, the privacy curtain in room [ROOM NUMBER] had grey and brown stains. RN 2 stated the curtains were washed, but the stains remained and should be cleaned again. During a concurrent observation and interview with the Director of Nursing (DON) on 6/11/21 at 10:11 AM, the privacy…

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 do background checks (a process a person or company uses to verify that an individual is who they claim to be, and this provides an opportunity to check and confirm the validity of someone's criminal record, education, employment history, and other activities from their past), for two staff (Licensed Vocational Nurse [LVN] 3 and LVN 5) prior to employment in accordance to the facility's policy and procedure. This deficient practice had the potential to place the residents at risk for harm and abuse. Findings: During an interview on 6/10/2021 at 3:28 pm, the Director of Staff Development (DSD) stated LVN 5's date of hire was 3/3/2021. During the concurrent interview and a review of LVN 5's employee file, DSD stated LVN 5's Office of the Inspector General (OIG, identifies individuals or entities that have been excluded from participation in Medicare), search result was dated 4/15/2021 (after the hire date), and LVN 5's California Megan's Law (provides information on registered sex offenders) Website (a set of pages or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement the individualized plan of care for one of 24 sampled residents (Residents 7) as indicated in the facility policy. Resident 7 did not have a care plan to prevent the recurrent dehydration (a dangerous loss of body fluid caused by illness, sweating, or inadequate intake). Resident 7's care plan to assess and monitor urine output, color, clarity, consistency and signs and symptoms of infection were not implemented. These deficient practices resulted to Resident 7 failing to receive necessary assessment, monitoring and interventions to prevent dehydration, bruises and bleeding. Findings: A review of the admission Record indicated Resident 7 was readmitted to the facility on [DATE]. Resident 7 diagnoses included chronic kidney disease (CKD, a failure of the kidney to filter extra fluids and toxins) and dementia (a progressive brain disorder that affects the thought process). A review of the Minimum Data Set (MDS, 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 observation, interview, and record review, the facility failed to provide one of two sampled residents (Resident 39) an activity based on the activity assessment, care plan and facility policy. This deficient practice had the potential not to meet the residents' interest and activity needs, which could affect the physical, mental, and psychosocial well-being of each resident. Findings: A review of the admission Record indicated Resident 39 was readmitted to the facility on [DATE]. Resident 39's diagnoses included epilepsy (seizure, a brain disorder caused by uncontrolled electrical activity which can result in convulsions, sensory disturbances or loss of consciousness) without status epilepticus (seizure that lasts longer than 5 minutes without a return to consciousness), cerebral palsy (a disorder that affects the ability to move and maintain balance and posture), stress incontinence (inability to control urge to urinate), intellectual disabilities and osteoarthritis (degenerative joint disease). 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 observation, interview and record review, the facility failed to provide the necessary care and treatment for two of 24 sampled residents (Resident 7 and 15) as indicated on the care plan and facility policy. a.1. There was no documented evidence Resident 7 was monitored for the presence of bruises (reddish purple discoloration) on both hands. a.2. There was no documented evidence Resident 7's moisture-associated skin damage (MASD, skin injury characterized by the inflammation and skin erosion due to prolonged exposure to moisture and irritants such as urine, stool, perspiration and wound exudates [discharge]) on the left and right buttock was assessed and documented daily for size and appearance. b. There was no documented evidence Resident 15's MASD on the sacrococcyx (tailbone) was assessed and monitored for any changes in status. This deficient practice had the potential to result in lack or delayed care, which could worsen Resident 7 and 15's bruises and MASD. Findings: a.1. A review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to offload (to suspend or take off pressure) left heel for one of three sampled residents (Resident 16) as indicated in the care plan and facility policy. This deficient practice had the potential to result in the development of pressure ulcer (localized injury to the skin and or underlying tissue usually over a bony prominence as a result of pressure or pressure in combination with shear and/or friction) and complications, which could affect resident's total well-being. Findings: A review of the admission Record indicated Resident 16 was admitted to the facility on [DATE]. Resident 16's medical diagnoses included high blood pressure and functional quadriplegia (complete immobility due to severe physical disability or frailty). A review of Resident 16's Minimum Data Set (MDS, standardized assessment and care screening tool), dated 3/26/21 , indicated Resident 16 had severe cognitive impairment (mental action or process of acquiring knowledge…

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 appropriate treatment and services to maintain or improve the highest level of range of motion (ROM, the full movement potential of a joint) for one of five sampled Residents (Resident 19) as indicated in the facility policy. This deficient practice had the potential for Resident 19 to experience a deterioration of the contracture (deformity from permanent shortening of muscle, tendon, or scar tissue) of the right hand. Findings: A review of the admission Record indicated Resident 19 was readmitted to the facility on [DATE]. Resident 19's diagnoses included hemiplegia (loss of muscle movement on one side of the body) and hemiparesis (weakness of one side of the body) following cerebrovascular disease (conditions caused by problems that affect the blood supply to the brain) affecting unspecified side and encephalopathy (disease, damage, or malfunction of the brain manifested by an altered mental state sometimes accompanied by…

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 supervise one of 24 sampled Residents (Resident 41) while eating lunch in the dining room as indicated in the facility policy and procedure. This deficient practice had the potential for the resident not to receive immediate care in an event of accidental aspiration (inhalation of food and fluid that could lead to choking or infection of the lungs). Findings: A review of the admission Record indicated Resident 41 was admitted to the facility on [DATE] with diagnosis of senile degeneration of the brain (a progressive decline in memory and thought process due to aging). A review of the Minimum Data Set (MDS) a resident assessment and care-screening tool, dated 3/2/21, indicated Resident 41 was moderately impaired with cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. Resident 41 required supervision (oversight, encouragement or cuing) with one-person assistance with eating. During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure nutritional care and services were provided to two of five sampled residents (Residents 7 and 25) as indicated in the physician's order, care plan, and/or facility policy by failing to: a. Assess, identify the risk and evaluate Resident 7 who was recently readmitted from the General Acute Care Hospital (GACH) due to dehydration (a dangerous loss of body fluid caused by illness, sweating, or inadequate intake). There were no documented evidence of interventions such as monitoring signs and symptoms of dehydration and monitoring intake and output implemented. This deficient practice had the potential to result in the resident to have fluid loss not immediately replaced and lead to a recurrent dehydration. b. Provide Resident 25 fortified diet, as ordered by the physician and adequate assistance during meals, according to the resident's nutritional plan of care. These deficient practices placed Resident 25 at risk for weight loss.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 15) received two liters of oxygen as indicated in the physician's order and facility policy. This deficient practice had the potential for Resident 15 to receive excessive amount of oxygen, which could lead to respiratory distress. Findings: A review of the admission Record indicated Resident 15 was readmitted to the facility on [DATE]. Resident 15's diagnosis included Chronic Obstructive Pulmonary Disease (COPD, progressive lung disease that results in difficulty breathing). A review of the Minimum Data Set (MDS, a resident assessment and care screening tool), dated 3/22/21, indicated Resident 15 did not have a memory and cognitive ( ability to think and reason) impairment. Resident 15 required total assistance with one person for toilet use, transfer and personal hygiene. A review of the Resident 15 physician's order, dated 5/3/21, indicated to administer oxygen inhalation at two liters…

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

Based on observation, interview, and record review the facility failed to ensure the physician for one of 24 sampled residents (Resident 7) reviewed the resident's total program of care and documented a history and physical assessment that included medications and treatments within 72 hours of readmission to the facility. The facility readmitted Resident 7 on 5/24/2021 from the hospital after the resident was diagnosed with dehydration (a dangerous loss of body fluid caused by illness, sweating, or inadequate intake of fluids), sepsis (severe blood infection) and acute renal failure (failure of the kidney to filter toxins and extra fluid in the body). This deficient practice had the potential for the resident and other potential residents not to receive the necessary care and treatments timely. Findings: A review of Resident 7's admission Record indicated the facility admitted Resident 7 to the facility on 5/16/2014 and readmitted the resident on 5/24/2021, with diagnosis that included chronic kidney disease (CKD, a failure of the kidney to filter extra fluids and toxins), dementia…

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 review and take timely action on medication regimen review (MRR) irregularity and ensure the MRR was conducted for the month of 5/2021 for three of 24 sampled residents (Residents 56, 32 and 27) as indicated in the facility policy. a. For Resident 56, the physician failed to review and take timely action on MRR irregularity identified by the pharmacy consultant. The MRR, dated 3/2021 indicated for the physician to consider increasing metformin (used to treat high blood sugar levels caused by a type of diabetes mellitus [persistently high levels of sugar in the blood]) dose based on tolerance and renal function. The facility also failed to ensure Resident 56's medication regimen was reviewed for 5/2021. b. For Resident 32, the facility failed to ensure the resident's medication regimen for 5/2021 was reviewed. Resident 32 was taking two medications for the same condition. c. For Resident 27, the facility failed to ensure the resident's medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to monitor one of 24 sampled residents (Resident 7) for the side effects of Pentoxifylline ER (medication used to improve the symptoms of a certain blood flow problem in the legs/arms with side effects that included brushing and bleeding) as indicated in the plan of care. This deficient practice had the potential for Resident 7 to bleed and experience other adverse (undesired) effects of the medication. Findings: A review of Resident 7's admission Record indicated the facility admitted Resident 7 on 5/16/2014 and readmitted on [DATE], with diagnoses of chronic kidney disease (CKD, a failure of the kidney to filter extra fluids and toxins), dementia (a progressive brain disorder that affects the thought process). A review of Resident 7's Minimum Data Set (MDS), a resident assessment and care screening tool, dated 3/24/2021, indicated Resident 7 had severe impairment in cognitive (ability to think and reason) skills and daily decision making…

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 monitor the behaviors for one of three sampled residents from a total sample of 24 residents (Resident 52) for the use of psychotropic (any drug that affects brain activities associated with mental processes and behavior) medication as indicated in the resident's care plan and the facility's policy. This deficient practice had the potential for inadequate monitoring for effectiveness, dose adjustments and adverse (harmful) consequences to Resident 52. Findings: A review of Resident 25's Face Sheet (admission Record), indicated the facility admitted Resident 52 on 2/22/2021 with diagnoses of major depressive disorder (mental disorder characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts), diabetes (a condition that affects the way the body processes blood sugar), and hyperlipidemia (high level of fats in the blood). A review of Resident 52's Minimum Data Set…

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 safe storage of medication for one of 24 sampled residents (Resident 16). This deficient practice had the potential for Resident 16 to receive expired or non-potent medication. Findings: A review of Resident 16's admission Record indicated the facility admitted the resident on 10/31/2010 with diagnoses of ataxia (the loss of full control of bodily movements) following cerebral infarction (occurs because of disrupted blood flow to the brain due to problems with the blood vessels that supply it, a lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off) and functional quadriplegia (complete inability to move due to severe disability). A review of Resident 16's History and Physical (H&P) Examination dated 3/25/2021, indicated Resident 16 did not have the capacity to understand and make decisions. A review of Resident 16's Minimum Data Set (MDS, a standardized assessment and screening tool) dated 3/26/2021, the MDS indicated the…

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

Based on observation, interview, and record review, the facility failed to provide sufficient dietetic service oversight when dietetic service supervisor (DS) was not working full time while registered dietitian worked on a consulting basis, as evidenced by lapses in the delivery of food services associated with staff competency (Cross Reference F802), therapeutic diet accuracy and following of puree recipes (Cross Reference F803 and F808), and food safety and sanitation (Cross Reference F812). This deficient practice could result in compromising the safety and nutritional status of residents through the potential transmission of foodborne illness, incorrect serving of physician ordered therapeutic diets, and/or decreased nutritional intake due to poor resident acceptance of pureed diets. Findings: During the annual recertification survey from 6/8/2021 to 6/10/2021, multiple issues surrounding the delivery of dietetic services were unmet in relation to: 1) The oversight of food safety, sanitation, and storage of food in the kitchen (cross reference F812). 2) The evaluation 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 food brought to resident by family members were appropriate, palatable (pleasant to taste), at a safe temperature, and was in accordance to resident's therapeutic (meal plan that controls the intake of certain food or nutrients for the treatment of a medical condition) diet for one of three sampled residents (Resident 51) as indicated in the physician's order, care plan and facility policy. Findings: A review of the Admissions Record indicated Resident 51 was admitted to the facility on [DATE]. Resident 51's diagnosis included Cerebral Infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it). A review of Resident 51's Nutrition Assessment, dated 5/4/2021, indicated a diet order of mechanical soft finely chopped (diet that involves only foods physically soft, with the goal of reducing or eliminating the need to chew the food) with thin liquids (liquids that become thin at room…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of 24 sampled residents (Resident 27) was served the food preferences listed on Resident 27's lunch tray card. This deficient practice had the potential to result in decreased meal satisfaction and consumption and negatively affect Resident 27 nutritional status. Findings: A review of Resident 27's care plan initiated on 3/31/2021, indicated the concern identified was Alteration in nutrition status, and the approach included Adhere to dietary preferences and restrictions and the responsible disciplines included dietary and nursing. A review of Resident 27's clinical record under Nutrition Note, and Nutrition Assessment, indicated food preference was reviewed and documented on 4/2/2021 and 6/8/2021. During an observation on 6/8/2021 at 12:50 pm, Resident 27's tray on the bedside table had mashed potatoes, ground meats with gravy, mixed vegetables, milk, and a cup of chocolate colored beverage labeled Hi Pro. During an interview…

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

Based on observation, interview, and record review, the facility failed to provide fortified diet (diet enhanced to increase caloric content) as ordered by the physician for two of 24 sampled residents (Resident 27 and Resident 45). This deficient practice had the potential to result in decrease caloric intake and lead to undesirable weight loss. Findings: a.A review of Resident 27's meal tray card indicated Resident 27 was on a fortified mechanical soft NCS (no concentrated sweets) diet. During an observation on 6/8/2021 at 12:50 pm, Resident 27's tray on the bedside table had mashed potatoes, ground meats with gravy, mixed vegetables, milk, and a cup of chocolate milk labeled Hi Pro. A review of facility's lunch spreadsheet (food portion serving guidelines) indicated to provide Super Soup 6 oz for fortified diets. During an interview with Resident 27 on 6/8/2021 at 12:55 pm, Resident 27 stated she did not receive soup at lunch. During an interview with the Dietary Manager (DM) on 6/8/2021 at 1:05 pm, DM stated if the spreadsheet indicated to provide Super Soup, kitchen staff…

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.