Marina Pointe Healthcare & Subacute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a resident-centered care plan, for one of five sampled residents (Resident 1), who had mobility deficit, requiring assistance with activities of daily living (ADLs) and who had complained of right arm pain. This deficient practice had the potential to result in providing poor quality patient care and had the potential to affect in maintaining the highest practicable physical, mental and psychosocial well-being of the resident.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness), following cerebral infarction (ischemic stroke, a type of stroke caused by a blocked blood vessel [thrombosis or embolism], leading to tissue death [necrosis] in the brain due to lack of oxygen) affecting right dominant side (right-side of the body), other…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure pain management was provided for one of five sampled residents (Resident 1). consistent with professional standards or practice. The facility failed to ensure: 1). Certified Nursing Assistants (CNA) 3 documented on a Stop and Watch form (a written statement of the situation), Resident 1's constant complains of right arm pain during movement and when it was reported to the charge nurse.2). Licensed Vocational Nurse (LVN) 2 properly assessed Resident 1's right arm pain after noting the family member's (FM) posted instruction in Resident 1's room reminding staff to be mindful when touching, moving or repositioning the resident's right arm, because of the pain.3). Implement its policy and procedure (P&P) titled Pain Assessment and Management, which indicated to assess the potential for pain, recognize the presence of pain, identify the characteristics of pain, address the underlying causes of the pain, develop and implement approaches to pain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure Certified Nursing Assistants (CNA) 1 and 2 implemented the Enhanced Barrier Precautions (EBP, an approach to the use of personal protective equipment [PPE] to decrease transmission of multidrug resistant organisms [MDROs] when contact precautions do not apply) when providing care to two of five sampled residents (Residents 2 and 3). This deficient practice had the potential to the transmission of disease causing MDROs to other residents, staffs and visitors in the facility, affecting the health conditions and causing infections, hospitalization or death. Findings: 1). During an observation on 3/26/2026 at 10:00 a.m., an isolation cart and an EBP sign were observed at the entrance of Resident 2's room. CNA 1 entered Resident 2's room without wearing an isolation gown (a personal protective equipment) and assisted Resident 2 with ADL care. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy and procedure titled Charting and Documentation, for one of three residents (Resident 1) when:Respiratory Therapist (RT 1) wrote a progress note on 1/6/2026 at 4:15 p.m. for an event that occurred at 4:23 p.m Licensed Vocational Nurse (LVN 1) did not document his respiratory assessment findings in Resident 1's medical record.These failures resulted in Resident 1's medical record being inaccurate and incomplete. These failures had the potential to result in delayed identification of Resident 1's change in condition, and delayed interventions.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including acute and chronic respiratory failure, pneumonia (an infection/inflammation in the lungs), tracheostomy (an opening in the neck into the windpipe for direct and improved airflow) and respirator (ventilator- a medical device to help…

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 to follow its policy and procedure (P&P) titled, Resident Going Out On Pass (OOP-short term leave from the facility) Policy, for three of three sampled residents (Resident 1, 2 and 3) by failing to:1.Ensure Residents 1, 2 and 3's OOP orders indicated whether the Residents may leave OOP without a responsible person and/or indicated the length of time the Resident may be OOP. 2.Ensure Resident 3 was assessed before and after the Resident went OOP. 3.Ensure Residents 1 and 3 had a responsible person to accompany the Residents while OOP when the physician did not specify whether the Residents may leave OOP without a responsible person. These failures had the potential to negatively affect Resident 1, 2, and 3's safety and well-being while OOP. Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE]. Resident 1's diagnoses included polyneuropathy (damage to nerves outside…

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), titled Bed-Holds and Returns and the Transfer/Discharge Documentation, by not providing the written Notice of Discharge and the written Notice of Bed-hold (to save the bed for 7 days) upon the residents' transfer to a general acute care hospital (GACH 1), for three of four residents (Residents 1, 2 and 3) or their family representatives. This failure had the potential to result in Resident 1, Resident 2, and Resident 3 and their representatives not knowing their rights. Findings: 1). During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and discharged to General Acute Care Hospital (GACH 1) on 4/28/2025. The admission Record indicated Resident 1 had a history of tracheostomy (a surgical opening fitted with a device to allow air to be administered through the neck, common for people with breathing problems), gastrostomy (a surgical opening…

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 its policy and procedure (P&P) titled, Bed-Holds (when a nursing home holds [reserve] a bed for seven (7) days) when the resident goes to the hospital) and Returns, by failing to hold the sub-acute bed (specialized unit of the facility providing care and services to residents with tracheostomy [surgical opening in the neck area for breathing]) for 7 days, when one of four residents' (Resident 1), was sent to the General Acute Care Hospital (GACH 1). This failure resulted in Resident 1 not re-admitted back to the facility within the 7-day bed-hold period. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility in room [ROOM NUMBER]A, in Sub-acute unit on 12/31/2024. The admission Record indicated Resident 1 had a history of tracheostomy ([trache] a surgical opening in the neck for breathing), gastrostomy (a surgical opening fitted with a device to allow feedings to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of five sampled residents (Resident 4 and Resident 5) received respiratory care and services according to professional standards, by failing to ensure: 1.Resident 4 ' s ventilator (a medical device to help a person breathe when they are unable to do so on their own) alarm (visual and/or audible warnings that alert caregivers to changes in a patient's condition or the ventilator's status) located outside Resident 4 ' s room (secondary alarm) was turned on in a timely manner. 2. Resident 5 ' s ventilator alarm located at the bedside (primary alarm) was set to high. These failures had the potential to result in a delay in care and services, respiratory compromise and death for Residents 4 and 5. Findings: a. During a review of Resident 4 ' s admission Record, the admission Record indicated Resident 4 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. The admission Record indicated Resident 4 ' s diagnoses…

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: 1. Ensure two out of six sampled residents (Resident 67 and 147) nasal cannulas (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) were not dated and labeled. This deficient practice of not dating and labeling the nasal cannulas placed Residents 67 and 147 at risk for respiratory infection (an infection affecting the nose, throat, sinuses, airways, and lungs). 2. Ensure there were not two bags of opened and emptied bottles of water, sparkling water, iced coffee, fruit juice, and energy drinks in the laundry room next to a washing machine. This deficient practice had the potential for attracting pests to the laundry room. a. During a review of Resident 67's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 67 was initially admitted to the facility on [DATE] and was readmitted on [DATE].…

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: 1. Ensure one of seven sampled residents (Resident 9) received supervision while smoking This deficient practice had the potential to result in Resident 9 being injured while smoking. 2. Ensure the entrance and exit doors were monitored to prevent the resident from leaving the facility unattended. This deficient practice had the potential for a resident to sustain an accidental injury while outside the facility's premises without staff supervision. Findings: a. During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was admitted to the facility on [DATE] with diagnoses including hypertension (HTN-high blood pressure), dementia (a progressive state of decline in mental abilities), and congestive heart failure ([CHF]-a heart disorder which causes the heart to not pump the blood efficiently). During a review of Resident 9's History and Physical (H&P), dated 9/29/2024, the H&P indicated Resident 9 has the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to 1. Provide appropriate intravenous (IV- a long thin catheter in the vein to deliver medications or fluids) care for one of three sampled residents (Resident 87) by not changing the IV dressing every 7 days and not changing the IV site every 72 hours as ordered. 2. Ensure one of three sampled resident's (Resident 5) intravenous line ([IV]- a thin, flexible tube inserted into a vein) site was labeled with the date/time of insertion. These deficient practices had the potential for Resident 87 and Resident 5 to experience complications associated with having an IV. Findings: a. During a review of Resident 87's Face Sheet, it indicated Resident 87 was readmitted on [DATE] with diagnoses that included sepsis (a life-threatening blood infection), and urinary tract infection (UTI- an infection in the bladder/urinary tract). During a review of Resident 87's Order Summary Report, it indicated Resident 87 was prescribed Zosyn (an antibiotic) 3.375 grams (gm- 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 During an interview and record review the facility failed to: 1. Ensure one out of six sampled residents (Resident 69) Physician Orders for Life-Sustaining Treatment ([POLST] - a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency) was completed. This deficient practice of not completing the POLST for Resident 69 placed the resident at risk for not receiving goods and services based on their needs. Findings: During a review of Resident 69's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 69 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 69's diagnoses included chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty in breathing), respiratory failure (when the body's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to: 1. Ensure a comfortable sound level, when staff was setting off the alarm when exiting the emergency door for two of 19 sampled residents (Residents 33 and 56). This deficient practice resulted in Resident 33 and 56 feeling annoyed and not being able to sleep or rest. Findings: a. During a review of Resident 33's admission Record, dated 2/20/2025, the admission Record indicated, Resident 33 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 33's diagnoses included cellulitis (a skin infection that causes swelling and redness) to right and left leg, chronic kidney disease (CKD-condition which the kidneys are damaged and cannot filter blood as well as they should), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling. A review of Resident 33's Minimum Data Set (MDS-a resident assessment tool), dated 12/24/2024, the MDS indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one out of six sampled residents (Resident 69) was accurately assessed for smoking. This deficient practice had the potential for the facility to not develop and implement an individualized plan of care for resident 69. Findings: During a review of Resident 69's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 69 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 69's diagnoses included chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty in breathing), respiratory failure (when the body's respiratory system is unable to exchange oxygen and carbon dioxide properly), and diabetes mellitus ([DM] -a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 69's History and Physical (H&P), dated 3/8/2024, the H&P indicated,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to: 1. Ensure a care plan (the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) was formulated for one of 19 sampled residents (Residents 76). This failure placed Resident 19 at risk of not having his care needs met. Findings: During a review of Resident 76's admission Record, dated 2/20/2025, the admission Record indicated, Resident 76 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 76's diagnoses included chronic respiratory failure with hypoxia (a serious condition where the lungs can't get enough oxygen into the blood), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and seizures (a sudden,…

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: 1. Ensure one out of six sampled residents (Resident 69) had a revised care plan (a previously established care plan for a patient that has been updated to reflect changes in their condition, needs, or response to treatment) to wear protective gear while smoking. This deficient practice had the potential to place the Resident at risk burns. Findings: During a review of Resident 69's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 69 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 69's diagnoses included chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty in breathing), respiratory failure (when the body's respiratory system is unable to exchange oxygen and carbon dioxide properly), and diabetes mellitus ([DM] -a disorder characterized by difficulty in blood…

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: 1. Ensure one out of six sampled residents (Resident 6) had heel protectors on while lying in bed. This had the potential of Resident 6 not receiving the appropriate care and services. Findings: During a review of Resident 6's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 6's diagnoses included metabolic encephalopathy (a brain dysfunction that occurs due to an imbalance of chemicals in the blood), respiratory failure (when the body's respiratory system is unable to exchange oxygen and carbon dioxide properly), and diabetes mellitus ([DM] -a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 6's History and Physical (H&P), dated 10/30/2024, the H&P indicated, Resident 6 had limited…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to: 1. Ensure one out of six sampled residents (Resident 6) staff followed physician orders. This deficient practice had the potential to cause a delay in Resident's 6 plan of care. Findings: During a review of Resident 6's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 6's diagnoses included metabolic encephalopathy (a brain dysfunction that occurs due to an imbalance of chemicals in the blood), respiratory failure (when the body's respiratory system is unable to exchange oxygen and carbon dioxide properly), and diabetes mellitus ([DM] -a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 6's History and Physical (H&P), dated 10/30/2024, the H&P indicated, Resident 6 had limited capacity. During a review…

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

Based on observation, interview, and record review, the facility failed to: 1. Ensure a bottle of Pro-Stat (a liquid protein supplement) and drawer in medication cart #4 was free of a sticky substance. This deficient practice had the potential to result in cross contamination (movement of bacteria from one place to another) that could result in an infection. Findings: During a current observation and interview on 2/20/2025 at 7:41 a.m. with Licensed Vocational Nurse (LVN) 1 at medication cart #4, a bottle of Pro-Stat was found with a large amount of sticky spillage down the container. There was a plastic bag with another medication stuck to the Pro-Stat bottle. Pro-Stat was spilled inside the medication drawer. LVN1 stated, It's sticky, staff are supposed to clean it. LVN1 stated there could be cross contamination that can lead to infection. During a review of the facility's policy and procedure (P&P) titled, Storage of Medications, dated April 2007, the P&P indicated the nursing staff shall be responsible for maintaining storage and preparation areas in a clean and sanitary manner.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure one of four sampled residents (Resident 71) had a Depakote level (a blood test to check the amount of this drug in your body) completed on the first Monday of every month per physician's order. Depakote is a drug given to control seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). This deficient practice had the potential to result in Resident 71 not receiving appropriate dosing of his Depakote. Findings: During a review of Resident 71's admission Record, the admission Record indicated Resident 71 was admitted to the facility on [DATE] with diagnoses including hypertension (HTN-high blood pressure), diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and seizure. During a review of Resident 71's History and Physical (H&P), dated 9/3/2024, the H&P indicated Resident 71 had mental retardation and is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to: 1. Ensure one of three sampled residents (Resident 87) had documentation related to the insertion and discontinuation of the intravenous (IV- a long thin catheter in the vein to deliver medications or fluids) line. This deficient practice had the potential to negatively affect the delivery of necessary care and services for Resident 87. Findings: During a review of Resident 87's Face Sheet, it indicated Resident 87 was readmitted on [DATE] with diagnoses that included sepsis (a life-threatening blood infection), and urinary tract infection (UTI- an infection in the bladder/urinary tract). During a review of Resident 87's Order Summary Report, it indicated Resident 87 was prescribed Zosyn (an antibiotic) 3.375 grams (gm- a unit of measurement) to be administered via IV every 8 hours for sepsis for 10 days until 9/18/2024. During a review of Resident 87's IV Administration Record, dated 9/8/2024, an order indicated for the nurse staff to ensure the IV…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a physician's order was obtained for ankle-foot orthotic (a device to provide support and stability to the ankle and foot, correct foot and ankle deformities, improve walking and mobility, reduce pain and inflammation, and control muscle spasms) device, before being implemented to one of three residents (Resident 1). This failure resulted in Resident 1 wearing ankle foot orthosis without an order. This failure placed Resident 1 at risk to receive inappropriate care resulting in skin breakdown and joint complications. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 1 had a history of dementia (a progressive state of decline in mental abilities) and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 1'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 ensure the physician's order to apply buddy strap (a hook and loop straps used to treat injured fingers by taping them to an uninjured finger) to one of three residents (Resident 1), were implemented for nine (9) days (from 1/21/2025 through 1/29/2025). The failure had the potential to delay the healing of Resident 1's right index finger (finger next to thumb) fracture (broken bone) and placed the resident at risk for complications. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 1 had a history of dementia (a progressive state of decline in mental abilities) and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 1's History and Physical (H&P), dated 1/3/2025, the H&P indicated Resident 1 had a history of hemiplegia (total…

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 environment for one of 4 sampled residents by failing to: 1.Provide adequate supervision and implement interventions for one of 4 sampled residents (Resident 1), who verbalized wanting to go Out on Pass ([OOP] short term leave from facility) and had previous episodes of leaving the facility without an Out on Pass ([OOP] short leave from facility) physician ' s order. 2. Implement Resident 1 ' s Care Plan to monitor Resident 1 ' s behavior symptoms such as wandering, inappropriate response to verbal communication and document. 3.Accurately assess Resident 1 ' s Elopement Risk 4.Ensure the facility ' s exit doors alarms were activated and monitored. These failures resulted in Resident 1 eloping (the act of leaving a facility unsupervised and without prior authorization) and placed other residents at risk for eloping which could lead to accidents, injuries, and death. Findings: During a review of Resident 1 ' s admission…

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 one of three sampled residents (Resident 1) who was admitted in the facility with cellulitis (skin infection caused by bacteria) of the right and left lower limb (leg) received care and services to meet the resident ' s needs by failing to: 1. Ensure Resident 1 received wound treatment as ordered by the physician. 2. Complete a weekly assessment of Resident 1 ' s wound. This deficient practice placed Resident 1 at risk for worsening, complications, and poor healing of the resident ' s skin condition. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted on [DATE], and re-admitted on [DATE] with diagnoses including infection of the skin and subcutaneous tissue ( bacterial, viral, or fungal – that enters any break in the skin and invade the subcutaneous tissue), lymphedema (swelling caused by a buildup of fluid in the body between the skin and muscle), and venous stasis dermatitis 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: 1. Ensure all doors that lead to the outside of the facility had an alarm to prevent one of five sampled residents (Resident 1), who was assessed as a high risk for elopement, (leaving the health care facility unsupervised and undetected) from leaving the facility without staff knowledge. This deficient practice had the potential for Resident 1 to be injured while out of the facility premises without supervision from staff. Findings: a. A review of Resident 1 ' s admission Record (Face Sheet), indicated Resident 1 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and toxic encephalopathy (brain dysfunction caused by exposure to toxic substances). A review of Resident 1 ' s Minimum Data Set ([MDS]- a standardized assessment and care planning tool),…

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 Certified Nursing Assistance (CNA) had the specific competencies and skill sets necessary to document and monitor three of 3 residents' (Resident 1, Resident 2, and Resident 3) meal intake percentage. This deficient practice increased the risk that Resident 1, Resident 2, and Resident 3 could have experienced undernourishment, which could result in weight loss, medical complications leading to hospitalization. Findings: a). A review of Resident 1 ' s admission record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE], with a diagnosis of hyperlipidemia (high levels of fat particles (lipids) in the blood), unspecified protein-calorie malnutrition (The lack of sufficient energy or protein to meet the body ' s metabolic demands), and iron deficiency anemia (a condition in which blood lacks adequate healthy red blood cells). A review of Resident 1 ' s history and physical (H&P) 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure three of 12 sampled residents (Resident 2, 69, and 23) medical records were updated to show documentation that advance directive's (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were discussed and written information were provided to the residents and/or responsible parties. This deficient practice had the potential for the residents not to receive necessary information, treatments and care regarding the end of life issues according to their wishes. Findings: a. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included chronic respiratory failure (a serious condition that makes it difficult to breathe on your own), and contracture of muscle (a permanent tightening of the muscles and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to: 1. Ensure adequate supervision was provided to a resident who was at risk for falls for one of 19 sampled residents (Resident 95). 2. Ensure personal extension cord was free of electrical safety hazards for one of 19 sampled residents (Resident 71). 3. Ensure the main ventilator was plugged into an emergency back-up power outlet (red plug outlet) instead of an extension cord for one of 19 sampled residents (Resident 68). Findings: a. During an observation on 1/25/24 at 10:24 a.m. at Resident 95's bedside, it was noted there was no padded mat on the floor for protection if a fall occurred. During an interview on 1/25/24 at 10:31 a.m. with LVN1, LVN1 stated when a resident is at risk for a fall the facility places a padded floor mat, ensures the bed is in a low position, and ensures the call light is within reach. LVN1 stated the resident could get out of bed and be injured if there is no padded mat. During an interview on 1/25/24 at 10:36…

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 to label the oxygen tubing weekly in accordance with the facility's policy and procedure, for two of three sampled residents (Resident 12 nad 71). This deficient practice had the potential for infection due to prolonged use of the oxygen tubing. Findings: a. During a review of Resident 12's admission record, the admission Record indicated, Resident 12 was admitted to the facility on [DATE], with diagnoses including pneumonitis (inflammation of lung tissue), acute respiratory failure with hypoxia (a condition where you don't have enough oxygen in the tissues in your body), and ischemic heart disease (a heart damage caused by poor blood flow to your heart). During a review of review of Resident 12's Minimum Data Set ([MDS] resident assessment and care screening tool) assessment, dated 12/15/2023, the MDS indicated, Resident 12's BIMS (Brief Interview for Mental Status) summary score was 11 (moderate cognitive impairment). 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the pharmacy consultant recommendation to consider discontinuing PRN (as needed) psychotropic (drug that affects behavior, mood, thoughts, or perception) was acknowledged and acted upon for two out of five sampled residents (Resident 86, Resident 2 and Resident 43). This deficient practice for failing to respond to recommendation from the pharmacy consultant places Residents at risk for unnecessary medication administration. Findings: During a review of Resident 86's admission Record, the admission Record indicated the facility originally admitted Resident 86 on 8/7/2023 and was readmitted on [DATE] with diagnoses including acute and chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), type 2 diabetes mellitus (mellitus (a disease that occurs when your blood sugar is too high), and cerebral infarction (damage to tissues in the brain due to 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.

Based on interview, and record review, the facility failed to provide sufficient dietetic service oversight when the dietary supervisor (DS) was overseeing three departments (housekeeping, maintenance, and dietary services) all at the same time, while registered dietitian worked on a consulting basis. This deficient practice resulted on the oversight of food safety, sanitation, and storage of food in the kitchen, lack of in-services and evaluation of competency of [NAME] 1 and [NAME] 2 on how to validate (verify that the measuring instrument continues to be suitable for its purpose) and calibrate (test its accuracy in a substance with a known temperature and adjust the thermometer to match that temperature) thermometer and had a potential to affect 77 out of 92 residents who received food from the facility. Findings: During the annual recertification survey from 1/23/2024 to 1/26/2024, multiple issues surrounding the delivery of dietetic services were unmet in relation to: a. The oversight of food safety, sanitation, and storage of food in the kitchen (cross reference F812). b. 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 ensure: 1. Staff were following the facility's policy when checking the accuracy and calibrating the thermometer. 2. Facility failed to ensure [NAME] 1 and [NAME] 2 has the competency to validate and calibrate thermometer. These failures had a potential to result the temperatures of food are not accurate resulting to possible food borne illnesses (an illness caused by contaminated food and beverages) or growth of bacteria in food in 77 of 92 medically compromised residents who received food from the kitchen. Finding: During an observation on 1/24/2024, at 11:34 a.m., in kitchen, observed [NAME] 1 and [NAME] 2 cleaning the thermometer with alcohol wipes. [NAME] 1 placed the manual thermometer stem into a glass of water with ice floating. The tip of thermometer was touching the bottom of the glass and resulted to temperature of 32 degree Fahrenheit. [NAME] 1 placed all the seven digital thermometer in the glass with the stems touching the bottom and side of the glass and the thermometer had a result of 42, 8,…

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 foods were handled, prepared, and stored in a manner that prevented foodborne illness by ensuring to: 1. Remov expired items from the walk-in refrigerator. 2. Keep food boxes off the floor. 3. Check refrigerator and freezer temperatures as scheduled. 4. Maintain the ice machine for cleanliness. 5. Keep the ice scoop outside the ice chest to prevent contamination. These failures had the potential to result in harmful bacteria growth and cross- contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness in 77 out of 92 medically compromised residents who received food and ice from the kitchen. Findings: a. During a concurrent observation and interview on 1/23/2024, at 9:06 a.m., with [NAME] 1, inside the walk-in refrigerator in the kitchen, the following were observed: Beef inside a red bin labeled as beef prep (preparation) dated 1/19/2024 and a use by date of 1/22/2024. Pork bacon…

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 medications were not left at a resident's bedside table, who was not capable of self-administering oral medications, for one of 19 sampled residents (Resident 71). This deficient practice had the potential to result in unsafe medication application or omission of medication. Findings During observation, on 1/23/2024, at 9:55 a.m., Resident 71 was lying in bed watching a movie on his tablet. A medicine cup containing 5 mL of a yellow liquid was observed on the bedside table in front of the resident, along with a plastic cup of a pink liquid with powder at the bottom of it. During an interview with the resident at the same time, he stated the liquid was medication for protein and wound healing and the pink drink with powder at the bottom of the cup was for protein. During a review of the admission record indicated Resident 71 was initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure two of 19 sampled residents (Resident 23 and 35) call light device was placed within reach at all times. This deficient practice had the potential to result in a delay in or in an inability for the residents to obtain necessary care and services. Findings: During a review of Resident 35's admission Record, the admission Record indicated Resident 35 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 35's diagnoses included epilepsy (a chronic disorder of the brain characterized by recurrent brief episodes of involuntary movement that may involve a part of the body or the entire body), chronic obstructive pulmonary disease (COPD, lung disease that causes blocked airflow from the lungs), and hemiplegia (paralysis of one side of the body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing). During a review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of three residents (Residents 36 and Resident 153) chose one of 3 billing options on the facility's SNF Beneficiary Notification form when there was a change in Medicare coverage related to skilled nursing needs. This deficient practice had the potential for residents to be unaware of their financial responsibilities for the services received at the facility, and for related standard claim appeal rights. Findings: a. During a review of the admission record indicated Resident 36 was originally admitted to the facility on [DATE] with a re-admission date of 6/22/2023 with diagnoses that included, but not limited to toxic encephalopathy, acute and chronic respiratory failure, type 2 diabetes and dementia. During a review of Resident 34's SNF Beneficiary Protection Notification Review form (Medicare beneficiaries have specific rights and protections related to financial liability and the right to appeal a denial of Medicare services under the Fee…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who had physical restraint were evaluated regularly and less restrictive measures were attempted for one of two sampled residents (Resident 31). This deficient practice had the potential to place residents at risk for unnecessary prolonged use of restraint that could lead to decline in physical functioning and residents not being treated with respect and dignity. Findings: During a review of Resident 31's admission Record, the admission Record indicated the facility originally admitted Resident 31 on 7/7/2022 and was readmitted on [DATE] with diagnoses including acute and chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), gastrostomy tube placement (a tube inserted through the belly that brings nutrition directly to the stomach), and Parkinson (a motor syndrome that manifests as rigidity, tremors, and slowness 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 provide accurate information in the Minimum Data Set ([MDS] resident assessment and care screening tool) for one of one sampled resident (Resident 31). This deficient practice had the potential to result inaccurate care and services for Resident 31 due to inappropriate MDS care screening and assessment tool practices. Findings: During a review of Resident 31's admission Record, the admission Record indicated the facility originally admitted Resident 31 on 7/7/2022 and was readmitted on [DATE] with diagnoses including acute and chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), gastrostomy tube placement (a tube inserted through the belly that brings nutrition directly to the stomach), and Parkinson (a motor syndrome that manifests as rigidity, tremors, and slowness of movement). During a review of Resident 31's Order Summary Report…

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 one of 19 sampled residents (Residents 43), change of condition PASRR was submitted to the Department of Health Care Services (DHCS). Resident 43's level one PASRR was not resubmitted after a change of condition to ensure the resident was re-evaluated. This failure had the potential to cause harm due to not receiving care and services in the most appropriate setting for the resident's needs. Findings: During a review of Resident 43's admission Record, the admission Record indicated Resident 43 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 43's diagnoses included pulmonary edema (a condition in which fluid builds up in the lungs, making it difficult to breathe), acute and chronic respiratory failure (a serious condition that makes it difficult to breathe on your own), and type 2 diabetes mellitus (abnormal blood sugar), generalized anxiety disorder (persistent and excessive worry that interferes with…

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 and consistent activities of interest for one of one sampled resident (Resident 66). This deficient practice had the potential to decrease Resident 66's social interaction, sense of belongings, depression, and emotional health. Findings: During a review of Resident 66'2 admission Record, the admission Record indicated Resident 66 was admitted to the facility on [DATE] with diagnoses including legal blindness (unable to see because of injury, disease, or congenital condition), chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), and type 2 diabetes mellitus (a disease that occurs when your blood sugar is too high). During a review of Resident 66's History and Physical (H&P), dated 12/29/2023, the H&P indicated, Resident 66 can make needs known but can not make medical decisions. During a review of Resident 66s Minimum Data Set ([MDS] resident assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide treatment and services for one of two sampled residents (Resident 31) who received gastrostomy tube feedings ([GT] tube surgically placed into the stomach for nutrient and medication administration) to ensure that feeding formula was labeled in accordance with the facility's policy and procedure. This deficient practice had a potential for feeding tube formula to be outdated that could cause side-effect to resident. Findings: During a review of Resident 31's admission Record, the admission Record indicated the facility originally admitted Resident 31 on 7/7/2022 and was readmitted on [DATE] with diagnoses including acute and chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), Parkinsonism (a motor syndrome that manifests as rigidity, tremors, and slowness of movement), and gastrostomy tube placement. During a review of…

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

Based on observation, interview, and record review, the facility failed to label one medication with an open date for a floor stock or house supply in medication cart two. This deficient practice had the potential to result in the prolonged use and loss of strength of the floor stock medication. Findings: During a concurrent observation and interview on 1/25/2024 at 9:50 a.m. with Registered Nurse 2 (RN 2) at medication cart two. RN 2 stated there was no open date for one bottle of loratadine (antihistamine). RN 2 stated she will change the bottle to a new one and put a date. RN 2 stated it is important to put the date on the bottle once you opened because the medication can lose its potency. During an interview on 1/25/2024 at 12:10 p.m. with the Director of Nursing (DON), the DON stated our policy for the house supply medications or floor stock was to label with an opened date and we have to discard the medication if there is no documented opened date so residents don't get expired medications. During a review of the facility's policy and procedure (P&P) titled, Medication Labels,…

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 document the dialysis (a treatment that removes wastes and extra fluid from your blood) access type for one of two sampled residents (Resident 15). This deficient practice had the potential for Resident 15 to receive misinformation and not receiving the appropriate care and services and poor continuity of care. Findings: During a review of Resident 15's admission Record, the admission Record indicated the facility originally admitted Resident 15 on 12/20/2023 and was readmitted on [DATE] with diagnoses including end stage renal disease (a medical condition in which a person's kidney cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), type 2 diabetes mellitus (a disease that occurs when your blood sugar is too high), and cerebrovascular disease (group of conditions that affect blood flow and the blood vessels in the brain) with hemiplegia…

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's Quality Assurance Performance Improvement committee ([QAPI] takes a systemic, interdisciplinary, comprehensive, and data driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families, and all nursing home caregivers in practical and creative problem solving) failed to identify facility and resident care issues, and develop and implement appropriate plans of action which included to evaluate measures to maintain resident supervision practices by having the dietary supervisor (DS) overseeing maintenance, dietary and housekeeping concerns. This had the potential to negatively impact resident safety, care and outcomes. Findings: During an interview on 1/26/2024, at 12:15 p.m., with the registered dietitian (RD), the RD stated she comes once or twice a week on a consulting basis. The RD stated the facility needed a full time DS at least 32 to 40 hours a week. The DS was in charge overseeing the kitchen, food, and training staff. During an interview on 1/26/2024, 1:14 p.m., with…

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 infection control measures by: 1. Failing to ensure staff was performing proper hand hygiene when going and out of a resident room. This deficient practice had the potential to transmit infectious microorganisms and increase the risk of infection and hospitalization. Findings: During an observation on 1/23/2024 at 3:38 p.m. in resident room [ROOM NUMBER], Licensed Vocational Nurse (LVN) 3 was observed entering the resident's room without performing hand hygiene. LVN 3 went to check on the resident in room [ROOM NUMBER] touching the curtain next to the resident and pressed the button to turn off the call light. LVN 3 exited the room without performing hand hygiene. During an interview on 1/23/2024 at 3:39 p.m. with LVN 3, LVN 3 stated hand hygiene is to be performed when you enter a room, soiled hands, when you touch resident's items or resident, and when you exit a room. LVN 3 stated hand hygiene is important as you can transfer…

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 reporting guidelines of All facilities Letter (AFL) 23-09, dated 1/18/2023, by failing to report the facility's COVID-19 (an infectioous disease caused by the SAR-CoV-2 virus) outbreak (at least one confirmed case of COVID-19 who had resided in the facility for at least 7 days) for 2 of 4 sampled residents (Resident 1 and Resident 2) to the California Department of Public Health (CDPH) District Office. This deficient practice resulted in the delay of the investigation by CDPH and had the potential to spread COVID-19 infection to the residents, staff, and visitors. Findings: During a review of Resident 1 ' s admission record dated 12/14/23, the admission ' s record indicated Resident 1 was re-admitted to the facility on [DATE] with diagnosis of hypertension (high blood pressure), acute upper respiratory infection (a contagious infection of your upper respiratory tract), and cerebral infraction (occurs because of disrupted blood…

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.