Delano District Skilled Nursing Facility

Based on interview and record review, the facility failed to: 1. Complete reference checks for two of three sampled employees (Certified Nursing Assistant/CNA 1 and CNA 2) prior to employment and;2. Complete the background check for CNA 1.These failures had the potential to put the residents at risk for abuse.Findings:During a concurrent interview and record review on 12/12/25 at 12:20 p.m. with Director of Nursing (DON) and Human Resource Assistant (HRA), CNA 1's employee file was reviewed. CNA 1's employee file indicated CNA 1 was hired 3/25/25. There were no reference checks done or exclusion (office of inspector general) background check completed prior to employment. DON and HRA stated per policy the reference checks and background check should have been completed prior to employment.During a concurrent interview and record review on 12/12/25 at 12:20 p.m. with DON and HRA, CNA 2's employee file was reviewed. CNA 2's employee file indicated CNA 2 was hired 1/9/23. There was no reference checks done prior to employment. DON and HRA stated per policy the reference checks should…

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

Based on interview and record review, the facility failed to ensure two of two sampled employees, (Certified Nursing Assistant [CNA 1] and CNA 2), had the required criminal background checks prior to their date of hire. This failure had the potential to expose the residents to staff with criminal backgrounds and exposing residents to risks for abuse.Findings:During a concurrent interview and record review, on 11/20/25 at 1:22 p.m. with the Director of Nursing (DON), CNA 1 and CNA 2's employee files were reviewed. DON stated CNA 1's date of hire was 10/6/25, and CNA 2's date of hire was 8/19/24. CNA 1 and CNA 2's criminal background checks were reviewed. DON confirmed no dates were documented on CNA 1 and CNA 2's criminal background checks.During an interview on 11/20/25 at 1:51 p.m. with Human Resources (HR), HR stated criminal checks were completed before hire date. HR stated she takes screen grabs (picture of computer screen) of criminal background checks; HR confirmed no dates were captured on the screen grabs. HR stated she was unable to provide evidence that criminal background…

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 discharge notice before discharging one of three sampled residents (Resident 1) to include the reasons for discharge. This failure had the potential for Resident 1 being discharged inappropriately and not prepared for his discharge.2. Send a copy of the notice of discharge to the Office of the State Long-Term Care Ombudsman (Ombudsman-an elderly advocacy agency) for 12 of 13 residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, Resident 11 and Resident 12). This failure had the potential to prevent the Ombudsman from assisting and advocating for Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, Resident 11 and Resident 12 during their discharge process.Findings:During a review of Resident 1's admission Record (AR), printed 11/14/25, the AR indicated Resident 1 was [AGE] years old was admitted 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement an effective discharge plan for one of three sampled residents (Resident 1) when Resident 1 was discharged home without home health services (where health care professionals provide health care services to the resident at his home) as ordered by the physician and failed to document a post-discharge plan of care in Resident 1's discharge summary. These failures had the potential to place Resident 1 at risk for not achieving his health care goals and preventable hospital and/or skilled nursing facility readmission.Findings:During a review of Resident 1's admission Record (AR), dated 11/14/25, the AR indicated Resident 1 was [AGE] years old, was admitted to the facility on [DATE] with diagnoses including generalized muscle weakness, difficulty walking, and unsteadiness on feet. The AR indicated Resident 1's Responsible Party (RP-the person who makes medical decisions on behalf of the resident) was Family Member (FM) 1.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 report an allegation of physical abuse for one of three sampled residents (Resident 1) to the California Department of Public Health (CDPH). This failure had the potential for abuse to continue and had the potential for other residents to be abused.Findings:During a review of Resident 1's admission RECORD (AR), dated 8/5/25, the AR indicated, Resident 1 was a [AGE] year old male who admitted to the facility on [DATE] with a diagnosis of anxiety disorder (a mental health condition characterized by excessive and persistent worry, fear, and nervousness that can significantly interfere with daily life), muscle weakness, legal blindness, history of falling, and need for assistance with personal care. During a review of Resident 1's ED (Emergency Department) Physician Notes (EDPN), dated 7/14/25, the EDPN indicated Resident 1 arrived at the acute hospital emergency department stating, Needed to get out of truck and that they [unknown] were crossing the road,…

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 for five of 72 sampled residents (Resident 47, Resident 86, Resident 96, Resident 105, Resident 92) call lights were answered promptly. This failure had the potential to result in residents' unmet needs. Findings: During a concurrent observation and interview on 2/4/25 at 9:30 a.m. in Resident 47's room, Resident 47's call light was on. Resident 47 stated she needed some help from her Certified Nursing Assistant (CNA) because she had a dirty brief. During a concurrent observation and interview on 2/4/25 at 9:31 a.m. in the hallway outside of Resident 47's room, a light was on above Resident 47's door indicating her call light was on. CNA 4 was observed walking past the call light and going in and out of rooms on the opposite side of the hallway. CNA 4 stated she was new to the facility and was not sure which CNA was assigned to Resident 47's side of the hallway. During an observation on 2/4/25 at 9:35 a.m., CNA 4 entered Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of three of 27 sampled residents (Resident 93, Resident 128, and Resident 96) when: 1. Staff did not follow Resident 93's physician order to remove a Lidocaine patch (a pain medication applied directly to the skin) from Resident 93's back after 12 hours of application. This failure resulted in Resident 93 having Lidocaine applied for a period longer than prescribed. 2. Staff administered a Nifedipine Extended Release tablet (a medication to treat high blood pressure especially formulated to slowly release the drug into the bloodstream over an extended period and to be administered whole) crushed into a powder to Resident 128. This failure resulted in Resident 128 receiving Nifedipine at a higher dose than prescribed. 3. Staff failed to ensure Morphine and Methadone (controlled drugs with a high potential for abuse and addiction) prescribed for Resident 96 were properly accounted for. This…

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 professional standards for food service safety and sanitary kitchen conditions when: 1. Dented canned products were retained in dry storage for use. 2. Dry food storage container lid was not closed and secured per safe storage and guidelines. These failures had the potential to cause foodborne illness (illness caused by the ingestion of contaminated food or beverages) for at-risk vulnerable residents. Findings: 1. During a concurrent observation and interview on 2/3/25 at 8:59 a.m. with Dietary Manager (DM), in the dry food storage room (DFSR), multiple dented 50-ounce tomato soup cans were stored. DM stated the dented tomato soup cans shouldn't be in here, and needed to be removed. DM stated there were nine out of 12 tomato soup cans dented. DM stated the dented tomato soup cans posed a food safety risk. During a concurrent interview and record review on 2/3/25 at 2:16 p.m. with DM, the facility's policy and procedure (P&P) titled, SANITATION AND INFECTION CONTROL SUBJECT: CANNED AND DRY GOODS…

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 practices when: 1. Three of three sampled personal laundry cart covers were soiled and discolored. This failure had the potential for contaminating clean linen and spread of infection to residents. 2. One of three sampled clean linen closets had a dark discolored floor with debris. This failure had the potential for contaminating clean linen and spread of infection to residents. 3. Two of two Registered Nurses (RN 1 and RN 3) failed to clean and disinfect glucometers (medical devices used to measure the amount of glucose[sugar] in the blood) according to facility policy and manufacturer's guidelines. after resident use. This failure had the potential to expose residents to bloodborne pathogens (microorganisms [bacteria or virus] in the blood that can cause life threatening disease). Findings: 1. During a concurrent observation and interview on 2/4/25 at 1:58 p.m. in the laundry room with Housekeeping and…

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

Based on interview and record review, the facility failed to ensure nine of nine employees' (Plant and Maintenance [PM], Housekeeper [HSK] 1, Certified Nursing Assistant [CNA] 1, CNA 2, Registered Nurse [RN] 2, Licensed Vocational Nurse [LVN] 1, Nursing Assistant [NA] 1, NA 2, and NA 3) Covid 19 (infectious respiratory illness) vaccination status were tracked and recorded. This failure had the potential to spread Covid-19 to residents, staff, and visitors. Findings: During a review of the facility's Employee Covid-19 Vaccination Log, (undated), the Employee Covid-19 Vaccination Log indicated, the following employees had no record of Covid-19 vaccination status: a) PM, hired on 7/16/24. b) HSK 1, hired on 11/14/24. c) CNA 1, hired on 8/12/24. d) CNA 2, hired on 8/15/24. e) RN 2, hired on 11/7/24. f) LVN 1, hired on 10/10/24. g) NA 1, hired on 1/2/25. h) NA 2, hired on 12/31/24. i) NA 3, hired on 1/2/25. During an interview on 2/5/25 at 9:05 a.m. with Infection Preventionist Nurse (IPN), IPN stated, The recently hired staff who have no Covid-19 vaccine immunization record were not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS- a standardized assessment tool that measures the health of nursing home residents) was accurate for one of one sampled resident (Resident 139). This failure resulted in an inaccurate medical record regarding Resident 139's discharge location. Findings: During a concurrent interview and record review on 2/6/25 at 1:29 p.m. with MDS Coordinator (MDSC), Resident 139's MDS was reviewed. The MDS indicated, Resident 139 was admitted to the facility on [DATE] and discharged on 12/20/24. MDS Section A2105 indicated Resident 139 was discharged to a short-term general hospital for acute care. MDSC stated Resident 139 was discharged to a short-term general hospital based on the MDS. MDSC stated the MDS was completed by the Social Services Director on 12/31/24. During a concurrent interview and record review on 2/6/25 at 1:32 p.m. with MDSC, Resident 139's Nurse's Notes, (NN) dated 12/20/24 were reviewed. The NN 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.

Based on observation, interview, and record review, the facility failed to ensure fluids were accessible at the bedside for one of eight sampled residents (Resident 47). This failure had the potential to result in Resident 47 not having sufficient fluid intake to maintain proper hydration. Findings: During a concurrent observation and interview on 2/4/25 at 10:33 a.m. in Resident 47's room, the bedside table containing a water pitcher and cup was located next to the window across from the bed and not within Resident 47's reach. No straw was observed on the bedside table. Resident 47 stated she could drink water by herself if a straw was available. Resident 47 stated she had been having diarrhea. During a concurrent observation and interview on 2/4/25 at 10:49 a.m. with Registered Nurse (RN) 3, Resident 47's bedside table containing her water pitcher and cup was observed to be located next to the window across from the bed. RN 3 stated the bedside table should be within Resident 47's reach. RN 3 stated Resident 47 was at risk for dehydration, especially since she was having diarrhea.…

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 two of two sampled residents (Resident 18 and Resident 41) oxygen saturations (how much oxygen is in the blood). This failure had the potential for Resident 18 and Resident 41 to not receive oxygen as ordered and become hypoxic (low levels of oxygen in the blood that can cause headache, difficult breathing, confusion and increased rate of breathing). Findings: During an observation on 2/3/25 at 9:14 a.m. in Resident 18's room, Resident 18 was laying in bed with eyes closed. Resident 18 was not wearing oxygen. During an observation on 2/4/25 at 8:40 a.m. in Resident 18's room, Resident 18 was laying in bed with eyes closed. Resident 18 was not wearing oxygen. During a concurrent interview and record review on 2/5/25 at 9:19 a.m. with Registered Nurse (RN) 2, Resident 18's Order Summary Report (OSR), dated 2/5/25 was reviewed. The OSR indicated, O2 [oxygen] INHALATION [breathing in] AT 2 LPM [liters per minute] VIA [by] NASAL CANNULA [flexible tube with two prongs that are inserted into the nostrils 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Registered Nurse (RN) 1 had current cardiopulmonary certification (CPR-healthcare provider demonstrated training in life-saving intervention competency when loss of pulse and/or breathing in a medical emergency) as indicated in the facility's job description titled, Registered Nurse (RN) for one of 15 sampled RN's (RN) 1. This failure resulted in RN 1's CPR certification employment requirement not being met and had the potential for adverse vulnerable resident outcomes. Findings: During a concurrent interview and record review on [DATE] at 2:42 p.m. with Human Resource Manager (HRM), RN 1's employee file was reviewed. The employee file indicated RN 1's date of hire was [DATE]. HRM stated RN 1 did not have current CPR certification to meet RN employment requirement. During a concurrent observation and interview on [DATE] at 3:19 p.m. with RN 1, RN 1 was working in the facility's East wing. RN 1 stated she did not have a current CPR…

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

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 18) was provided adaptive equipment (specialized tools, devices and modifications designed to assist individuals with disabilities or functional limitations with eating) during meals. This failure had the potential to result in nutritional decline. Findings: During a review of Resident 18's Order Summary Report (OSR), dated 2/5/25, the OSR indicated, Pt [Patient] to have build [sic] up foam utensils with all meals, with an order date of 11/3/23. During a review of Resident 18's Care Plan (CP), (undated), the CP indicated, Resident at risk for Nutritional Decline Due to.Need Adaptive Equipment r/t [related to] lack of coordination.Resident to use utensils with soft build-up handles (brown). During a concurrent observation and interview on 2/5/25 at 12:27 p.m. with Registered Nurse (RN) 2 in Resident 18's room, Resident 18 was eating lunch with regular utensils. RN 2 stated Resident 18 was using regular utensils and would have to check to see if adaptive equipment…

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 resident shower rooms in a clean and sanitary condition for five of five sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, and Resident 5). This failure had the potential for spread of infection and/or negative health outcomes. Findings: During a concurrent observation and interview on 12/16/24 at 11:20 a.m. with Facility Director (FD) the following was observed: a. In the East Wing Shower Room (EWR), there was blackish spotted discoloration noted to the grout (paste-like material used to fill in gaps between tiles) in the second and third shower stall. The grout to the toilet in the EWR was brown, black, and yellow in discoloration with the grout noted to be missing and/or cracked. Moving further into the EWR where there was a storage of resident shower chairs and shower gurneys was black spotted discoloration to the ceiling and floor tile that was markedly discolored with dirt/grim (a built-up combination of dirt, dust, and grease). The EWR had two blue green shower chairs that 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 treat one of five sampled residents (Resident 1) with dignity and respect. This failure had the potential for emotional distress for Resident 1. Findings: During an interview on 11/18/24 at 9:51 a.m. with Director of Nursing (DON), DON stated on 11/9/24, Certified Nursing Assistant (CNA) 1 observed Restorative Nurse Assistant (RNA) 1 placed her hand over Resident 1's mouth as she was screaming to quiet Resident 1 down. During a review of Resident 1's Minimum Data Set (MDS- an assessment tool) under the section BIMS (Brief Interview for Mental Status – an assessment of cognition [mental processes including perception, memory, and thought]), dated 10/24/24, the BIMS indicated, Resident 1 had a score of 9 (cognition moderately impaired). During an interview on 11/18/24 at 11:09 a.m. with Resident 1, Resident 1 stated she could not recall the incident occurred on 11/9/24. During an interview on 11/18/24 at 12:15 p.m. with CNA 1, CNA 1 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 implement their policy and procedure on Abuse Prevention Program for one of five sampled residents (Resident 1). This failure had the potential for further abuse to occur. Findings: During an interview on 11/18/24 at 9:51 a.m. with Director of Nursing (DON), DON stated on 11/9/24, Certified Nursing Assistant (CNA) 1 observed Restorative Nurse Assistant (RNA) 1 placed her hand over Resident 1's mouth in an attempt to stop Resident 1 from screaming. During an interview on 11/18/24 at 12:15 p.m. with CNA 1, CNA 1 stated on 11/9/24 at approximately 10 a.m. she observed Resident 1 in her wheelchair coming out of her room and screaming, Help me. CNA 1 stated she then saw RNA 1 placed her hand over Resident 1's mouth to stop her from screaming. CNA 1 stated Resident 1 was screaming help me through RNA 1's hand. CNA 1 stated she reported this allegation of abuse immediately to her supervisor. During a concurrent observation and interview on 11/18/24 at 12:50 p.m. with DON, security camera footage for 11/9/24 in…

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

Based on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) on safety for residents when tools were found on the floor unattended. This failure had the potential to result in injury for residents, staff, and visitors. Findings: During a concurrent observation and interview on 9/27/24 at 2:06 p.m. with Administrator in the hallway by the Director of Nursing (DON) office, there were nine one-inch screws on the floor. Administrator verified the findings. During an observation on 9/27/24 at 2:06 p.m. in an office, by the door, there was screwdriver and repair parts on the floor. The office door was left open. During an interview on 9/27/24 at 2:20 p.m. with the Maintenance Assistant (MA), the MA stated he left the tools and repair parts unattended. He stated it was not safe to leave tools on the floor. He stated he was supposed to clean up before he left his work area. During an interview on 9/27/24 at 2:26 p.m. with Administrator, Administrator stated, The door was not closed. A resident could reach out (the tools). During an…

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 two of four sampled residents (Resident 1 and Resident 3) who are high risk for falls were near the nurse's station according to the plan of care. This failure had the potential to result in Resident 1 and Resident 3 falling repeatedly and sustaining injury. Findings: During an observation on 9/18/24 at 9:54 a.m. in Resident 1's room, Resident 1's bed is by the window. There were two rooms, one supply room down the hallway, and around the corner between Resident 1's room and the nurse's station. During a review of Resident 1's Care Plan (CP), dated 3/13/24, the CP indicated, Resident [1] with actual unwitnessed fall on 3/13/24. Interventions: Keep resident [1] close to [nursing] station for closer monitoring. The CP dated 6/18/24 indicated, Resident with actual fall on 6/18/24. Interventions: Keep resident close to station for closer monitoring. During a review of Resident 1's SBAR (Situation, Background, Assessment, and Recommendation) Communication and Progress Note (SBAR), dated 9/15/24 at 12:16…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to report allegations of abuse to the state agency for five of eight sampled Residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5) when: A. Resident 1 reported to staff multiple incidents of physical altercation with Resident 2. B. Resident 3 reported to staff multiple incidents of sexual allegations against Resident 4. C. Staff witnessed Resident 4 being sexually inappropriate with Resident 5. These failures had the potential for delayed investigation and put all residents at risk for further abuse. Findings: A. During an interview on 9/12/24 at 2:51 p.m. with Social Services Assistant (SSA), SSA stated on 8/19/24, Resident 1 informed the staff he had a physical altercation with Resident 2. SSA stated her and Social Services Director (SSD) checked the facility security cameras and found no evidence Resident 1 and Resident 2 had a physical altercation. SSA stated the allegation of physical abuse between Resident 1 and…

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

Based on observation, interview, and record review, the facility failed to obtain dental services for two of eight sampled residents (Resident 6 and Resident 7). This failure had the potential to result in progressive oral health decline, oral pain, infection, and weight loss. Findings: During a review of Resident 6 ' s Minimum Data Set (MDS- an assessment tool) under the section BIMS (Brief Interview for Mental Status – an assessment of cognition [mental processes including perception, memory, and thought]), dated 8/21/24, the BIMS indicated, Resident 6 had a score of 15 (cognitively intact). During a concurrent observation and interview on 9/12/24 at 11:18 a.m. with Resident 6 in his room, Resident 6 was observed to have multiple discolored dark brown to yellowed stained teeth specifically to his lower mouth. Some of the teeth appeared broken exposing the inner aspects of the tooth. Resident 6 ' s lower gums appeared red in color and swollen. Resident 6 stated he cannot get anyone to get him an appointment with the dentist. Resident 6 stated he talked to the social services (not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure four of four sampled residents (Resident 1, Resident 2, Resident 3, Resident 4) complaints were processed according to their policy and procedure. This failure had the potential to jeopardize the health and safety of the residents. Findings: During a review of Resident 2's Minimum Data Set (MDS- an assessment tool) under the section BIMS (Brief Interview for Mental Status - an assessment of cognition [mental processes including perception, memory, and thought]), dated 7/10/24, the BIMS indicated, Resident 2 had a score of 15 (cognitively intact). During an interview on 8/28/24 at 10:53 a.m. with Resident 2, Resident 2 stated there were issues with the Registry Nurses (RNN - licensed nurses who receives compensation from a third party to work at a nursing facility as needed) (not identified) not passing the medications on time during the night shifts. During a review of Resident 3's MDS- under the section BIMS, dated 7/8/24, the BIMS 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.

Based on interview and record review, the facility failed to ensure a Licensed Vocational Nurse (LVN) 2 was competent to pass medications to one of four sampled residents (Resident 1). This failure had the potential for adverse health outcomes. Findings: During an interview on 8/28/24 at 11:02 a.m. with LVN 1, LVN 1 stated approximately one week ago (not sure of the exact date), she noticed at the beginning of her shift (morning) that Resident 1 ' s tube feeding (an open system used for nutrition provided to a resident via a tube inserted through the stomach) bag had an abnormal color and appeared to have medication floating in it. LVN 1 stated LVN 2 had worked the prior shift (night shift) before she came in and noticed the issue with Resident 1 ' s tube feeding bag. During a review of Resident 1 ' s Minimum Data Set (MDS- an assessment tool) under the section BIMS (Brief Interview for Mental Status - an assessment of cognition [mental processes including perception, memory, and thought]), dated 8/2/24, the BIMS indicated, Resident 1 had a score of 13 (cognitively intact). 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 interview and record review, the facility failed to implement their fall intervention for one of three sampled residents (Resident 1). This failure had the potential for Resident 1 to have serious injury or harm. Findings: During a review of Resident 1 ' s admission RECORD (AR), dated 8/5/24, the AR indicated, Resident 1 was admitted to the facility on [DATE], diagnosis including Hemiplegia (inability to move one side of the body), hemiparesis (one sided muscle weakness), cerebral infarction (disrupted blood flow to the brain), aphasia (difficulty reading, speaking, understanding and writing due to damage of the brain), muscle weakness, history of falls. During a review of Resident 1 ' s Minimum Data Set (MDS- an assessment tool) under the section BIMS (Brief Interview for Mental Status – an assessment of cognition [mental processes including perception, memory, and thought], dated 7/1/24, the BIMS indicated, Resident 1 was not able to be assessed due to being rarely/never understood. 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 follow their policy and procedure titled, Enteral Therapy/Tube Feeding, to ensure two of five sampled residents' (Resident 1 and Resident 5) tube feeding (tube attached to the stomach used to pass through nutrition, hydration, and medication) bags were labeled with dates and time. This failure had a potential to result in Resident 1 and Resident 5 consuming contaminated feeding formula from old tube feeding bags and result in adverse health outcomes. Findings: During an observation on 7/19/2024 at 9:45 a.m. in Resident 1's room, there were two tube feeding bags hanging on a pole which were not labeled with time and date. During a review of Resident 1's admission Records (AR), dated 4/23/2024, the AR indicated, Resident 1 had a diagnosis of encounter for attention to gastrostomy (G-Tube-tube inserted through the wall of the abdomen directly into the stomach for nutrition, hydration, and medication). During a review of Resident 1's Progress Notes (PN), dated 7/14/2024, the PN indicated Resident 1 is on Jevity…

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 a comfortable and safe temperature for one of 13 sampled residents (Resident 1). This failure had the potential for harm due to heat related issues and/or for residents to be uncomfortable. Findings: During a concurrent observation and interview on 6/27/24 at 11:55 a.m. with Facility Director (FD), in Resident 1's room, Resident 1's room had a temperature of 84.4 degrees (°) Fahrenheit (F). FD verified Resident 1's room was 84.4°F. During an interview on 6/27/24 at 12:31 p.m. with Administrator, Administrator stated room temperatures are to be between 71°F and 81°F. During a review of Resident 1's admission RECORD (AR), dated 5/17/24, the AR indicated Resident 1 had the following medical diagnosis: a. Epilepsy (abnormal electrical brain activity also known as a seizure). b. Aphasia (a language disorder that affects how you communicate). c. Hemiplegia (one-sided muscle paralysis [inability to move] or weakness). d. Encephalopathy (damage or disease that affects the brain). e. Dysphagia (difficulty…

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 implement their policy and procedure (P&P) on abuse for one of three residents (Resident 1) when: a. Certified Nursing Assistant (CNA) 1 did not immediately report an allegation of abuse to facility management. b. CNA 1 was not removed from working with residents immediately after an allegation of abuse. These failures resulted in a potential delay in investigation, had the potential for abuse to continue and had the potential for other residents to be abused. Findings: During a review of Resident 1's Minimum Data Set (MDS- an assessment tool) under the section BIMS (Brief Interview for Mental Status – an assessment of cognition [mental processes including perception, memory, and thought], dated 3/1/24, the BIMS indicated, Resident 1 had a score of 14 (Cognitively intact). During an interview on 6/20/24 at 11:27 a.m. with Resident 1, Resident 1 stated he had an altercation with CNA 1, in which CNA 1 allegedly punched him. Resident 1 could not recall the date the alleged abuse occurred. During an interview on 6/20/24 at…

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 an effective pest control program for two of four sampled residents (Resident 1 and Resident 2). This failure had the potential for negative consequences such as insect bites (both poisonous and non-poisonous) and spreading of pest to resident areas (outdoors and indoors). Findings: During a review of Resident 1's Minimum Data Set (MDS – an assessment tool) under the section Brief Interview for Mental Status (BIMS – an assessment tool for cognition [the gaining of knowledge and understanding]), dated 1/18/24, the BIMS indicated, Resident 1 had a score of 15 (cognitively intact). During a concurrent observation and interview on 5/29/24 at 2:12 p.m. with Resident 1, in the north side resident patio area, Resident 1 stated she comes out to the resident patio every day for about one to two hours. Resident 1 stated yesterday (5/28/24) she was sitting in a patio chair and there was a possible black widow spider (a very poisonous spider with an appearance of a black body with an hourglass shaped red mark.…

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

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was treated with dignity and respect when Resident 1 was moved to the dining room to sleep for one night. This failure had the potential to result in psychological harm and Resident 1 experiencing fearfulness. Findings: During an interview on 2/29/24 at 5:04 p.m. with Registered Nurse (RN) 1, RN 1 stated, Yes, we had a resident [Resident 1] in the dining room last night [2/28/24]. It was late last night, we had a late admission that ended up testing positive for COVID after showing symptoms upon arrival to the facility. RN 1 stated the facility does not have any other rooms available (for the new admission), so Resident 1 ended up sleeping in the dining room. During an interview on 2/29/24 at 5:13 p.m. with the Administrator, the Administrator stated, This is not our normal process, we have never had to have a resident sleep in the dining room. During an interview on 2/29/24 at 5:15 p.m. with Director of Nursing (DON), DON stated, The family was called last night 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 interview and record review, the facility failed to treat four of seven sampled residents (Resident 1, Resident 2, Resident 3, and Resident 7) with dignity and respect. This failure had the potential for negative consequences up to and including psychological harm. Findings: During a review of Resident 2 ' s Minimum Data Set (MDS - an assessment tool) under Brief Interview for Mental Status (BIMS – an assessment tool for cognition), dated 12/11/23, the BIMS indicated, Resident 2 had a score of 15 out of 15 (cognition is intact). During an interview on 12/11/23 at 1:30 p.m. with Resident 2, Resident 2 stated approximately three Sundays ago he had a concern for his friend Resident 1 ' s health. Resident 2 stated Resident 1 was having multiple uncontrolled seizures (sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness). Resident 2 stated he told Registered Nurse (RN) 1 about Resident 1 not looking good and she (RN 1) told him,…

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 two of 62 sampled resident's (Resident 334 and Resident 25) change in condition notification was not provided when: 1. Resident 334's Responsible party (RP) was not notified for a change in medical treatment plan. This failure resulted in the Resident 334's RP to be unable to participate in the plan of care. 2. Resident 25's Physician (MD) was not notified for refusal of medications. This failure had the potential to result in increased psychological behaviors, memory impairment, swelling, and blood pressure. Findings: 1. During a concurrent observation and interview on 1/9/24 at 10:25 a.m. with Licensed Vocational Nurse (LVN) 5, in Resident 334's room, Resident 334's right and left feet great toes nails were thick and overgrown past the nail bed. LVN 5 stated, Resident 334 needed podiatry [treatment and care of the foot] care. LVN 5 stated, Resident 334's right and left great toenails were about 1/2 inch [unit of measurement] thick and the right great toe tip had a reddened area. During a concurrent…

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

Based on observation, interview, and record review, the facility failed to ensure one of 62 residents (Resident 80), received an accurate Minimum Data Set (MDS-a comprehensive assessment used as a care-planning tool) Section B 1000 Vision (uses numerical scale 0-4, a score of 0 indicates Adequate-sees fine details and regular print in newspaper/books, score of 1 indicates Impaired-sees large print but not regular print in newspaper, score of 2 indicates Moderately Impaired-limited vision, not able to see newspaper headlines but can identify objects, score of 3 indicates Highly Impaired-object identification in question, but eyes appear to follow objects, and a score of 4, indicates Severely Impaired-no vision or sees only light, colors or shapes; eyes do not appear to follow objects) assessment by a MDS trained Social Services Assistant (SSA). This failure had the potential to negatively impact Patient 80's safety, psychosocial, and care needs. Findings: During a concurrent interview and record review on 1/10/24 at 2:55 p.m. with SSA, Resident 80's MDS Section B 1000 Vision, 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 interview and record review, the facility failed to accurately complete and coordinate the Pre-admission Screening and Resident Review (PASRR-federal requirement to help ensure that individuals are not incorrectly placed in nursing homes or long-term care facilities, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs) process for one of 62 sampled residents (Resident 25). This failure had the potential for Resident 25 to not receive necessary services to meet mental and psychosocial needs. Findings: During a concurrent interview and record review on 1/10/24 at 11:41 a.m. with Director of Nursing (DON), Resident 25's Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 8/9/23 was reviewed. The PASRR indicated, Does the individual have a serious diagnosed mental disorder such as Depressive Disorder (a mental illness that can cause depressed mood), Anxiety Disorder (worry and fear about everyday situations), Panic Disorder (anxiety disorder characterized 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 ensure one of 62 residents (Resident 133) had a baseline care plan (includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs) developed which guided his dialysis catheter site (dialysis catheter - a tube inserted into a vein to carry blood to dialysis machine used to filter blood) care. This failure had the potential to place Resident 133 at risk for skin and blood borne infections. Findings: During a review of Resident 133's admission Record (AR) dated [DATE], the AR indicated, Resident 133 was admitted to the facility on [DATE]. During an interview on [DATE] at 9:38 a.m. with Director of Nursing (DON), DON stated Resident 133 was admitted to the facility on [DATE] and was discharged due to his death on [DATE]. During a review of Resident 133's History and Physical (H&P) dated [DATE], the H&P indicated, Diagnosis' included: Type 2 DM (diabetes mellitus-high blood sugar), End…

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 two of 62 residents (Resident 80 and Resident 95) had a comprehensive care plan (includes measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs) developed and implemented which addressed: 1. Resident 80's visual impairment needs. This failure had the potential to negatively impact Patient 80's safety, psycosocial, and care needs. 2. Resident 95's Foley catheter (FC- a device that drains urine from the bladder into a collection bag). This failure had the potential for Resident 95 to develop an infection and have care needs not met. Findings: 1. During a concurrent interview and record review on 1/10/24 at 2:55 p.m. with SSA, Resident 80's MDS Section B 1000 Vision (uses numerical scale 0-4, a score of 0 indicates Adequate-sees fine details and regular print in newspaper/books, score of 1 indicates Impaired-sees large print but not regular print in newspaper, score of 2 indicates Moderately Impaired-limited vision, not able to see newspaper headlines…

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 meet professional standards of practice for four of 62 sampled residents (Resident 5, Resident 69, Resident 83 and Resident 21) when: 1. CNA 5 served meals without ensuring Resident 5 and Resident 69 had performed hand hygiene. This failure had the potential to affect Resident 5 and Resident 69's health. 2. Housekeeping was not wearing a protective gown while handling unclean residents linen. This failure had the potential to spread infection to residents and staff. 3. Transmission-based precautions (TBP) were not followed for Resident 83. This failure had the potential to result in the transmission of infection and communicable diseases to residents, staff and visitors. 4. The enteral feeding bag (method of supplying nutrients directly into the stomach by use of a feeding tube) label was not labelled consistent with Resident 21's physician's order (PO). This failure had the potential to result in weight loss, dehydration, and malnutrition (lack of proper nutrition, caused by not having enough to eat).…

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 Low Air Loss (LAL) mattress was set according to weight for one of 62 sampled residents (Resident 21). This failure had the potential to result in a new or worsening pressure injury. Findings: During a concurrent observation and interview on 1/10/24 at 8:16 a.m. in Resident 21's room, with Licensed Vocational Nurse (LVN) 3, Resident 21's LAL mattress was set to over 320 pounds (lbs-unit of weight measurement). LVN 3 stated the LAL mattress was not set correctly. LVN 3 stated if it is too firm, it can cause a pressure injury. During a review of Resident 21's Weights and Vitals Summary (WVS), dated 1/10/24, the WVS indicated, 12/09/2023.150.9 Lbs. During an interview on 1/10/24 at 11:57 a.m. with Director of Nursing (DON), DON stated the LAL for Resident 21 should have been set to the correct weight, or else he can get a decubitus ulcer (pressure injury) or it could get worse. DON stated Resident 21 recently had a new stage 2 (partial thickness loss of top layers of skin, presenting as a shallow open…

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 a resident who was identified as high risk for falls was free from fall hazards for one of 62 sampled residents (Resident 21). This failure had the potential to result in a fall with injury. Findings: During a concurrent observation and interview on 1/8/24 at 12:15 p.m. in the hall outside of Resident 21's room, with Certified Nursing Assistant (CNA) 1, Resident 21 was being repositioned in bed. When staff left the room they left the bed in the highest position. CNA 1 stated the bed should not have been left that high for any Resident. During an interview on 1/10/24 at 11:55 a.m. with Director of Nursing (DON), DON stated, the bed should not have been left up in high position. The bed should have been lowered after the CNAs were done providing care. DON stated Resident 21 could have fallen and gotten injured. During a review of Resident 21's Fall Risk Assessment, (FRA) dated 12/19/23, the FRA indicated, Score: 15 Category: High Risk. During a review of the facility's policy and procedure (P&P) titled,…

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

Based on interview and record review, the facility failed to ensure the controlled substance (highly addictive drug or chemical regulated to prevent abuse) count was being completed before and after each shift for three of four sampled medication carts (East Wing (C2), East Wing (C 2-3), and [NAME] Wing). This failure had the potential to result in loss or diversion (concept involving the transfer of any legally prescribed controlled substance from the individual for whom it was prescribed to another person for any illicit use) of controlled substances. Findings: During a concurrent interview and record review on 1/9/24 at 11:09 a.m. with Licensed Vocational Nurse (LVN) 2, East Wing C2's Shift Verification of Controlled Substances (SVCS), dated December 2023 and January 2024 were reviewed. The SVCS forms had missing signatures on multiple dates for different shifts in December 2023 and January 2024. LVN 2 stated there were blanks in the record. During a concurrent interview and record review on 1/9/24 at 11:15 a.m. with Registered Nurse (RN) 1, [NAME] Wing Shift Verification 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 follow their policy and procedure (P&P) titled, Medication Storage, when medications were improperly stored for one of two sampled medication carts (North Medication Cart).This failure had the potential to result in contamination of medications and adverse outcomes. Findings: During a concurrent observation and interview on 1/10/24 at 10:35 a.m. with Licensed Vocational Nurse (LVN) 4, on North Wing's Medication Cart, a jar of Vicks VapoRub Cough Suppressant [reduce intensity] Topical [applied to the skin] Analgesic [pain relieving] Ointment was stored next to a roll of prepackaged medications intended for oral consumption. LVN 4 stated the VapoRub should have been stored on the treatment cart or in a container separate from the oral medications. During an interview on 1/10/24 at 12:11 p.m. with Director of Nursing (DON), DON stated internal and external medications should be stored separately in the medication carts. During a review of the facility P&P titled, Medication Storage, dated 2018, the P&P…

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. To implement infection surveillance measures that meet infection prevention standards. 2. Follow transmission-based precautions for one of eight residents sampled (Resident 1). 3. Review infection control policy and procedures (P&P) annually. These failures had the potential to contribute to increased Covid-19 cases, and adverse health outcomes for vulnerable residents. Findings: 1. During a concurrent observation and interview on 1/3/24, at 8:09 a.m. with Receptionist, the facility front entrance did not have an observed process for Covid-19 symptoms screening upon entry into the facility. Receptionist stated the facility does not screen for Covid-19 symptoms for everyone entering the facility. During an interview on 1/3/23, at 8:42 a.m., with Director of Nursing (DON), DON stated the current process for persons entering the facility as visitors and staff is to wear an N-95 mask (a mask that has high filtration for the respiratory…

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

Based on observation, interview, and record review, the facility failed to protect three of four sampled residents (Resident 1, Resident 2, Resident 3) from being inappropriately touched by Resident 4. This failure had the potential to place these residents at risk for further abuse and feeling unprotected in the facility. Findings: During a review of Resident 1's facility chart the CHARTING – Alleged Perpetrator (CAP), dated 9/24/23, the CAP indicated, Resident 4 on 9/23/23 inappropriately touched Resident 1's breast and lifted the blouse of Resident 2 on separate times of the day. Under the section titled other pertinent information, the facility indicated the interventions to be put into place for Resident 4 were to monitor Resident 4 closely while socializing with other residents and to monitor Resident 4's whereabouts and monitor closely while awake and out of his room. During a review of Resident 4's BIMS [Brief Interview Mental Status – an assessment tool for memory and orientation], dated 9/13/23, the BIMS indicated, Resident 4 had a score of 14 (a score of 14 indicates 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 follow its policy and procedure (P&P) titled, Transfer or Discharge for one of three sampled residents (Resident 1). This failure resulted in Resident 1's inappropriate discharge and violation of resident's rights. Findings: During an interview on 10/10/23 at 9:32 a.m. with Complainant, Complainant stated the facility sent Resident 1 to the acute hospital for treatment on 10/6/23. Complainant stated the acute hospital informed him Resident 1 was ready to be discharged back to the facility on [DATE] but the facility refused to take Resident 1 back. Complainant stated the acute hospital had to place Resident 1 at another skilled nursing facility. Complainant stated he went to the facility and spoke with the Chief Executive Officer (CEO) who informed him Resident 1 did not meet the criteria to be in their facility and the facility was not a hotel. During an interview on 10/10/23 at 11:15 a.m. with Medical Biller (MB), MB stated Resident 1 was on a bed…

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.

ased on observation, interview and record review the facility failed to implement their intervention for one of three sampled residents (Resident 1) to ensure she was kept away from Resident 3 who scratched her left forearm during an altercation. This failure resulted in Resident 3 continuing to enter Resident 1's room without consent, Resident 1 being struck again by Resident 3 after the initial physical altercation, resulted in another resident (Resident 2) having his room entered by Resident 3 without consent and had the potential for other residents to be affected. Findings: During an interview 9/12/23 at 10:56 a.m. with Director of Nursing (DON), DON stated on 9/3/23, Resident 3 entered Resident 1's room. Facility staff (not identified) heard screaming from the room and observed Resident 1 and Resident 3 tugging a marker from each other. After facility separated Resident 1 and Resident 3, Resident 1 stated Resident 3 had grabbed and clawed her left forearm. Nursing (not identified) noticed Resident 1 had fresh scratch marks to her left forearm. DON stated Resident 3 had 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 observation, interview, and record review, the facility failed to ensure: 1. Air mattress (designed to prevent pressure injury from occurring) used were set at the appropriate therapeutic setting for two of nine sampled residents (Resident 2 and Resident 3). 2. Turning and repositioning was performed for two of nine sampled residents (Resident 2 and Resident 3). These failures had the potential for worsening of pressure injury (localized damage to the skin and/or underlying tissue that usually occur over a bony prominence as a result of usually long-term pressure, or pressure in combination with shear or friction) and/or development of new pressure injury. Findings: 1a. During an observation on 9/11/23 at 10:22 a.m. in Resident 2's room, Resident 2 was on air mattress with the setting set to approximately 287 pounds (lbs.). During a concurrent observation and interview on 9/11/23 at 10:52 a.m. with Licensed Vocational Nurse (LVN 1), in Resident 2's room, LVN 1 observed the setting on Resident 2's air mattress. LVN 1 stated Resident 2 weighed 165.8 lbs. as of 9/10/23. LVN 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.

Based on observation, interview, and record review, the facility failed to follow its policy and procedure on General Dose Preparation and Medication Administration for one of four sampled residents (Resident 1) when Licensed Vocational Nurse (LVN) 1 gave the wrong medication to the Family Member (FM) who took Resident 1 out on pass (temporary out of the facility). This failure resulted in Resident 1 taking her medication two hours late and had the potential for Resident 1 having adverse health outcomes. Findings: During an interview on 8/23/23 at 3 p.m. with FM, FM stated she took her Resident 1 out on pass. FM stated when she got home, she looked at the package of the medications given to her by LVN 1 and noticed that it (medication) was not Resident 1's medication. FM stated her mother did not take her due medication at 5 p.m. and (Resident 1) took her medications two hours late on that day (at 7 p.m., two hours later, on 8/12/23). During an interview on 8/24/23 at 1:15 p.m. with Director of Nursing (DON), DON stated Resident 1 was sent home with incorrect medication. DON 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: 1. Follow the physician's order to provide foot care and/or refer to Podiatry (the study, diagnosis, and treatment of disorders of the foot, and ankle) for one of four sampled residents (Resident 1) when Resident 1 had long, thick, and curled toenails. 2. Develop a plan of care for foot care for Resident 1. 3. Implement plan of care of skin assessment for Resident 1. These failures resulted in Resident 1 having skin breakdown on her toes and potential for skin infection and discomfort. Findings: 1. During an interview on 8/23/23 at 3 p.m. with Family Member (FM), FM stated her mother's (Resident 1) toenails were long and were not trimmed. FM stated she had reported it (long toenails) to Certified Nursing Assistant (CNA) 1 several times who stated she would tell her supervisor. During an interview on 8/24/23 at 10:30 a.m. with Resident 1, Resident 1 stated since admission she had not had her toenails trimmed. Resident 1 stated her daughter (FM) has told the staff (CNA 1) to trim her toenails. Resident 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 provide supervision and assistance to one of four sampled residents (Resident 1) when Resident 1 who required assistance with toilet use was left in the restroom. This failure resulted in Resident 1 falling and had the potential for injury. Findings: During an interview on 8/23/23 at 3 p.m. with Family Member (FM), FM stated her mother (Resident 1) had a fall in the facility in the restroom and hit her head. FM stated her mother (Resident 1) was not taken to the hospital and they (staff) just gave her Tylenol (medication for mild pain). During a concurrent interview and record review on 8/24/23 at 11:39 a.m. with Charge Nurse (CN), CN stated Resident 1 had a fall in the facility. Resident 1 ' s SBAR (Situation-Background-Assessment-Recommendation-change in condition report) dated 8/4/23 was reviewed. CN reviewed the SBAR. Resident 1's SBAR indicated, CNA (Certified Nurse Assistant 2) on orientation was passing out nourishment when…

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. Pre-made food items were labeled with use-by-date and discarded when expired. 2. Perishable foods were labeled and dated. 3. Food brought in from outside the facility was dated. These failures had the potential to cause foodborne illness (sickness resulting from contaminated food) to the residents residing in the facility. Findings: 1. During a concurrent observation and interview on 1/3/22, at 9:20 AM, with Dietary Aide (DA), in the walk-in refrigerator, the following was noted: Two small cups of pre-made mixed fruits labeled F on plastic wrap, dated 12/27. Four small cups of pre-made mixed fruits labeled F on plastic wrap, dated 12/28. Three small cups of pre-made mixed fruits labeled F on plastic wrap, dated 12/29. DA stated, the date on the mixed fruits indicated the date of preparation. The DA stated, the mixed fruit should have been discarded three days following the labeled date. During a concurrent observation and interview on 1/3/22, at 9:40 AM, with DA, in the ice-cream freezer, two cups…

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

Based on observation, interview, and record review, the facility failed to ensure one of four medication carts was locked when left unattended by licensed nurse. This failure had the potential for residents and staff to have access to medications inside the medication cart with the potential to cause adverse outcomes. Findings: During an observation, on 1/5/22, at 11:30 AM, in the East Wing of the facility by the nurses station, the medication cart was observed unlocked and unattended by a licensed nurse. During a concurrent observation and interview, on 1/5/22, at 11:32 AM, with Registered Nurse (RN) 1, RN 1 verified the medication cart was left unlocked and unattended. RN 1 stated, Oh no, the med cart should always be locked at all times. During a review of the facility's policy and procedure (P&P) titled, General Dose Preparation and Medication Administration, dated 1/20/18, the P&P indicated, Facility should ensure that medication carts are always locked when out of sight or unattended.

Based on interview and record review, the facility failed to ensure a resident requested advance directive (AD-legal document for decisions about end-of-life care) was executed for one of 50 sampled residents (Resident 27). This failure had the potential for Resident 27's end-of-life decisions to not be honored. Findings: During a review of Resident 27's Advance Directive Acknowledgement (ADA) form, dated 8/16/19, the ADA indicated, I want to execute an Advance Directive. There was no executed AD found in Resident 27's clinical record. During a concurrent interview and record review, on 1/5/22, at 9:05 AM, with Social Services Director (SSD), SSD verified Resident 27 requested an AD to be executed and Resident 27 had been deemed to have capacity to make decisions for his care by his primary care provider. SSD was unable to locate an executed AD in Resident 27's clinical record. SSD stated the process for executing an AD is for the ombudsman (an official appointed to advocate for the residents in nursing homes) to be notified, a packet is sent to the facility from the ombudsman's…

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

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of 50 sampled residents (Resident 49). This failure had the potential for unmet care needs. Findings: During an interview on 1/4/22, at 9:34 AM, with Resident 49, Resident 49 stated, he had diarrhea (loose stool) for more than one episode. Resident 49 stated diarrhea went on the floor when he got up to the bathroom. During a concurrent interview and record review, on 1/5/22, at 2:12 PM, with Director of Nursing (DON), Resident 49's Order [physician] Details (OD), dated 7/29/21, were reviewed. The OD indicated, Senna (loosens stools and increases bowel movement, treats and prevents constipation) Tablet 8.6 MG (milligrams-unit of measure), give 1 tablet by mouth two times a day for constipation hold if loose stool. DON verified the information. Resident 49's Bowel and Bladder Elimination (BBE) form, dated 12/7/21 through 1/5/22, was reviewed with DON. The BBE indicated Resident 49 had loose (stools)/diarrhea on: 12/8/21 at 11:53 PM. 12/10/21 at 1:05 PM.…

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

Based on interview and record review, the facility failed to ensure the physician's orders were followed for one of 50 sampled residents (Resident 49). This failure had the potential to result in Resident 49 to have diarrhea (loose stool). Findings: During an interview on 1/4/22, at 9:34 AM, with Resident 49, Resident 49 stated, he had diarrhea for more than one episode. Resident 49 stated diarrhea went on the floor when he got up to the bathroom. During a concurrent interview and record review, on 1/5/22, at 2:12 PM, with Director of Nursing (DON), Resident 49's Order [physician] Details (OD), dated 7/29/21, were reviewed. The OD indicated, Senna (loosens stools and increases bowel movement, treats and prevents constipation) Tablet 8.6 MG (milligrams-unit of measure), give 1 tablet by mouth two times a day for constipation hold if loose stool. DON verified the information. Resident 49's Bowel and Bladder Elimination (BBE) form, dated 12/7/21 through 1/5/22, was reviewed with DON. The BBE indicated Resident 49 had loose (stools)/diarrhea on: 12/8/21 at 11:53 PM. 12/10/21 at 1:05 PM.…

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 infection control and prevention for two of 50 sampled residents (Resident 53 and Resident 6) when: 1. Certified Nursing Assistant (CNA) 2 did not wear appropriate personal protective equipment (PPE-items such as gowns, gloves, and masks used to prevent the spread of infection) while passing meal trays. 2. Housekeeper (HSK) did not wear appropriate PPE while cleaning resident room. 3. Charge Nurse/Treatment Nurse (CN/TN) did not follow infection control protocols while doing wound care treatment. Findings: 1. During an observation on 1/3/22, at 11:34 AM, in Resident 53's room, in the Yellow Zone (quarantined area of facility), CNA 2 entered room to set up Resident 53's lunch tray without wearing a gown. CNA 2 placed the lunch tray on the bedside table, placed a clothing protector (bib) on Resident 53, adjusted the foot pedals on Resident 53's wheelchair, and moved the wheelchair closer to the bedside table. During an interview on 1/3/22, at 12 PM, with CNA 2, CNA 2 stated, she does not wear a gown…

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.