Valley View Care Center

Based on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, Food Safety Requirements, when molded bread was not thrown out. This failure had the potential for residents to acquire foodborne illness. Findings:During an observation on 12/15/25 at 8:42 a.m. in the kitchen's storage room, there was sandwich breads with handwritten date R [received by]: 11/26/25 and UB [use by] 12/2/25. The storage room contained a bag of English muffins with two muffins green in colored. During an interview on 12/15/25 at 8:45 a.m. with Dietary [NAME] (DC), DC stated there should not be any expired food. DC stated storage food should be checked daily and expired food thrown away in the trash. DC stated these breads are dated incorrectly and she is unsure of its manufactured expiration date. DC stated the English muffins where overlooked. During a review of the facility's P&P titled, Food Safety Requirements, dated 2025, the policy indicated, Policy. Food will also be stored, prepared, distributed and served in accordance with professional…

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 follow its policy and procedure (P&P) titled Influenza (Flu- contagious respiratory disease) Vaccine when:1. The Infection Preventionist (IP) did not provide and document the education of explanation of risks and benefits for the flu vaccine for four of five sampled Residents (Resident 9, Resident 10, Resident 5, and Resident 2). 2. The IP did not contact Resident 53's representative (RP) for Resident 53 to receive the flu vaccine.These failures resulted in inaccurate documentation, and had the potential to spread infectious diseases.Findings:1. During a concurrent interview and record review on 12/17/25 at 8:49 a.m. with IP, Resident 9's Vaccine Consent Form. (VCF), dated 7/14/25 and Progress Note (PN), dated 7/14/25 were reviewed. The VCF indicated Resident 9's vaccine consent was signed on 7/14/25 by the RP. The PN did not indicate there was any education provided to Resident 9's RP about the risk and benefits of the flu vaccine. IP stated there was no documentation of education provided to Resident 9's RP for the flu…

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 follow its policy and procedure (P&P) titled Infection Prevention and Control Program when three of five sampled residents (Resident 9, Resident 10, and Resident 5)'s representatives (RP) were not explained of risks and benefits of the Covid-19 vaccines (Coronavirus disease- a highly contagious respiratory disease). This failure had the potential for inaccurate medical records and spread of infectious diseases to staff and visitors. Findings:During a concurrent interview and record review on 2/17/25 at 8:49 a.m. with Infection Preventionist (IP), Resident 9's Vaccine Consent Form (VCF), dated 7/14/25 and Progress Note (PN), dated 7/14/25 were reviewed. The VCF indicated Resident 9's VCF was signed on 7/14/25 by the RP. The PN did not indicate there was any education provided to Resident 9's RP about the risk and benefits of the COVID-19 vaccines. IP stated there was no documentation of education provided to Resident 9's RP for the COVID-19 vaccines. During a concurrent interview and record review on 12/17/25 at 8:53 a.m.…

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:1.Follow its policy and procedure (P&P) titled, Nursing Care of the Older Adult with Diabetes Mellitus [a condition where the body cannot properly control blood sugar (glucose) levels], for one of one sampled resident (Resident 56). This failure had the potential for Resident 56 to experience hyperglycemia (blood sugar above target levels) symptoms (such as increase thirst, fatigue, headache, and blurred vision) and complications (such as heart disease, stroke, kidney disease, diabetic eye disease, foot complications, and nerve damage [neuropathy]).2.Follow its policy and procedure (P&P) titled, Lab and Diagnostic Test Results-Clinical Protocol, when a physician failed to review one of two sampled residents (Resident 30)'s test results in a timely manner and provide treatment to Resident 30. This failure had the potential for a delay in care and experience adverse health outcomes. 1.During a record review of Resident 56's admission RECORD (AR), dated 12/18/25, the AR indicated on admission date of 11/19/25 a diagnosis 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 its policy and procedure (P & P) titled, Safe and Homelike Environment, for one of six sampled residents (Resident 13), when cold air entered the room from the closed sliding door. This failure resulted in Resident 13 feeling cold in her room and had the potential for Resident 13 to become hypothermic (extreme cold temperature). Findings:During a concurrent observation and interview on 12/15/25 at 11:21 a.m. with Resident 13 in Resident 13's room, a piece of plastic was covering bottom of the closed patio sliding door. Resident 13 stated the air leaking from under the sliding door made her feel cold. Resident 13 stated the room was freezing cold.During an interview on 12/18/25 at 11:57 a.m. with Environmental Supervisor (ES), ES stated Resident 13 complained about being cold in her room. ES was unable to provide documentation a door company was contacted regarding Resident 13's patio door leaking cold air.During a review of the facility's Policy and Procedure (P&P) titled, Safe and Homelike…

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 follow its policy and procedure (P&P) titled, Resident Participation- Assessment/Care Plans, when one of one sampled resident (Resident 10)'s representative (RP) was not followed up to attend the Interdisciplinary Team Meetings (IDT-a meeting where professionals meet to collaborate, develop, review, and coordinate a care plan) to participate and follow-up after those meetings when the RP was not in attendance for the last six months. This failure had the potential to result in Resident 10's unmet care needs. Findings: During an interview on 12/15/25 at 3:03 p.m. with Family Member (FM) 1, FM 1 stated she has never been asked to participate in care planning or care conferences to discuss the care provided to Resident 10. FM 1 stated she had concerns about the care being provided to Resident 10 that had not been addressed by the facility. During a concurrent interview and record review on 12/17/25 at 9:32 a.m. with Director of Nursing (DON), Resident 10's IDT Care Conference Summary (IDTCCS), dated 6/19/25 and 9/11/25 were…

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

Based on interview and record review the facility failed to provide activities which reflected two of five sampled residents' (Resident 5 and Resident 53) choices and/or interests. This failure had the potential to negatively impact mental and psychosocial well-being of Resident 5 and Resident 53. Findings: 1a. During a review of Resident 5's Quarterly Activities Participation Review (QAPR), dated 11/9/25, the QAPR indicated, [Resident 5] needs encouragement and assistance during activities. [Resident 5] likes to play ball/balloon toss and sensory touch materials.Resident is up daily in his wheelchair and is dependent on staff to take him to activities. Activity staff will continue to provide assistance and encouragement during activities. During a review of Resident 5's Care Plan (CP), dated 2/3/25, the CP indicated, [Resident 5] is dependent on staff for meeting emotional, intellectual [related to thinking], physical, and social needs.Provide 1:1 [one-to-one] room visit if unable to attend group activities to monitor activity needs and offer activity materials and socialization.…

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 follow its policy and procedure (P&P) titled, Hemodialysis [HD - a life-sustaining treatment that filters blood when failing kidneys cannot], for one of one sampled resident (Resident 56) when blood pressure (BP) was taken on the dialysis access arm. This failure had the potential for Resident 56 to acquire complications such as clotting, damage to the access, and increase risk of infection. Findings: During a review of Resident 56's admission RECORD (AR), dated 12/18/25, the AR indicated, END STAGE RENAL [kidney] DISEASE. During a review of Resident 56's Nursing - Pre Dialysis Evaluation & Communication (NPDEC), dated November and December 2025, the NPDEC indicated left AV shunt (a surgically created connection between an artery and a vein to provide reliable, long-term access for HD). The NPDEC indicated BP was taken on the left arm on 11/21/25 and 12/1/25. During a review of Resident 56's Nursing - Post Dialysis Evaluation (NPDE), dated November and December 2025, the NPDE indicated BP was taken on the left arm on…

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

Based on observation, interview, and record review, the facility failed to ensure one of 27 twenty-seven sampled residents' (Resident 48) medication was ordered. This failure resulted in the delay of administering medication and potential for Resident 48 experiencing adverse health outcomes. During a concurrent observation and interview on 12/16/25 at 7:59 a.m. in the hallway, with Licensed Vocational Nurse (LVN) 1, LVN 1 was passing medication, she searched for Resident 48's Pantoprazole (stomach acid reducing medication) medication. LVN 1 was unable to locate Resident 48's medication in the medication cart.During a concurrent interview and record review on 12/16/25 at 8:06 a.m. with LVN 1, Resident 48's Medication Administration Record (MAR), dated December 2025 was reviewed. The MAR indicated, on 12/15/25 code 9 other see nursing notes.During a review of Resident 48's Order Summary (OS), dated 12/16/25 the OS indicated Protonix Tablet Delayed Release 40 mg (milligrams- unit of measure) (Pantoprazole Sodium) Give 1 tablet by mouth two time a day for GERD (medication used to treat…

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 dignity and respect for one of three sampled resident (Resident 1) when Certified Nursing Assistant (CNA) was observed repeating Resident 1 calling out for help and laughing. This failure has the potential to result in emotional distress for Resident 1. Findings:During an interview on 11/18/25 at 1:02 p.m. with Administrator, Administrator stated CNA was observed having an unprofessional interaction with Resident 1. Administrator stated on 11/16/25. Resident 1 was shouting ayudame [meaning, help me in Spanish]. Administrator stated CNA was heard repeating Resident 1's cry for help and chuckling. Administrator stated CNA's behavior was unprofessional. During an interview on 11/18/25 at 1:43 p.m. with Director of Staff Development (DSD), DSD stated on 11/16/25 CNA was observed getting down to Resident 1's level and repeated ayudame several times and was laughing. DSD stated CNA's behavior was inappropriate.During an interview on 11/19/25 at 11:25 a.m. with CNA, CNA stated on 11/16/25 at approximately 8:15 a.m. she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to timely develop and implement a care plan to prevent elopement (leaving the facility without authorization or a discharge order) for one of one sampled resident (Resident 1) who was at risk for elopement. This failure had the potential for Resident 1 to elope from the facility and sustain injury. Findings:During a review of Resident 1's admission Record (AR), dated 8/1/25, the AR indicated, Resident 1 was admitted to the facility on [DATE] with a primary diagnosis of hemiplegia and hemiparesis (paralysis and severe weakness of one side of the body after a stroke).During a review of Resident 1's Care Plan (CP), dated 7/22/25, the CP indicated, Resident 1 had a BIMs [Brief Interview for Mental Status - a cognitive assessment] score of 3 [scores of 0-7 indicated severe cognitive impairment].During a review of Resident 1's Progress Note (PN), dated 7/23/25 at 1:28 pm, the PN indicated, Resident 1 was oriented x2 (Resident 1 knew who he was and where he 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.

Based on interview and record review, the facility failed to implement their policy and procedure on abuse for one of three sampled residents (Resident 1) when the financial abuse allegation was not reported to the California Department of Public Health (CDPH) and the alleged perpetrator (SSA/Social Services Assistant) was not placed on suspension. These failures had the potential for ongoing financial abuse towards Resident 1.Findings:During a review of Resident 1's Insurance Letter Addressed to Facility (ILAF), dated 6/2/25, the ILAF indicated, Dear Management . on 5/27/25, we [insurance company] received a complaint from the above named member [Resident 1]. We require your assistance in the form of a written response for your interpretation of the encounter stated by the member below . Member said she gave [SSA] her cash aid and food stamp card to bring her back food and kept the card. [Resident 1] said cash was also missing from her wallet and she [Resident 1] knows it was the [SSA] because she knew [Resident 1] was not able to get up to go into her purse.During an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement their care plan for one of three sampled residents (Resident 1). This failure resulted in Resident 1 physically touching Resident 2 on the jaw with a closed fist. Findings: During a review of Resident 1's admission RECORD (AR), dated 5/6/25, the AR indicated, Resident 1 was admitted to the facility on [DATE] with a diagnosis of schizoaffective disorder (a mental health condition in which the person experiences hearing voices, hallucinations and/or false beliefs) bipolar (a mental health condition that causes extreme shifts in mood, energy, and activity levels) type, and adjustment disorder (an emotional or behavioral reaction to a stressful life event or change) with mixed anxiety (a feeling of worry, fear, or nervousness about something that's happening or might happen) and depressed mood (consistently feeling sad, empty, or hopeless, and losing interest in activities you once enjoyed). During a review of Resident 2's AR dated 1/24/25, 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 implement their policy and procedure on grievances for one of three sampled residents (Resident 1). This failure had the potential for the grievances to not be addressed and result in negative consequences. Findings: During a review of Resident 1's admission RECORD (AR), dated 3/21/25, the AR indicated, Resident 1 had a diagnosis of epilepsy (a brain disorder that causes repeated seizures [brief periods of abnormal brain activity], often manifesting as unusual behaviors, sensations, or loss of awareness. Bright light in some individuals can trigger an episode), and capsular glaucoma (a condition in which the eye's ability to transmit images to the brain is damaged and bright light can negatively affect some individuals). 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 of cognition [how well a person thinks, remembers, and learns]), dated 3/20/25, the BIMS indicated, Resident 1 had a score of 15 (cognition [how…

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 staff were provided education on Prevention and Recognition of signs and symptoms of Legionnaires' Disease (waterborne bacteria that cause serious lung disease) and/or other opportunistic waterborne pathogens. 2. Ensure surveillance for infection were properly conducted, data collected, analyzed, track and trended for 52 of 52 residents residing in the facility. 3. Follow infection prevention and control practices in accordance with the Centers for Disease Control and Prevention (CDC, national health organization) guidelines in the facility. 4. Ensure one of one suction machines was maintained in a clean and sanitary manner. These failures had the potential to transmit infectious diseases. Findings: 1. During a concurrent interview and record review on 12/3/24 at 9:15 a.m. with Infection Preventionist (IP) and Maintenance Supervisor (MS), Water Management Program (WMP) dated 10/31/24, was reviewed. The WMP indicated, The…

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

Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled Resident Rights for three of nine sampled residents (Resident 19, Resident 28, and Resident 43) when the residents were unaware of the Ombudsman (an independent advocate who helps protect the rights of residents in long-term care facilities, including nursing homes) contact information and how to contact the Office of the Ombudsman. This failure had the potential for Resident 19, Resident 28, and Resident 43 not to be able to report concerns/issues regarding their rights. Findings: During a group interview on 12/3/24 at 10:20 a.m. with Resident 19, Resident 28, and Resident 43, all three residents (Resident 19, Resident 28, and Resident 43) stated they did not know how to contact the Ombudsman office and did not know where Ombudsman posters were located or posted. During an interview on 12/3/24 at 10:21 a.m. with Resident 43, Resident 43 stated how to contact the Ombudsman was not discussed during their group meetings. During an interview on 12/03/24 at 11:37 a.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.

Based on interview and record review, the facility failed to ensure 12 of 32 sampled residents (Resident 1, Resident 3, Resident 7, Resident 8, Resident 13, Resident 21, Resident 22, Resident 24, Resident 31, Resident 199, Resident 201, and Resident 301) had an Advance Directive (AD- a legal document that provides instructions for medical care and only go into effect if the individual is unable to make decisions for themselves) in the medical record. This failure had the potential for responsible parties and/or medical professionals to not honor resident's healthcare wishes and to not provide appropriate treatment in the event of an emergency medical situation. Findings: During a concurrent interview and record review on 12/4/24 at 8:36 a.m. with Social Services Director (SSD) and Medical Record Director (MRD), Resident 31's medical record (MR) was reviewed. MRD stated, He (Resident 31) does not have one, referring to a copy of a Durable Power of Attorney for Health Care- advance directive [DPAHC] in Resident 31's MR. During a concurrent interview and record review on 12/4/24 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Binding Arbitration Agreement (BAA - formed when two parties enter into a contract and agree in writing that any disputes arising between them out of that contract will have to be resolved without going to the courts and with the assistance of a neutral person) offered to six of six sampled residents (Resident 2, Resident 21, Resident 25, Resident 34, Resident 40, and Resident 149) were provided in a form and language that the residents and/or resident representatives understood. This failure had the potential for Residents 2, 21, 25, 34, 40, and 149 to not fully understand the terms and conditions stipulated in the arbitration agreement. Findings: During a concurrent interview and record review on 12/3/24 at 3:19 p.m. with Business Office Manager (BOM), BOM stated there were 30 residents who signed the BAA. BOM stated the residents and/or resident representatives did not request for the arbitration agreement, but she offered the arbitration…

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 physicians provide the informed consent (process that a healthcare provider fully informs patient and/or family) for the use of antipsychotic (drugs that treat psychosis [mental distress, mental disorder]) medications for three of three sampled residents (Resident 1, Resident 40, and Resident 149) and verified by two licensed personnel when verbal or telephone consents were obtained. This failure had the potential for the residents to not receive accurate information about the drugs and not fully understand the risks, benefits, and alternative of the medications. Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was readmitted on [DATE] with diagnosis including visual hallucination (involves seeing things that aren't real), schizoaffective disorder (chronic mental illness that combines symptoms of schizophrenia [disruptions in thought processes, perceptions, emotions, and social interactions] and a mood…

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

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 101) was trained in self-administration of suction. This failure had the potential to place Resident 101 at risk for respiratory infection and/or respiratory complications. Findings: During a concurrent observation and interview on 12/2/24 at 9:24 a.m., inside Resident 101's room, Resident 101 appeared alert and was able to verbalize his needs. On the bedside table next to Resident 101's bed, a suction machine with a plastic container attached with tan frothy liquid inside the plastic collection container was noted. During an observation on 12/2/24 at 9:31 a.m., in Resident 101's room, Licensed Vocational Nurse (LVN) 6 was seen replacing the plastic container on the suction machine at Resident 101's bedside. During a concurrent interview and record review on 12/4/24 at 10:45 a.m. with LVN 8, Resident 101's medical record (MR), dated 12/4/24, was reviewed. LVN 8 was unable to locate an Interdisciplinary Team (IDT- a collaborative team where a variety 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 interview and record review, the facility failed to provide the Office of the State Long-Term Care (OSLTCO) Ombudsman (independent advocate who helps protect the rights of residents in long-term care facilities/nursing homes) a Notice of Transfer for one of one sampled resident (Resident 25) transferred to an acute care facility. This failure had the potential for Resident 25 to not receive the added protection from being transferred or discharged in and out of the facility. Findings: During a concurrent interview and record review, on 12/5/24 at 10:26 a.m. with Director of Nursing (DON) and Medical Records Director (MRD), Resident 25's Situation, Background, Assessment, and Recommendation (SBAR-a communication tool) on hospitalization, dated 10/4/24, 10/18/24, and 11/13/24, were reviewed. Resident 25's hospitalization on 10/4/24 indicated weakness and lethargy (a state of fatigue and low energy) due to low hemoglobin (few red blood cells carrying oxygen to the body. The normal range for hemoglobin levels is 12 grams per deciliter to 17.4 grams per deciliter of blood for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 149) had a completed Baseline Care Plan (BCP-an initial person-centered care plan within the first 48 hours of admission that provide instructions for care of the resident) and a summary provided to the resident within 48 hours of admission. This failure had the potential for Resident 149 to not receive the care and the safeguards necessary within the 48-hour of admission. Findings: During a review of Resident 149's admission Record (AR), the AR indicated, Resident 149 was admitted on [DATE] with diagnosis including Chronic Obstructive Pulmonary Disease (COPD-a common lung disease causing restricted airflow and breathing problems), Diabetes Mellitus (high blood sugar in the body), and Congestive Heart Failure (heart can't pump blood well enough to supply one's body with blood) with difficulty walking and needed assistance with personal care. During a concurrent interview and record review on 12/4/24 at 3:58…

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 update and develop a comprehensive person-centered care plan for three of 10 sampled residents (Resident 1, Resident 3, and Resident 31). This failure had the potential for unmet care needs. Findings: 1. During a concurrent observation and interview on 12/2/24 at 9:59 a.m. with Certified Nursing Assistant (CNA) 1, in Resident 3's room, Resident 3's feet were dangling from the wheelchair and were noted to have foot drop (neurological symptom characterized by difficulty lifting the front part of the foot due to muscular or nerve problem) on both feet. The skin on both feet was dry and scaly. The big toenail on the right foot was long, hard, and thick with ragged edges, yellowish in color and had fungus-like appearance. Resident 3's right big toe was swollen with purplish discoloration. The right second and third toes were reddish purple in color and swollen. In between the toes, the skin was black in color. The skin on the left foot was also dry and scaly, especially the skin close to the left toes. The left toes were…

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

Based on observation, interview, and record review, the facility failed to notify the physician of a psychiatrist (physician whose specialty is mental health) recommendation for one of one sampled resident (Resident 149) state of depression (loss of pleasure or interest in activities for long periods). This failure resulted in Resident 149 's noncompliance and adherence with basic care needs and activities of daily living to meet his physical, mental, and psychosocial needs. Findings: During a concurrent observation and interview on 12/2/24 at 11:38 a.m. with Resident 149, in Resident 149's room, Resident 149 appeared unkempt. Resident 149's hair was oily, and wore a T-shirt and black pants that had a smell of urine. Resident 149's lower extremities were edematous, skin was dry and scaly with small blood tinged on the right foot, toenails on both feet were long and hard. There was a black substance inside the big toenails and in between the toes. Resident 149 had broken and missing teeth. Resident 149 stated he loved to sing but he did not feel like doing anything because of his…

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 licensed nurses assessed and notified the physician of foot problems identified for two of two sampled patients (Resident 3 and Resident 149). 2. Ensure the podiatry recommendation dated 6/18/24 to refer one of one sampled resident (Resident 3) to a vascular surgeon was acted upon. 3. Ensure the attending physician documented visit for one of one sampled resident (Resident 149) in the Progress Notes and addressed Resident 149's need for podiatry consult. These failures had the potential to result in adverse consequences when treatments were delayed. Findings: 1. During a concurrent observation and interview on 12/2/24 at 9:59 a.m. with Certified Nursing Assistant (CNA) 1, in Resident 3's room, Resident 3's feet were dangling from the wheelchair and were noted to have foot drop (neurological symptom characterized by difficulty lifting the front part of the foot due to muscular or nerve problem) on both feet. The skin on both feet was dry and scaly. The big toenail on the right foot was long, hard,…

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

Based on observation, interview, and record review, the facility failed to ensure the physician ordered catheter care for one of one sampled resident (Resident 25) who had an indwelling urinary catheter (soft, plastic or rubber tube that is inserted into the bladder to drain the urine) due to neuromuscular dysfunction of the bladder (when a person lacks bladder control due to brain, spinal cord, or nerve problems). This failure had the potential for Resident 25 to develop urinary tract infection or other bladder infections. Findings: During a review of Resident 25's admission Record, (AR) dated 7/10/24, the AR indicated Resident 25's admitting diagnosis included Neuromuscular Dysfunction of Bladder. During a concurrent observation and interview on 12/2/24 at 9:37 a.m. with Resident 25 in Resident 25's room, Resident 25 had an indwelling urinary catheter, with the catheter tubing noted to be cloudy. Resident 25 stated she's had an indwelling Foley catheter for the last three years, and has frequent urinary tract infections due to prolonged use of an indwelling Foley catheter. 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.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 199) had a full portable oxygen tank (cylinder used to store oxygen) for use. This failure had the potential to cause an adverse reaction to Resident 199 including hypoxia (decreased oxygen level). Findings: During an observation on 12/4/24 at 8:42 a.m. in the facility's outside patio, Resident 199 was sitting in her wheelchair. Resident 199 had a nasal cannula (a thin plastic tube that delivers oxygen directly into the nose through two small prongs). Resident 199 was pursed lip breathing (an exercise that helps slow your breathing and maximizes the amount of oxygen that goes in and out of your lungs). Resident 199's nasal cannula tubing was attached to an empty oxygen tank. During a concurrent observation and interview on 12/4/24 at 8:45 a.m. with Licensed Vocational Nurse (LVN) 8 in the facility's outside patio, Resident 199 was noticed with pursed lip breathing while wearing a nasal cannula attached to the oxygen tank. The gauge in the oxygen tank indicated the…

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

Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled Abuse [inappropriate treatment of an individual], Neglect [refusal to provide the needs of the resident], and Exploitation [taking improper advantage of an individual], for twenty-seven of forty two sampled Certified Nursing Assistants ([CNA] 1, CNA 6, CNA 7, CNA 8, CNA 9, CNA 10, CNA 11, CNA 12, CNA 13, CNA 14, CNA 15, CNA 16, CNA 17, CNA 18, CNA 19, CNA 20, CNA 21, CNA 22, CNA 23, CNA 24, CNA 25, CNA 26, CNA 27, CNA 28, CNA 29, CNA 30, and CNA 31), 17 of 22 sampled Licensed Vocational Nurses ([LVN] 1, LVN 6, LVN 7, LVN 9, LVN 10, LVN 11, LVN 12, LVN 13, LVN 14, LVN 15, LVN 16, LVN 17, LVN 18, LVN 19, LVN 20, LVN 21, and LVN 22), and seven of eight sampled Registered Nurses ([RN] 1, RN 2, RN 3, RN 4, RN 5, RN 6, and RN 7), annual training. This failure had the potential for abuse in residents to go unnoticed and unreported within the facility. Findings: During a concurrent interview and record review on 12/4/24 at 9:15 a.m. with Director of Staff Development (DSD), 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 interview and record review, the facility failed to ensure two of five sampled residents (Resident 25 and Resident 40) had social services follow-up for medically-related social services. This failure resulted in delay of medically-related social services for Resident's 40's vision and dental services and Resident 25's dental services. Findings: During a concurrent observation and interview on 12/2/24 at 9:17 a.m. with Resident 40, in Resident 40's room, Resident 40 had missing teeth and only had six teeth on the bottom. Resident 40 stated the dentist saw her three months ago and had not returned. During a concurrent interview and record review on 12/4/24 at 3:05 p.m. with Social Service Director (SSD) 2, Resident 40's Dental Consult Notes (DCN), dated 10/7/24 was reviewed. The DCN indicated, Resident 40 was seen and examined on 10/7/24. Resident 40 needed a full mouth dentures and impressions. DSS 2 stated impressions take 2-3 months for approval from the insurance company but Resident 40's dental recommendations should. have been followed-up in November. SSD 2 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 follow its policy and procedure on Medication Storage for one of one sampled resident (Resident 99) when a medication was left unattended at bedside. This failure had the potential for residents to inadvertently use medication without being monitored. Findings: During an observation on 12/2/24 at 8:42 a.m. in Resident 99's room, a 30 milliliter (ml) a plastic medication cup was ¾ full of a blue gel-like substance sitting on the bedside table. During a concurrent observation and interview, on 12/2/24 at 8:47 a.m. with Licensed Vocational Nurse (LVN) 6, in Resident 99's room. LVN 6 lifted the 30 ml medication cup up to her nose and smelled the contents. LVN 6 stated, Its Bio-freeze gel (medication used to treat minor aches and pains of the muscles/joints). LVN 6 stated she did not know how long the medication cup had been sitting on Resident 99's bedside table. LVN 6 stated, It's something that is found on the medication treatment cart. During a concurrent observation and interview on 12/2/24 at 8:55 a.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.

Based on observation, interview, and record review, the facility failed to: 1. Ensure one of one sampled resident (Resident 1) received the food as written on the meal ticket to meet the resident's nutritional requirement. 2. Assess Resident 1's ability to cut the meat in bite size and feed herself. These failures had the potential for Resident 1 to not be able to eat and receive the necessary nutritional value. Findings: 1. During meal observation on 12/2/24 at 12:13 p.m. in Resident 1's room, Resident 1's lunch tray was placed on the overbed table. The lunch tray included roasted pork loin, parmesan crusted sweet potatoes, butter cabbage, peach cobbler, house shake, a glass of milk, and a cup of coffee. During a concurrent interview and record review on 12/2/24 at 12:15 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's meal ticket was reviewed. The meal ticket indicated, Notes: Ice cream lunch and dinner; fortified (food has an extra nutrient added) soup for lunch; add sandwich with tray; add Nutri juice in a cup for lunch and dinner. LVN 1 stated Resident 1's meal tray…

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 an assistive feeding device was available for one of one sampled resident (Resident 13). This failure had the potential to negatively impact Resident 13's nutritional status. Findings: During a concurrent observation and interview on 12/2/24 at 12:43 p.m. with Certified Dietary Manager (CDM) in Resident 13's room, Resident 13's lunch tray was at his bedside. On the tray was a regular ceramic lunch plate. CDM stated Resident 13 has a regular plate and she thinks he needs a different type of plate. During a concurrent interview and record review on 12/2/24 at 12:44 p.m. with CDM, Resident 13's undated Meal Ticket (MT) was reviewed. The MT indicated Divided Plate. CDM stated Resident 13 should have been served on a divided plate and he was served on a regular plate. During a review of the facility's policy and procedure (P&P) titled, Adaptive Equipment-Feeding Devices, dated 2020, the P&P indicated, a. the facility will provide residents appropriate assistance to ensure that the resident can use 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 interview and record review, the facility failed to maintain an effective antibiotic stewardship program (efforts in hospitals, long-term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate) when: 1. The Infection Preventionist (IP) failed to evaluate and follow up one of one resident (Resident 199) treated with antibiotic for fungal infection. 2. Antibiotic Stewardship Meeting under the leadership of the Pharmacist, the Medical Director, and Director of Nursing has not been conducted. 3. Antibiotic Stewardship education has not been provided to the nursing staff. These failures had the potential for residents to be inappropriately treated with antibiotics, which could be detrimental to the residents' medical care related to antibiotic use. Findings: 1. During a concurrent interview and record review on 12/5/24 at 11:34 a.m. with IP, Resident 199's Antibiotic Stewardship Log (ASL), dated 11/2024, was reviewed. The ASL indicated Resident 199 was started on Fluconazole (used to treat serious fungal or yeast…

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 follow its policy and procedure (P&P) titled Influenza (Flu contagious respiratory disease)Vaccine for five of 32 sampled residents (Resident 2, Resident 7, Resident 8, Resident 10, and Resident 100) when: 1. Resident 10, Resident 8, and Resident 7 were given influenza vaccine without informed consents obtained from the residents or their legal representatives (LR). 2. Resident 100 and Resident 2 did not receive explanation of risks and benefits for their refusal of the flu vaccines. 3. There was no documentation of date, lot number (essential for tracking the exact vaccine used especially in case of adverse reactions or recalls), expiration date, person administering, and site of injection of the flu vaccine vaccine administered to Resident 7. These failures had the potential for inaccurate documentation and spread of infectious diseases. Findings: 1. During a concurrent interview and record review on 12/5/24 at 8:38 a.m. with Infection Preventionist (IP), Resident 10's clinical record was reviewed. IP stated she could…

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

Based on interview and record review the facility failed to complete the Covid-19 (Coronavirus disease (COVID- a highly contagious respiratory disease) consent form for four of 31 sampled residents (Resident 10, Resident 7, Resident 100, and Resident 2) when: 1. Resident 10 and Resident 7 received Covid-19 vaccine without consent from the residents or their legal representatives (LR). 2. Resident 100 and Resident 2 were not explained of risks and benefits for refusing the Covid-19 vaccines. These failures had the potential for inaccurate medical records and spread of infectious diseases. Finding: 1. During a concurrent interview and record review on 12/5/24 at 8:38 a.m. with Infection Preventionist (IP), Resident 10's Consent for COVID -19 Vaccination, [undated] was reviewed. IP stated she could not find a consent for Covid-19 vaccine for Resident 10. IP stated Resident 10 should have a consent. During a review of Resident 7's Consent, [undated], the Consent indicated there was no signature of Resident 7 or her LR. 2. During a concurrent interview and record review on 12/5/24 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 ensure one of one resident (Resident 11)'s oxygen tank with an attached gauge (a medical device designed to display the pressure level in an oxygen tank or cylinder) was secured when stored. This failure had the potential for health hazard and place residents at risk for harm. Findings: During a concurrent interview and record review on 12/2/24 at 12:41 p.m. with Licensed Vocational Nurse (LVN) 1, in Resident 11's room, an oxygen tank with an attached gauge meter and oxygen tubing wrapped around the tank, was found standing unsecured on the right side of Resident 11's bed. LVN 1 stated the oxygen tank should be in a rack. During an interview on 12/2/24 at 2:45 p.m. with Respiratory Therapist (RT), RT stated the director of respiratory care was aware, after the fact, that an oxygen tank was found standing unsecured, not in an oxygen rack. RT stated, That was absolutely not acceptable. RT stated it's dangerous and could hurt the resident and the staff. During a review of the facility's policy and procedure…

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 two sampled residents (Resident 1) personal funds were accounted for when they were kept secured in the nurse's medication cart. This failure resulted in Resident 1's personal funds being unaccounted for and the potential for emotional distress for Resident 1. Findings: During a review of the facility's 5-day report (DR), dated 9/23/24, the DR indicated, On 9/16, it was reported to Administrator, the resident (Resident 1) alleges staff of stealing his money. There was only 2 twenty-dollar bills and one ten dollar bill left in resident envelope. During a review of Resident 1's Progress Notes (PN), dated 4/30/24 (approximately 5 months prior to reporting) at 1:32 p.m., the PN indicated, Resident came into writers office requesting to have a place to store his money. Writer informed resident that money could be counted in front of resident and two RNA's (Restorative Nursing Assistance) present in writer's office. Resident agreed to have money stored in nurses med (medication) cart and money was counted it was 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 physician ordered treatments for four of four sampled residents (Resident 1, Resident 2, Resident 3, and Resident 4). This failure had the potential for worsening of resident condition, increased chance for infection, and increased healing times. Findings: During a concurrent interview and record review on 9/25/24 at 10:53 a.m. with Director of Nursing (DON), Resident 1, 2, 3 and 4 ' s TREATMENT ADMINISTRATION RECORD (TAR), dated September 2024 were reviewed. The TAR indicated the following: A. Resident 1 had a physician order for Mupirocin External Ointment (a medicated cream used to treat skin infections) 2 % (percent – a unit of measurement). Apply to affected area topically two times a day for skin infection. The TAR indicated Resident 1 did not receive this medicated cream at 9 a.m. on 9/2/24, 9/3/24, 9/4/24, 9/5/24, 9/6/24 and 9/10/24. The TAR indicated Resident 1 did not receive this medicated cream at 6 p.m. on 9/5/24, 9/6/24, 9/8/24, 9/9/24, 9/10/24, 9/11/24 and 9/13/24. B. Resident 1 had a physician order…

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 treat one of three sampled residents (Resident 1) with dignity and respect. This failure had the potential to affect Resident 1 ' s feeling of self-worth. Findings: During an interview on 8/14/24 at 11:27 a.m. with Administrator, Administrator stated on 8/5/24, Certified Nursing Assistant (CNA) 1 told Resident 1, You are lucky you get three meals a day because there are starving children in the world. Administrator stated the following day on 8/6/24 during breakfast, CNA 1 passed the breakfast trays to everyone in Resident 1 ' s room (not identified) but not to Resident 1. Administrator stated CNA 1 and all other facility staff had just been in-serviced recently that all meal trays are to be passed to everyone in the room before moving onto the next room. During an interview on 8/14/24 at 11:39 a.m. with CNA 1, CNA 1 stated on 8/5/24, she was discussing food with Resident 1 and told him, You know there are some kids on the street that have nothing to eat and picking in the trash. CNA 1 stated the following day 8/6/24 she…

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

Based on interview and record review, the facility failed to treat one of three sampled residents (Resident 1) with dignity and respect. This failure had the potential for negative self-esteem, lack of self-worth and other negative consequences. Findings: During a review of Resident 1's admission RECORD (AR), dated 12/13/21, the AR indicated, Resident 1 diagnosis including anxiety disorder (involves persistent and excessive worry that interferes with daily activities) and paraplegia (inability to move lower part of the body). 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 4/25/24, the BIMS indicated, Resident 1 had a score of 13 (cognition intact). During an interview on 8/1/24 at 10:31 a.m. with Resident 1, Resident 1 stated staff (not identified) placed a towel in her rectal area, and she screamed out (could not give exact date). Resident 1 stated when she screamed out Licensed Vocational Nurse (LVN)…

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 follow its policy and procedure on reporting allegations of abuse for one of three sampled residents (Resident 1). This failure resulted in placing Resident 1 at risk for further abuse and had the potential to place other residents at risk for abuse. Findings: During a review of Resident 1's admission RECORD (AR), dated 12/13/21, the AR indicated, Resident 1 diagnosis including anxiety disorder (involves persistent and excessive worry that interferes with daily activities) and paraplegia (inability to move lower part of the body). 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 4/25/24, the BIMS indicated, Resident 1 had a score of 13 (cognition intact). During a review of Resident 1's MDS under the section GG (an assessment of the level a care a resident requires), dated 4/25/24, the GG indicated, Resident 1 required maximum assistance from…

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 assess one of three sampled residents (Resident 1) for fall risk. This failure had the potential for Resident 1 to not have the appropriate interventions in place to prevent fall incidents. Findings: During an interview on 5/23/24 at 11 a.m. with Director of Nursing (DON), DON stated Resident 1 had 10 fall incidents since the beginning of 2024. During a review of Resident 1's admission RECORD (AR), dated 6/5/24, the AR indicated, Resident 1 diagnosis including Parkinson's disease (a brain disorder causing uncontrollable movement), convulsions (involuntary muscle contractions), Schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), difficulty in walking and need for assistance with personal care. During a concurrent interview and record review on 6/4/24 at 11:55 a.m. with DON, Resident 1's Nursing - Fall Risk Evaluation (NFRE), was reviewed. The NFRE indicated the following: a. On 2/10/24 (after a fall incident), Resident 1 had a fall risk score of five (moderate fall…

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

Based on interview and record review, the facility failed to treat one of three sampled residents (Resident 1) with dignity and respect. This failure had the potential for Resident 1 to have low self-esteem and other negative psychosocial outcomes. Findings: During an interview on 1/31/24 at 1:44 p.m. with Director of Nursing (DON), DON stated Resident 1 filed a grievance on 1/17/24, indicating Licensed Vocational Nurse (LVN 1) was rude to her. DON stated an investigation was done. DON stated LVN 1 confronted Resident 1 by the facility medical records office about the alleged rumor Resident 1 was making up stories about LVN 1. DON stated Resident 1 alleged LVN 1 followed Resident 1 to her room and was shouting at her but there were no witnesses to this claim. DON stated LVN 1 did not act per facility expectations. DON stated, She [LVN 1] should not have confronted the resident [Resident 1] about rumors. DON stated Resident 1 was no longer a resident in the facility as she had discharged home as planned. During an interview on 1/31/24 at 2:20 p.m. with LVN 1, LVN 1 stated on 1/17/24,…

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 its policy and procedure titled Discharge Planning Process for one of three sampled residents (Resident 1). This failure had the potential for unsafe discharge. Findings: During an interview on 11/14/23 at 10:19 a.m. with Family Member (FM) 1, FM 1 stated Resident 1 was supposed to be discharged to an assisted living facility but was discharged home. FM 1 stated he is not able to provide the care she needs. During an interview on 11/14/23 at 9:54 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 was a very confused and would try to always get out of her wheelchair. LVN 1 stated Resident 1 was placed near the nursing station for close observation. During an interview on 11/14/23 at 9:59 a.m. with Activity Director (AD), AD stated Resident 1 was a very confused and would constantly be looking for her young granddaughter in the facility. AD stated Resident 1 would also not eat and needed encouragement with her meals. During a concurrent interview and record review on 11/14/23 at 10:02 a.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.

Based on interview and record review, the facility failed to ensure residents completed an Advance Directive (AD- legal document which specifies a person's health care related choices and what actions should be taken when the person is no longer able to make decisions for themselves because of illness or incapacity) Acknowledgement (ADA- asks if resident had or did not have an advanced directive) or were given the option to formulate an AD, for four of 40 sampled residents (Resident 36, Resident 31, Resident 7, and Resident 201). This failure had the potential for health care decisions to not be honored. Findings: During a concurrent interview and record review on 12/5/23 at 11:07 a.m. with Director of Nursing (DON), Resident 36's Medical Record (MR) was reviewed. The MR indicated, no ADA was found. DON stated there was not an ADA in Resident 36's MR. During a concurrent interview and record review on 12/5/23 at 11:29 a.m. with DON, Resident 31's MR was reviewed. The MR indicated, no ADA was found. DON stated there was not an ADA in Resident 31's MR. During a concurrent interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment for three of 40 sampled residents (Resident 39, Resident 201 and Resident 40). These failures had the potential for negatively impacting residents well-being. Findings: During a concurrent observation and interview on 12/4/23 at 7:59 a.m. with Resident 39, in Resident 39's bathroom, Resident 39 stated his toilet had been leaking for over two weeks with water leaking on the floor. During a concurrent observation and interview on 12/4/23 at 8:03 a.m. with Certified Nursing Assistant (CNA) 2, in room [ROOM NUMBER], CNA 2 stated there were broken floor tiles in the room and had been broken for a long time. During a concurrent observation and interview on 12/6/23 at 12:18 p.m. with Nurse Consultant (NC) and Maintenance Supervisor (MS) in Resident Rooms (Resident Rooms 11, 12, 13, 14, and 15) and Hallways of the South Wing, the following was noted: room [ROOM NUMBER] - behind Bed C,…

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 in-room activities for three of 40 sampled residents (Resident 17, Resident 20, and Resident 303). This failure had the potential to affect the overall well-being and quality of life for Resident 17, Resident 20 and Resident 303. Findings: During an interview on 12/7/23 at 9:10 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she observes the RNA (restorative nurse assistant - trained assistant provides skill in activities of daily living such as walking, mobility, dressing, and grooming) in the rooms providing exercises for the residents but she had not seen any activity staff engage in-room activities with the residents. CNA 1 stated the residents have to go to the activity room. During an interview on 12/7/23 at 9:27 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated he doesn't see activity staff go to resident's rooms and offer activities. During an interview on 12/7/23 at 9:29 a.m. with CNA 3, CNA 3 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 interview and record review, the facility failed to ensure the Level II PASRR (Preadmission Screening and Resident Review-a form to determine if a resident has, or is suspected of having a mental illness) was completed after part I was positive for one of 40 sampled residents (Resident 8). This failure had the potential to not meet the needs and mental health services for Resident 8. Findings: During a review of Resident 8's admission Record (AR), dated 9/25/23, the AR indicated, Resident 8 had a diagnosis of Paranoid Schizophrenia (A mental illness that exhibits behaviors in which a person hears voices with delusions and hallucinations). During a review of Resident 8's PASRR Level I (PLI), dated 9/24/23, the PLI indicated, Level I screening for [Resident 8] submitted on 9/24/23 is positive for suspected mental illness and level II mental health evaluation referral is required. During an interview on 12/5/23 at 11:17 a.m. with Director or Nursing (DON), DON stated that social services is responsible for PASRR's and was unable to find documentation Resident 8 had a PASRR II…

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 develop and implement a comprehensive person-centered care plan to reflect the resident's needs for three of 40 sampled residents (Resident 44, Resident 303, and Resident 4). These failures had the potential of not providing appropriate, consistent, and individualized care to these residents. Findings: During an observation on 12/4/23 at 9:56 a.m. in Resident 44's room, Resident 44 was wearing a life vest (a wearable vest that is designed to protect patients at risk of sudden cardiac death) with a battery pack attached to it. During an interview on 12/6/23 at 9:56 a.m. with Director of Nursing (DON), DON stated she was unable to find a care plan for the life vest Resident 44 was wearing. DON stated Resident 44 should have a care plan in place for the life vest. During an observation on 12/4/23 at 10:08 a.m. in Resident 303's room, Resident 303 did not have any seizure precautions (padded side rails, etc) in place. During a concurrent interview and record review on 12/6/23 at 9:56 a.m. with DON, Resident 303'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 meet standards of practice for two of 40 sampled residents (Resident 8 and Resident 303) when speciality consults were ordered and never arranged. This failure resulted in the delay of care and treatment needed by the specialist. Findings: During a review of Resident 8's Lab Results (LR), dated 10/18/23, the LR indicated, Resident 8 had a Blood Urea Nitrogen (BUN) result of 44 with a Normal Range of 6-20. Creatinine Level of 1.91 with a normal range of 0.50-1.30 (BUN and creatinine levels show how well a person's kidneys are functioning). During a concurrent interview and record review on 12/6/23 at 9:50 a.m. with Social Services Designee (SSD), Resident 8's Order Listing Report (OLR), dated 11/10/23 was reviewed. The OLR indicated, Referral for nephrologist [kidney specialist] due to high creatinine levels. SSD stated she needed to follow up and look for documentation. During a concurrent interview and record review on 12/6/23 at 2:50 p.m. with SSD, SSD provided a Nephrologist referral for Resident 8 dated 12/6/23 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 ensure one of 40 sampled residents (Resident 16) received podiatry (foot and nail) care. This failure resulted in Resident 16's nailcare not being met. Findings: During a concurrent observation and interview on 12/4/23 at 12:44 p.m. with Administrator, Resident 16's right big toe was observed. Administrator measured Resident 16's toenail and stated it was ½ inch (a unit of measurement) beyond the tip of the toe, ¼ inch thick, and was a dark gray color. During a review of the facility's policy and procedure (P&P) titled, Podiatry Services, dated 2023, the P&P indicated, It is the policy of this facility to ensure residents receive proper treatment and care within professional standards of practice and state scope of practice, as applicable, to maintain mobility and good foot health. Foot care that is provided in the facility, such as toe nail clipping for residents without complicating disease process, should be provided by staff who have received education and training to provide. Residents requiring foot…

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 routine dental services were provided to two of 40 sampled residents (Resident 34 and Resident 44). This failure had the potential for these residents dental care not being met. Findings: During an observation on 12/7/23 at 9:37 a.m. in Resident 34's room, Resident 34 was observed to have many missing teeth, plaque (sticky film that coats teeth and contains bacteria), and discoloration. During a concurrent interview and record review on 12/7/23 at 1:21 p.m. with Social Services Designee (SSD), Resident 34's Order Listing Report (OLR), dated 6/14/23 was reviewed. The OLR indicated, Dental Consult as needed. SSD stated she was unable to find documentation showing the last time Resident 34's dental checkup was completed. SSD stated Resident 34 hasn't had one since she's been at the facility. During a concurrent observation and interview on 12/7/23 at 1:25 p.m. with Licensed Vocational Nurse (LVN) 2, in Resident 34's room, Resident 34's teeth were observed. LVN 2 stated Resident 34 needs to see a dentist.…

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 qualified dietary staff member supervised the dietary staff and food service department. This failure had the potential for foodborne illness to spread to residents. Findings: During an interview on 12/6/23 at 2:26 p.m. with Dietary Manager (DM), DM stated she does not have the qualifications to be a Certified Dietary Manager (CDM). DM stated she is in school to become a CDM and may finish sometime next year. DM stated she has worked at the facility for two years. During a review of the facility's Job Description Manual- Dietary Supervisor (JDM), dated 10/11/21, the JDM indicated, Qualifications. Trained as a Certified Dietary Manager.Certification in food safety as required by state regulations. The JDM was signed by DM on 10/11/21.

Based on observation, interview, and record review, the facility failed to ensure: 1. Refrigerator logs were being recorded per policy. 2. Staff was cooling cooked foods per policy. 3. Dishware stored in sanitary conditions. 4. Repair water damage areas of tile and wall. These failures had the potential to spread foodborne illnesses to residents, and the potential to lead to pest infestation. Findings: 1. During a concurrent interview and record review on 12/4/23 at 7:29 a.m. with Dietary Aide (DA) 1, the REFRIGERATOR TEMPERATURE LOG (RTL), dated 12/2023, and the FREEZER TEMPERATURE LOG (FTL), dated 12/2023 were reviewed. The RTL indicated, the a.m. temperature check for 12/5/23 had already been recorded as 39 degrees Fahrenheit (F- a unit of measure). The FTL indicated, the a.m. temperature check for 12/5/23 had already been recorded as 0 degrees F. DA 1 stated she got ahead of herself. During a concurrent interview and record review on 12/6/23 at 3:17 p.m. with Dietary Manager (DM), the RESIDENT FOOD REFRIGERATOR/FREEZER TEMPERATURE LOG (RFRFTL), dated 12/2023 was reviewed. 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 infection precautions were followed when a Medical Records (MR) staff member passing meal trays had long artificial fingernails. This failure had the potential to spread infection to residents. Findings: During an observation on 12/4/23 at 12:21 p.m., MR staff was observed passing meal trays while wearing long artificial fingernails. During an interview on 12/4/23 at 12:47 p.m. with MR and Administrator, MR stated the nails were not natural. Administrator stated artificial nails should not be worn in the facility. During an interview on 12/6/23 at 9:43 a.m. with Infection Preventionist (IP), IP stated, Meal tray pass is providing resident care, and long or artificial nails should not be worn during meal tray pass. During a review of the facility's EMPLOYEE HANDBOOK, (undated), the handbook indicated, For safety and infection control, dietary employees and those who provide direct resident care must keep their fingernails clean and trimmed. Fingernails must not extend beyond the end of each finger.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide adequate space (80 square feet for each resident) in 15 of 19 rooms. This failure had the potential to affect resident's comfort, health and safety. Findings: During an interview on 12/7/23 at 8:08 a.m. with Certified Nursing Assistant (CNA) 4, CNA 4 stated, each Resident has their own separate closet and bedside table and she has not had any Resident complain about not having enough space. During an interview on 12/7/23 at 8:15 a.m. with CNA 5, CNA 5 stated, Residents do not complain about the space provided and she has enough room to provide care for the Residents. During a concurrent interview and record review on 12/07/23 at 8:25 a.m. with Director of Nursing (DON), the facility's Midnight Census Report (MCR), dated 12/4/23 was reviewed. DON stated the room sizes and measurements of the rooms had not changed since the previous survey. DON confirmed the following rooms were 228 square feet and each room contained three residents. room [ROOM…

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