Downey Community Health Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of six sampled residents' (Resident 129) assessment entry on the Minimum Data Set ([MDS], a resident assessment tool) was accurate and included the depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) diagnosis. This deficient practice had the potential to negatively affect Resident 129's plan of care and delivery of necessary care and services related to depression. Findings: During a review of Resident 129's admission Record, the admission Record indicated Resident 129 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included psychosis (a state where a person loses touch with reality by experiencing things that are not real), dementia (a progressive state of decline in mental abilities), and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 129's MDS, dated [DATE], the MDS indicated Resident…

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

Based on interview, and record review, the facility failed to ensure a care plan (a document that outlines a resident's care needs, diagnosis, and treatment goals) for Pregabalin (medication to treat nerve pain by calming overactive nerves in the body was developed and implemented for one of four sampled residents (Resident 479). This deficient practice placed Resident 479 at risk for delayed monitoring and implementing interventions. Findings: During a review of Resident 479's admission Record [(Face Sheet) front page of the chart that contains a summary of basic information about the resident], the admission Record indicated the facility admitted Resident 479 on 3/25/2025, with diagnoses including arthritis (a condition that causes inflammation and pain in the joints), muscle weakness (a reduced ability to contract or exert force with muscle), polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body) and acute pulmonary edema (a medical emergency characterized by a rapid buildup of fluid in the lungs, making it difficult to breath). During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to revise the person-centered care plan (document that helps nurses and other team care members organize aspect of resident care) for one of seven sampled residents (Resident 328) who was on dual (two) antiplatelet medication (medication to prevent blood clots from forming). This deficient practice had the potential to result in confusion between licensed nurses regarding Resident 328's appropriate use of dual antiplatelet medication and navigation of Resident 328's plan of care. Findings: During a review of Resident 328's admission Record, the admission Record indicated Resident 328 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) affecting the right dominant side following a cerebral infarct (also known as stroke, a loss of blood flow to a part of the brain) and nontraumatic intracerebral hemorrhage (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care and services to maintain good grooming and personal hygiene for two of four sampled residents (Residents 112, and 75) by failing to keep the residents' fingernails clean and neat. This failure had the potential to result in negative impact on Residents 112 and 75's quality of life and self-esteem, and had the potential for development of infection. Findings: a. During a concurrent observation and interview on 4/7/2025 at 9:47 a.m., with Resident 112, in Resident 112's room, observed Resident 112's fingernails long with black substance underneath. Resident 112 stated her fingernails looked long and that she would like to have her fingernails cut and cleaned. During a review of Resident 112's admission Record, the admission Record indicated Resident 112 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus ([DM]- a disorder characterized by difficulty in blood sugar control and poor wound…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the accurate and complete documentation on the Controlled Record for two of two sampled residents (Residents 155 and 178). This deficient practice resulted in the inaccurate count of medications left in the medications bubble packs (a card used to store medications for the resident) and had the potential to result in an additional dose administered, for drug diversion (the act of health care providers stealing prescription medicine for their own use), and/or the potential for medication error to occur. Findings: a. During a review of Resident 178's admission Record, the admission Record indicated Resident 178 was admitted to the facility on [DATE] with diagnoses that included radiculopathy (also known as pinched nerve where the nerve root in the spine is compressed or irritated), cervicalgia (neck pain), and low back pain. During a review of Resident 178's History and Physical (H&P), dated 4/9/2025, the H&P indicated Resident 178…

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 Resident 479 for signs of being over medicated while on Pregabalin (medication to treat nerve pain by calming overactive nerves in the body) for one of four sampled residents (Resident 479). This deficient practice placed Resident 479 at risk for adverse medication side effects. Findings: During an observation on 4/7/2025 at 10:21 a.m. in Resident 479's room, Resident 479 was observed lying in bed with eyes closed. During an observation on 4/7/2025 at 11:53 a.m., in Resident 479's room, Resident 479 was observed lying in bed with eyes closed. During an observation on 4/9/2025 at 10:00 a.m., in Resident 479's room, Resident 479 was observed lying in bed with eyes closed. During an observation on 4/10/2025 at 11:18 a.m. in Resident 479's room, Resident 479 was observed lying in bed with eyes closed. During a review of Resident 479's admission Record [(Face Sheet) front page of the chart that contains a summary of basic information about the resident], the admission Record indicated the facility admitted…

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 eight sampled resident (Resident 230) was free from significant medication error (one which causes the resident discomfort or jeopardizes his or her health and safety) by failing to: 1. Ensure Resident 230 received glipizide (lowers blood sugar) 30 minutes before breakfast. 2. Ensure licensed nurses followed the physician's orders. These deficient practices placed Resident 230 at a higher risk to experience extremely lower blood sugar levels. Findings: During a review of Resident 230's admission Record, the admission Record indicated Resident 230 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing) and long-term use of insulin (a hormone that helps regulate blood sugar levels). During a review of Resident 230's History and Physical (H&P) dated 4/3/2025, the H&P indicated Resident 230 had the capacity to understand and make…

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 remove outside food from the bedside after two hours for one out of seven residents (Resident 79) in accordance with the facility's Policy and Procedure (P&P) titled, Foods brought by family or visitors. This deficient practice had the potential to result in food-borne illnesses (food poisoning) for Resident 79, with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever. It could lead to other serious medical complications (a medical problem that occurred during a disease) and hospitalization. Findings: During a review of Resident 79's admission Record, the admission Record indicated Resident 79 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of metabolic encephalopathy (a brain dysfunction caused by imbalances in the body's chemistry, like electrolyte or blood chemical problems, due to other health issues) and gastroesophageal reflux disease (GERD, a condition…

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 clinical records were maintained in accordance with accepted professional standards and accurately complete the Advance Directives Acknowledgement ([ADA]- a form gives you the right to give instructions about your own health care) for one of four sampled residents (Resident 132). This deficient practice resulted in inaccurate and incomplete medical records and had the potential to result in confusion in the resident's care and services. This also placed Resident 132 at risk of not receiving necessary care or not receiving care based on the resident's wishes due to inaccurate and incomplete information. Findings: During a review of Resident 132's admission Record, the admission Record indicated Resident 132 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), gastrostomy (a surgical…

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 touch pad (button activated by light touch) call light for one out of eight residents (Resident 86). This deficient practice had the potential to cause a delay or an inability in Resident 86 obtaining necessary care and services. Findings: During an observation on 4/9/2025 at 2:19 p.m., in Resident 86's room, the call light was observed near Resident 86's left hand. Resident 86 unsuccessfully attempted to press the call light button. During a review of Resident 86's admission Record, the admission Record indicated Resident 86 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of left body hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiplegia and hemiparesis (weakness) of the right dominant side. During a review of Resident 86's History and Physical (H&P) dated 11/30/2024, the H&P indicated Resident 86 did not have the capacity to understand 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 ensure a Certified Nursing Assistant (CNA 1) did not continue to have access to one of two sampled residents (Resident 1) after an allegation of physical abuse. This deficient practice resulted in CNA 1 still being assigned to the care of Resident 1 ' s roommates after Resident 1 ' s allegation of abuse. Findings: During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included low back pain, muscle weakness (when muscles did not have the strength they normally do), and diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 1 ' s Minimum Data Set ([MDS], a resident assessment tool), dated 1/8/2025, the MDS indicated Resident 1 ' s cognition (process of thinking) was intact. The MDS indicated Resident 1 required supervision with eating; partial assistance (helper did…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to document records completely for one of two sampled residents (Resident 1) when: 1. Resident 1 had concerns with Certified Nurse Assistant (CNA) 1 during care on 3/15/2025. 2. The facility failed to document a change of condition when Resident 1 had an allegation of abuse on 3/17/2025. These deficient practices had the potential to result in a lack of or a delay in communication between the staff and could interrupt provision of care/intervention to Resident 1. Findings: 1.During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included low back pain, muscle weakness (when muscles did not have the strength they normally do), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 1 ' s Minimum Data Set (MDS, a resident assessment tool), dated 1/8/2025, the MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow professional standards of practice for one of the 3 sampled residents (Resident 1) by failing to ensure the physician order to check Resident 1 ' s blood sugar (BS) levels were implemented on 2/28/2025, 3/1/2025 and 3/2/2025. This failure placed Resident 1 at risk for hypoglycemia (low blood sugar) and/or hyperglycemia (high blood sugar) episodes, and potential for complications and hospitalization. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis including diabetes (DM-high blood sugar), hypertension (HTN-high blood pressure) and anxiety disorder (a feeling of fear, dread, and uneasiness). During a review of Resident 1 ' s History and Physical (H&P) dated 2/24/2025, the H&P indicated Resident 1 had the mental capacity to understand and make medical decisions. During a review of residents 1 ' s Minimum Data Set (MDS – a federally…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was readmitted to the facility after Resident 1 was transferred and treated at the General Acute Care Hospital (GACH). This deficient practice resulted in Resident 1 remaining at the GACH for two additional days after Resident 1 was deemed appropriate for discharge back to the facility but was denied readmission by the facility. Findings: A review of Resident 1 ' s admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of right hemiplegia (a condition caused by a brain injury, that results in a varying degree of weakness, stiffness, and lack of control in one side of the body) and chronic kidney (disease gradual loss of kidney function. Kidneys are unable to filter wastes and excess fluids from blood). A review of Resident 1 ' s History and Physical (H&P), dated 8/26/2024, the H&P indicated Resident 1 did not have the capacity to understand…

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 its infection prevention and control measures by failing to ensure clear signage was posted for two of five sampled residents (Resident 4 and Resident 5) who were on Enhanced Barrier Precautions ([EBP] use of gown and gloves during high-contact resident care activities to reduce the transmission of multidrug-resistant organisms ([MDROs] bacteria or other microorganism resistant to multiple classes of antibiotics)). This deficient practice had the potential to result in staff and visitors entering the room without the proper personal protective equipment ([PPE] specialized clothing or equipment such as gloves and gown, worn to minimize exposure to serious illness) and increasing the risk of transmitting disease-causing organisms leading to illness. Findings: During a review of Resident 4 ' s admission Record, the admission Record indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE] with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement the care plan intervention of bilateral floor mats. This failure had the potential to result in Resident 3 being injured if she fell. Findings: During an observation on 4/24/2024 at 9:16 a.m. in Resident 3's room, there was no fall mat on the right side of the bed. The fall mat on the left side of the bed was closest to the roommate's bed. During an interview on 4/24/2024 at 12:00 p.m. with Registered Nurse (RN1), RN1 stated fall mats are placed to minimize injury by providing a cushion. During a concurrent interview and record review on 4/24/2024 at 12:16 pm with Licensed Vocational Nurse (LVN1), LVN1 showed RES3 had a doctor's order for fall mats on both sides of the bed while in bed. LVN1 states the fall mats were ordered to catch the resident if she slides off the bed. If the resident falls without the mat in place she can hit her head and need to go to the hospital. During a review of Resident 3's change of condition…

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 did not implement infection practices as outlined in the facility's infection control program when the facility did not perform the following: 1. Implement Enhanced Barrier Precautions ([EBP]-the use of gown and gloves for specific care activities that involve a high chance of the spread of infection), as mandated, to limit the spread of infections. 2. Ensure the Treatment Nurse wore proper personal protective equipment ([PPE] -a barrier precaution which includes use of gloves, gown, mask, face shield, shoe covers, head covers, respirators, etc. when you anticipate contact with blood or body fluids or other communicable toxins or agents) during Resident 88's wound treatment. 3. Ensure certified staff used PPE when providing wound treatment for Resident 129. 4. Follow their own policy and procedures (P&Ps) titled, Hand Washing/Hand Hygiene, dated 1/2023, to ensure licensed nurses wash or sanitized hands before and after taking the blood pressure…

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 medications brought from home (Home Medications) were reviewed by the pharmacist for two of two residents (Resident 65 and Resident 113) prior to administering Home Medications stored inside of two of four medication carts inspected (Medication Cart 2 located on Station 3 and Medication Cart 3 on Station 1) respectively. 2. Accurately account for and document the administration of eight out of 12 doses of Lorazepam, a controlled medication (has a high potential for abuse) affecting Resident 36 on Station 2, Medication Cart 2. These deficient practices increased the risk for unsafe medication administration, potential for diversion, medication errors due to lack of documentation, possibly resulting in serious health complications that could lead to hospitalization or death. Findings: a. During a review of Resident 65's admission Record, the admission record indicated Resident 65 was admitted to the facility on [DATE] and was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure lorazepam (a medication used to treat mental illness) was used for a medical condition as diagnosed and documented in the resident's clinical record between 3/25/2024 and 4/2/2024, for one of five residents sampled for unnecessary medications (Resident 36). 2. Define resident-specific target behaviors regarding the use of lorazepam for one of five residents sampled for unnecessary medications (Resident 36). 3. Monitor lorazepam for adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) and effectiveness between 3/35/2025 and 4/2/2024, for one of five residents sampled for unnecessary medications (Resident 36). 4. Quantify episodes of constant fidgeting, per the physician's order related to the use of lorazepam (a medication used to treat anxiety, excessive worry and feelings of fear, dread, and uneasiness) between 3/21/2024 and 4/2/2024, for one of five residents sampled for unnecessary medications (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 maintain a medication error rate of less than 5 percent (%) during medication pass for four of five sampled residents (Residents 10, Resident 16, Resident 53, and Resident 621) observed during medication administration by failing to: 1. Ensure Resident 621's physician orders for hydroxychloroquine and potassium chloride extended release (ER) were administered in accordance with manufacturer's specification, the facility's policy and procedure (P&P) titled Medication Administration-General Guidelines, dated 5/2016, and/or the form titled, Medications Not To Be Crushed, list dated 7/2015 (Cross Ref F-tag F760). 2. Ensure Resident 621's physician order for aspirin was administered as prescribed on 4/2/2024. 3. Ensure Resident 10 was administered Metformin (a medication used to treat diabetes, a chronic [long-term] condition, in which a high level of glucose [sugar] is present in the bloodstream), within 60 minutes of the scheduled time as…

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 prepare food by methods that conserved texture and appearance for 23 of 23 residents receiving a pureed diet (a regular diet that has been designed for residents who have difficulty chewing and or swallowing). The texture of the pureed diet was lumpy and not smooth with large pieces of pasta present requiring chewing before swallowing. This deficient practice had the potential to result in meal dissatisfaction, decreased food intake, risk for unplanned weight loss, and placed al 23 residents receiving a pureed diet at risk for choking. Findings: During an initial facility tour on 4/1/2024 at 8:30 AM, complaints about the flavor of the food was identified. During a concurrent observation and interview on 4/2/2024 at 11:30 AM, with [NAME] 1, in the kitchen, [NAME] 1 was observed taking the temperatures of the lunch meal items on the steam table. [NAME] 1 stated the lunch on 4/2/2024 included lasagna, Italian green beans, and garlic bread. [NAME] 1 stated a portion of the regular lasagna was taken and pureed to…

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

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen when: 1. Six plastic bags of packed lunch with meat sandwiches for residents were stored in the refrigerator with use by dates of 3/27/2024, 3/30/2024, and 3/31/2024, exceeding the storage period for previously prepared sandwiches. There was one medium size container of tomato sauce with a use by date of 3/26/2024, and one medium size container of cooked green beans with a use by date of 3/28/2024, stored in the walk-in refrigerator exceeding use by date mark. There were four ham and cheese sandwiches stored in walk in refrigerator with no date. One container of a liquid egg carton with an open date of 3/27/2024 and manufactures instruction to use within 3 days stored in the walk-in refrigerator exceeding manufactures use by date. One large bowl of previously prepared whipped cream stored in the walk-in refrigerator uncovered and open to the refrigerator environment. Ready to eat deli meats including ham and roasted turkey 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to keep a resident informed and did not ensure a resident exercised his right to choose for one out of eight sampled residents (Resident 74) by failing to: 1. Ensure licensed nursing staff informed Resident 74 of the medications being administered prior to administration. 2. Ensure Resident 74 was given an opportunity to participate during medication administration. These deficient practices violated Resident 74's rights. Findings: During a review of Resident 74's admission Record, the admission record indicated Resident 74 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included congestive heart failure (CHF, a chronic condition in which the heart does not pump blood adequately) and chronic kidney disease (CKD, a gradual loss of kidney function). During a review of Resident 74's History and Physical (H&P) dated 2/10/2024, the H&P indicated Resident 74 had fluctuating capacity 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 respect and dignity was provided for one of eight sampled residents (Resident 134) by not ensuring Resident 134 was served meals with disposable plastic utensils and not informing Resident 134 of the reason she received the disposable plastic utensils. This deficient practice violated Resident 134's right to be treated with respect and dignity and had the potential to negatively impact Resident 134's psychosocial well-being. Findings: During a review of Resident 134's admission Record, the admission record indicated Resident 134 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included fibromyalgia (a chronic disorder characterized by widespread pain and other symptoms such as fatigue and muscle stiffness) and depression (a common and serious medical illness that negatively affects how a person feels, the way they think and act, causes feelings of sadness and/or a loss…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to respect a residents' right to personal privacy for one out of eight sampled residents (Resident 90) by failing to ensure the facility's case manager did not open Resident 90's mail. This deficient practice violated Resident 90's right to privacy and had the potential to cause psychosocial harm to Resident 90. Findings: During a review of Resident 90's admission Record, the admission record indicated Resident 90 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, group of chronic lung diseases that block airflow and make it harder to breathe air out of the lungs) and congestive heart failure (CHF, a chronic condition in which the heart doesn't pump blood as well as it should). During a review of Resident 90's History and Physical (H&P) dated 3/6/2024, the H&P indicated Resident 90 did the capacity to understand and make decisions. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and/or implement an individualized person-centered care plan (document helps nurses and other team care members organize aspect of resident care) with measurable objectives, timeframes, and interventions to meet the residents' needs addressing one out of eight sampled residents (Resident 134) suicidal ideations (Intrusive thoughts and a preoccupation with death and dying). This deficient practice had the potential to negatively affect the delivery of necessary care and services for Resident 134. Findings: During a review of Resident 134's admission Record, the admission record indicated Resident 134 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including fibromyalgia (a chronic disorder characterized by widespread pain and other symptoms such as fatigue and muscle stiffness) and depression (a common and serious medical illness that negatively affects how a person feels, the way they…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain appropriate grooming and personal hygiene for two of 12 sampled residents (Residents 88 and 222) by failing to keep the residents' nails clean and neat. This failure had the potential to result in negative impact on the residents' quality of life and self-esteem and had the potential for development of infection. Findings: a. During a review of Resident 88's admission Record (Face Sheet), the admission Record indicated Resident 88 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included but not limited to cellulitis of the left lower limb (skin infection that spreads rapidly), type 2 diabetes mellitus (a condition that results in too much sugar circulating in the blood), and cerebral infarction (also known as a stroke; refers to damage to the tissues in the brain due to a loss of oxygen to the area). During a review of Resident 88's Minimum Data Set (MDS, a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to assess and identify the potential hazard and resident's risk factors for falls for one of three sampled residents (Resident 36), by failing to complete a Post-Fall Assessment and conduct an Interdisciplinary Team (IDT, a group of healthcare professionals with various areas of expertise who work together towards the goals of the residents) meeting after Resident 36 had an unwitnessed fall. This failure had the potential for Resident 36's cause of fall to be undetermined and increased the potential for reoccurrence of future falls and injury. Findings: During a review of Resident 36's admission Record (Face Sheet), the admission Record indicated Resident 36 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included but not limited to cerebral infarction (also known as a stroke, refers to damage to the tissues in the brain due to a loss of oxygen to the area), metabolic encephalopathy (problem 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of two residents (Resident 621) were free from significant medication errors when Resident 621 received Potassium Chloride ER ([ER- Extended Release] a medication used to prevent or treat low potassium levels in the body) crushed and administered as a mixture with other medications, which was not in accordance with the manufacturer's specifications, and the facility's Policy & Procedure (P&P) titled, Medication Administration-General Guidelines, dated 5/2016 and/or as indicated on the form titled, Medications Not To Be Crushed, list dated 7/2015. These failures resulted in Resident 621 receiving non-crushable Potassium Chloride ER with other medications as crushed and administered as a mixture with the potential to result in drug incompatibilities, adverse reactions leading to changes in potassium levels, irritation, or ulceration to the gastrointestinal ([GI] organ system in human body that includes mouth, throat, esophagus,…

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 tortillas served during lunch time were served in accordance with a physician order for mechanical soft diet (a type of texture-modified diet for people who have difficulty chewing and swallowing) for one of three sampled residents (Resident 81). This failure had the potential to result in Resident 81 being unable to properly chew the tortilla that could result in Resident 81 choking. Findings: During a review of Resident 81's admission Record (Face Sheet), the admission Record indicated Resident 81 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (problem in the brain caused by chemical imbalances in the blood), type 2 diabetes mellitus (a condition that results in too much sugar circulating in the blood), and chronic obstructive pulmonary disease (COPD, a lung disease characterized by long-term poor airflow). 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 observation, interview, and record review, the facility failed to assess the need for modifications to the call light system for one out of eight sampled residents (Resident 124), who had difficulty activating the call light. This deficient practice had the potential to result in a delay in obtaining necessary care and services. Findings: During a review of Resident 124's admission Record, the admission record indicated Resident 124 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included respiratory failure (serious condition that makes it difficult to breathe) and blindness to one eye. During a review of Resident 124's History and Physical (H&P) dated 3/1/2024, the H&P indicated Resident 124 did not have the capacity to understand and make decisions. During a review of Resident 124's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 3/13/2024, the MDS indicated Resident 124's cognitive (mental action or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two out of three sampled residents (Resident 2 and Resident 3) were free from avoidable falls. As a result, this failure had the potential to cause a fracture (a complete or partial break of a bone) or head injury for Resident 2 and Resident 3. Findings: a. During a review of Resident 2 ' s admission Record, dated 2/5/2024, the admission record indicated Resident 2 was admitted to the facility on [DATE] with an admitting diagnosis of open-angle glaucoma (chronic, progressive, and irreversible optic nerve damage with loss of peripheral and central visual field loss which leads to blindness) of both eyes, muscle wasting and atrophy (loss of muscle mass), abnormalities of gait and mobility (does not walk or move normally), and generalized muscle weakness. The admission record further indicated Resident 2 had a history of falling, and a history of a traumatic fracture. During a review of Resident 2 ' s Minimum Data Set ([MDS] a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of four sampled residents (Resident 1 and 4) who had a physicians' orders to receive two liters of oxygen (O2) by a nasal cannula ([NC] a device used to deliver supplemental oxygen) instead of three liters of O2, per minute. This deficient practice had the potential to result in Resident 1 and r 4 receiving more oxygen than required amount of oxygen which can negatively impact their health. Findings: a. During a review of Resident 1's admission record, the admission record indicated Resident 1 was admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses including coronal virus ([COVID-19] a respiratory infection that causes difficulty breathing), allergic rhinitis (a disorder caused by allergy-causing substance, such as pollen, dust, and pet hair) and muscle weakness. During a review of Resident 1's history and physical (H&P) dated 7/24/2023, the H&P indicated Resident 1 had the capacity to understand 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 ensure one of four sampled residents (Resident 1) clinical record was maintained in accordance with accepted professional standard and practice, by not documenting activities of daily living (ADL) sheet correctly by Certified Nursing Assistant (CNA) This deficient practice can result in a lack of or a delay in communication between the staff and can interrupt provision of care/intervention to Resident 1. Findings: During a review of Resident 1's admission record, the admission record indicated Resident 1 was admitted on [DATE], and re-admitted on [DATE] with a diagnosis that included muscle weakness (full effort doesn't produce a normal muscle contraction or movement), other intervertebral disc degeneration, lumbar region (is defined as the wear and tear of lumbar intervertebral disc), and other symptoms and signs involving the musculoskeletal system(different musculoskeletal disorders, such as autoimmune disorders) During a review of Resident 1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a copy of medical records in a timely manner upon request from an authorized representative for one of three sampled residents (Resident 1). This deficient practice violated the rights of Resident 1's representative to obtain copy of the resident ' s medical records. Findings: During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted on [DATE] with a diagnosis that included dementia (confusion or mild cognitive [though process] impairment), muscle weakness (commonly due to lack of exercise, aging, muscle injury), and hypertension ([HTN], high blood pressure). During a review of Resident 1 ' s History and Physical (H&P) dated 6/12/2023, the H&P indicated Resident 1 had fluctuating capacity to understand and make medical decisions. During a review of Resident 1 ' s Minimum Data Set ([MDS], a standardized care assessment and care screening tool), dated 6/13/2023, the MDS indicated 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 interview and record review, the facility failed to ensure Licensed Staff had active/current Cardiopulmonary Resuscitation (CPR) cards (a credential to perform a medical procedure by repeated chest compressions, to restore blood circulation, heart function and breathing of a person who has suffered a life-threatening emergency) on file. This deficient practice had the potential of delayed provision of emergency care for 184 residents residing in the facility and for current 124 residents whose wishes were to have full treatment in a life-threatening situation. Findings: During an interview with the Director of Staff Development (DSD) on [DATE] at 8:04 a.m., the DSD stated that he was responsible for hiring, scheduling, training, and making sure all the staff in the facility can fulfil their duties by reminding staff of their annual physical checkups, tuberculosis (TB) test, skills competency, license or certificate renewals including CPR cards that expire every two years. 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 interview and record review, the facility failed to ensure that licensed nurses' records of Cardiopulmonary resuscitation ([CPR] a medical procedure involving repeated compression of a patient's chest, performed in an attempt to restore the blood circulation, and breathing of a person who has suffered cardiac arrest.) certification and skill sets necessary to care for residents in the facility were current or active. This deficient practice had the potential for 126 residents out of 184 residents in the facility whose wishes to have a full code (full support which includes cardiopulmonary resuscitation (CPR) status, if the patient has no heartbeat and/or is not breathing) during a life-threatening situation, not to get quality CPR. Findings: During an interview on [DATE] at 8:22 a.m. with the Director Staff Developer (DSD), DSD stated he was responsible for hiring employees, education of staff on policies and monitoring their performance, skills, and records; need to perform their job well. DSD 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. Ensure Dietary Aide (DA) 1 covered an open wound on the right wrist while working in the kitchen. This failure had the potential to result in transmitting possible infectious diseases to a resident population of 176 residents who were served food. 2. Ensure DA 1 was competent with testing the concentration of the sanitizer to ensure it was effective in sanitizing food contact surfaces. This failure had the potential to result in ineffectively sanitizing the food contact surfaces and dishes. Ineffective sanitizing of food contact surfaces and counters had the potential to result in food borne illness in a resident population of 176 residents who were served food. Findings: a. During a kitchen observation on 2/24/2022 at 9:30 a.m., DA 1 was observed washing dishes wearing gloves but noted to have an open wound on the right wrist, measuring approximately three (3) centimeter [(cm) unit of measurement) in length and 3cm in width, wound bed with 30 % (percentage) epithelialization (light pink with a shiny…

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

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage practices in the kitchen when: 1a. Foods were placed directly on the floor. 1b. Foods were not labeled with opened-on dates, nor received-on dates and food was left opened and uncovered in the storage bin. 1c. Foods were stored in bins, the refrigerator, and freezer without removing them from original packaging. Failed to ensure safe and sanitary food preparation practices when: 2a. Dietary staff did not check all the food temperatures prior to service of the meal. 2b. [NAME] 1 and Dietary Aide (DA) 2 did not wash their hands after changing their gloves during tray line and food handling. These failures had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to food borne illness for 176 of 184 medically compromised residents who received food from the kitchen. Findings: 1a. During a concurrent kitchen observation and interview with the Dietary Staff Supervisor (DSS) 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 interview and record review, the facility failed to ensure: a. Actual copies of staff COVID-19 (a highly contagious infection) vaccination (treatment with a vaccine [medication that provides protection against disease]) cards were kept on file. b. Their COVID-19 vaccine policy addressed a process by which staff may request an exemption (medical or religious or clinical contraindications from the vaccine) from vaccination requirements (required documentation for staff who request exemption). This deficiency had the potential to increase the risk of spreading COVID-19 to residents in the facility. Findings: a. During a concurrent interview with the facility's Infection Preventionist (IP) and record review of the facility staff vaccination list on 2/24/2022 at 9:19 a.m., IP confirmed that the data on the vaccination list were from visual confirmations of the staff's COVID vaccination status. IP stated the facility did not keep copies of all of staffs' COVID vaccination records. During the continued interview with the IP and record review of Office Staff (Office 1) and Licensed…

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 properly address 6 of 10 sampled residents' (Resident 100, 392, 388, 383, 95 and 67) wishes regarding end-of-life care (support and medical care given during the time surrounding residents death) as evidenced by: a. The facility failed to ensure Resident 95's advanced directives (legal documents that allow you to spell out your decisions about end-of-life care ahead of time) were in the physical chart. b. The facility failed to update Resident 100, 392, 388, 383's medical records to show documentation that advance directives were discussed and written information was provided to the residents and/or responsible parties. c. The facility failed to ensure Resident 67's Physician Orders for Life Sustaining Treatment ([POLST] written medical order from a licensed practitioner that gives residents with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness) was provided 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 failed to provide services that met professional standards for four sampled residents (173, 59, 142, and 11) by ensuring: a. Licensed Vocational Nurse (LVN) 3 failed to perform weekly skin assessments and follow-up with the physician regarding a wound for one of six sampled residents (Resident 173). b. Nursing staff failed to implement the physician's written orders to monitor orthostatic hypotension (low blood pressure) for three of five residents sampled (Residents 59, 142, and 11). These deficient practices resulted in the resident's physician not being informed of Resident 173's wound status, which could potentially lead to delay in care and decreased wound healing, and the potential to place Residents 142, 11, and 59 at risk of falls leading to injury. a. A review of Resident 173's admission Record (Face sheet), dated 2/25/22, indicated the resident was admitted to the facility on [DATE]. Resident 173's diagnoses included heart failure (condition 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 8 of 37 sampled residents (Residents 100, 386, 387, 139, 12, 388, 380, and 387) were provided care and services to maintain good grooming and personal hygiene by failing to: a. Ensure Residents 100, 386, and 387 nails were clean and neat. b. Ensure Residents 12, 139, 388, 380, and 387 were provided their scheduled showers. These deficient practices had the potential to result in a negative impact on the residents' quality of life and self-esteem. Findings: a. During a review of Resident 100's admission Record (Face Sheet), the Face Sheet indicated Resident 100 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 100's diagnoses included sepsis (a life-threatening organ dysfunction caused in response to infection), urinary tract infection ([UTI] bacteria that infects any part of your urinary system which can include kidneys, ureters, bladder and urethra), type 2 diabetes (high blood sugar). 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the resident's environment was free from potential accidental hazards by not maintaining and repairing the laminated wood flooring in Station 1. This deficient practice had the potential to cause injury for 184 residents, staff and visitors when ambulating (walking), or when utilizing wheelchairs, walkers, shower chair or gurneys for mobility. Findings: During an initial tour of the facility on 2/22/2022 at 10:00 a.m., the hallway floor at Station 1 was observed to have laminated wood flooring. Three laminated wood floor planks in between Rooms 101 to 107 was noted to have damaged edges, which were chipped, flaking and peeling creating an uneven, rough floor. During an observation on 2/25/2022 at 8:00 a.m., noted at least one plank of laminated wood floor at the hallway near the entryway to room [ROOM NUMBER] to have raised corners approximately an eighth of an inch high creating sharp edges and an uneven floor. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Follow physician orders for one of eight residents (Resident 156) with an indwelling urinary catheter (used to drain urine from your bladder into a bag outside the body). 2. Ensure physician orders were received for one of one residents (Resident 156) using oxygen. These deficient practices had the potential for health complications associated with lack of guidance from the physician, delay in assessment, delay of necessary services and treatment, poor continuity of care and follow-up on the resident's status. Findings: a. A review of Resident 156's admission Records indicated Resident 156 was admitted to the facility on [DATE]. Resident 156's diagnoses included urinary tract infection ([UTI] an infection in any part of urinary system [kidneys, ureters, bladder and urethra]), diabetes mellitus (high blood sugar), major depressive disorder (persistent and intense feelings of sadness for extended periods), pneumonia (an infection of one…

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

Based on interview and record review, the facility failed to ensure nursing staff received and demonstrated competency skills checks related to caring for the facility residents diagnosed with dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment). This deficient practice had the potential for staff not providing quality care tailored to dementia residents, due to lack of knowledge. Findings: During an interview on 2/25/2022 at 8:22 a.m., with the Director Staff Developer (DSD), DSD stated he was responsible for the education of staff on policies, and monitoring the performance skills and records, so staff can perform their jobs well. DSD further stated that he did the dementia training upon hire and yearly thereafter, DSD said that the schedule for training is usually quarterly (every three months) to meet the staff training/education requirements. During a concurrent interview and record review on 2/25/2022 at 8:30 a.m. with the DSD, DSD stated that Certified Nurse Assistant 2's (CNA 2's) personnel file did…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain adequate water pressure for six of 32 sampled residents (Residents 11, 20, 60, 61, 88, and 131). This deficient practice had the potential to result in inadequate hand washing and increase the risk of spreading bacteria and infections due to the low water pressure. Findings: During a concurrent observation and interview on 2/23/2022 at 3:40 p.m. with Maintenance Supervisor (MS), in Resident 60, 88, and Resident 131's room (room [ROOM NUMBER]) and Resident 11, 20, and Resident 61's room (room [ROOM NUMBER]) the sink water had a low-pressure flow for both hot and cold water in room [ROOM NUMBER] and low-pressure flow for cold water in room [ROOM NUMBER]. MS stated, The water pressure is not right, and it is not supposed to be this way, somebody must have messed with it and shut the water off, I don't know, I will go fix it right now. During a review of Resident 11's admission Record (Face Sheet), the Face Sheet indicated Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure four of seven sampled residents (Residents 90, 101,105, and 156) were treated with respect to promote dignity by failing to serve Residents 101 and 105 meals at the same time as their roommates. This deficient practice had the potential to cause psychosocial harm or decline to the residents, and violated the residents' right to be treated with dignity. Findings: a. During a review of Resident 101's admission Record, the admission Record indicated Resident 101 was admitted to the facility on [DATE]. Resident 101's diagnoses included hemiplegia (severe weakness on one side of the body), hemiparesis (weakness on one side of the body), dysphagia (difficulty swallowing), and contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) on both ankles, knees, and hands. During a review of Resident 101's Minimum Data Set (MDS-a standardized assessment and care planning tool)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide reasonable accommodations for resident needs and preferences for thirteen (13) of twenty-two (22) sampled residents (Residents 55, 62, 70, 65, 77, 167, 378, 12, 137, 139, 388, 380, and 387) by failing to: 1. Ensure Residents 55, 62, 70, 65, 77, 167, and 378 have their call lights within reach. 2. Ensure Residents 12, 137, 139, 388, 380, and 387 were provided their scheduled showers. These deficient practices had the potential to result in delayed provision of quality care and negatively impact the psychosocial well-being of residents. Findings: 1. During a review of Resident 55's admission Record (Face Sheet), the Face Sheet indicated Resident 55 was admitted to the facility on [DATE] with diagnosis including post COVID-19 (previous infection of Coronavirus), cough (expel air from the lungs with a sudden sharp sound), and fatigue (extreme tiredness due to mental or physical effort or illness). During a review of Resident 55's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a comprehensive assessment (a detailed assessment and care planning process due to or after a significant change in health status assessment [SCSA] for the minimum data set ([MDS] standardized assessment and care screening tool) for one of two sampled residents (Resident 637). This deficient practice had the potential to result in any new concerns or needs in Resident 637's health status not being addressed or monitored. Findings: During a record review of Resident 637's admission Record (face sheet) printed 2/11/2022, the face sheet indicated the facility admitted Resident 637 on 7/27/2021. Resident 637's diagnoses included COVID-19 (a highly contagious infection), pneumonia (infection of the lungs), chronic obstructive pulmonary disease ([COPD] lung problem making it difficult to breath), gastroesophageal reflux disease (stomach acid goes back into the tube that connects the stomach to the mouth), paranoid schizophrenia (a mental disorder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure: a. Resident 67 assessment was reviewed, updated, and changed to reflect the significant change identified by Interdisciplinary team ([IDT] a group of experts from several different fields working together towards a common goal for a resident) conducted. b. Resident 101's Braden assessment (an assessment tool for predicting the risk of pressure ulcer [injury to skin and underlying tissue resulting from prolonged pressure on the skin, that often develop on skin that covers bony areas of the body, such as the heels, ankles, hips and tailbone] based on the total scores given in the categories sensory perception, moisture, activity, mobility, nutrition, and friction and shear) and pain assessment was updated and reviewed after a change of condition. c. Resident 173's weekly wound assessment was completed to monitor progress of the wound. These deficient practices had the potential to result in delay in the necessary medical care and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop an individualized person-centered plan of care with measurable objectives, timeframe, and interventions to meet the residents' needs for two of six sampled residents (Residents 36 and 149) by failing to: 1. Develop an individualized/person-centered care plan with goals and interventions to address Resident 36's use of side rails (barrier attached to the side of a bed). 2. Develop an individualized/person-centered care plan with goals and interventions to address Resident 149's risk for elopement (resident aware that he/she is not permitted to leave but does so with intent) tendencies. These deficient practices had the potential to result in a delay of nursing care, interventions, and services for Resident 36 and 149. Findings: a. During a review of Resident 36's admission Record information, the admission record indicated Resident 36 was admitted to the facility on [DATE], with diagnoses that included acute gastritis (inflammation…

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 update one of two sampled resident's (Resident 637) care plans after a significant change in status assessment (SCSA) for the minimum data set ([MDS] standardized assessment and care screening tool) was completed on 2/4/2022. This deficient practice had the potential to result in a poor execution of relevant nursing care plans for Resident 637 that could decrease the resident's physical and psychosocial well-being. Findings: During a record review of the Resident 637's admission record (face sheet) printed 2/11/2022, the face sheet indicated the facility admitted Resident 637 on 7/27/2021. Resident 637's diagnoses included COVID-19 (highly contagious infection), pneumonia (infection of the lungs), chronic obstructive pulmonary disease (lung problem making it difficult to breath), gastroesophageal reflux disease (stomach acid goes back into the tube that connects the stomach to the mouth), paranoid schizophrenia (a mental disorder causing the resident 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 failed to provide services that met professional standards of care for four of four sampled residents (173, 59, 142, and 11) when: a. Licensed Vocational Nurse (LVN 3) failed to perform the weekly skin assessments and follow-up with physician regarding wound for one out six sampled residents (Resident 173). b. Nursing staff failed to implement the physician's written orders to monitor orthostatic hypotension (low blood pressure [low blood pressure is when the heart is unable to pump enough blood] when you stand up from a sitting or lying position) for three of four sampled residents (Residents 59, 142, and 11). These deficient practices resulted in the physician not being aware of Resident 173's wound status, which could potentially lead to delay in care and decreased wound healing and the potential to place Residents 142, 11, and 59 at risk of falling and leading to injury. Findings: a. During a review of Resident 173's admission record, dated 2/25/2022, the record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident was evaluated by the facility's Registered Dietician (RD) timely to manage a facility acquired pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) for one of 2 sampled residents (Resident 101). This deficient practice had the potential to delay provision of necessary care and services that could help in wound healing or prevent the pressure ulcer from getting worse. Findings: During a review of Resident 101's admission Record, the admission record indicated Resident 101 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (paralysis [inability to move] on one side of the body), hemiparesis (weakness on one side of the body), dysphagia (difficulty swallowing), and contracture on both ankles, knees, and hands. A review of Resident 101's Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 08/25/2021, indicated Resident 101's cognition…

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 residents (Resident 479) was positioned correctly for enteral feeding ([tube feeding] a way of delivering nutrition directly to the stomach through a plastic tube) when Resident 479's head was not elevated at least 30 degrees while the tube feeding was running. The deficiency had the potential to result in Resident 479's aspiration (when food, saliva, liquids, or vomit is breathed into airways leading to the lungs instead of going into the stomach) that can lead to pneumonia (infection of the lungs) or even death. Findings: During a review of Resident 479's discharge summary from the acute care facility, dated 2/21/2022, the discharge summary indicated Resident 479's diagnoses included respiratory failure (serious condition in which blood does not have enough oxygen), recent COVID-19 (highly contagious respiratory infection) pneumonia, dementia (loss of cognitive function-- thinking, remembering, and reasoning-- to such extent that interferes with daily life), 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to obtain an order for the use of oxygen therapy in accordance with professional standards for one of one sampled resident (Resident 156). This deficient practice had the potential for health complications associated with lack of guidance from the physician, delay in assessment, treatment plan and poor continuity of care and follow-up on the resident's status. Findings: A review of Resident 156's admission Records indicated the resident was admitted to the facility on [DATE]. Resident 156's diagnoses included diabetes mellitus (high blood sugar), major depressive disorder (persistent and intense feelings of sadness for extended periods), pneumonia (an infection of one or both of the lungs caused by bacteria, viruses, or fungi), chronic obstructive pulmonary disease ([COPD] a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and asthma (a respiratory condition marked by spasms in the bronchi of the lungs,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medications brought into the facility from home, were accounted for and stored for safekeeping for one of one resident (Resident 478). These deficient practices placed Resident 478 at risk to receive medication that had not been reviewed by the physician, verified and accounted for due to improper storage, possibly leading to health complications resulting in hospitalization or death. Findings: During a review of Resident 478's admission Record (face sheet), the face sheet indicated the resident was admitted to the facility on [DATE]. Resident 478's diagnoses included diabetes type 2 (abnormal blood sugar), hypertension ([HTN] condition present when blood flows through the blood vessels with a force greater than normal), hyperlipemia ([HLD] a condition that causes the levels of certain bad fats, or lipids, to be too high in the blood), dysphagia (difficulty swallowing), hemiplegia (total or partial paralysis [inability to move] of…

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

Based on observation, interview, and record review, the facility failed to ensure a face shield (personal protective equipment used for protection of the eyes, nose, mouth from splashes, sprays, and spatter of body fluids) was discarded appropriately. This deficient practice had the potential to place staff and residents at risk for cross-contamination. Findings: During an observation on 2/24/22 at 11:37 a.m., one face shield was observed on top of the desk at Nursing Station 1 unattended. During an interview on 2/24/22 at 11:45 a.m. with the Director of Nursing (DON), the DON stated personal protective equipment (PPE) was not to be stored or reused because there was enough PPE provided by the facility. The DON stated if staff go on break, they are to discard the PPE, including the face shield and obtain a new one. The DON stated the face shield should not be sitting at the nursing station and was unsure whether it was clean or not, but stated it was already exposed and could be contaminated. During an interview on 2/25/22 at 9:59 a.m. with Infection Preventionist Nurse ([IP] nurse…

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 the interview and record review, the facility failed to implement an Antibiotic Stewardship Program ([ASP] a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events [unwanted, uncomfortable, or dangerous effects which may impair a resident's ability to function at their highest possible level of physical, mental, and psychosocial well-being) related to antibiotic use including, but not limited to developing resistance to infections], associated with antibiotic use) for two of three sampled residents (Resident 140 and 147). This deficient practice had the potential for the resident to receive an inappropriate antibiotic and develop antibiotic resistance (when infection causing bacteria develop the ability to defeat the antibiotic designed to kill them). Findings: a. During a review of Resident 140's admission Record, the admission information indicated the resident was admitted on [DATE], with diagnoses not limited to urinary tract infection…

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 call lights were in safe operating condition with wires not being exposed for one of 32 sampled residents (Resident 381). This deficient practice had the potential for a fire due to exposed wires, placing Resident 381 at risk for burns. Findings: During a review of Resident 381's admission Record (Face Sheet), the Face Sheet indicated Resident 381 was admitted to the facility on [DATE] with diagnosis including urinary tract infection (an infection in any part of the urinary system, which includes kidneys, bladder, ureters, and urethra), atrial fibrillation (an irregular and often very rapid heart rhythm that occurs when the electrical signals to the two upper chambers of the heart fire rapidly at the same time), and essential (primary) hypertension (abnormally high blood pressure that is often due to obesity, family history, and an unhealthy diet). During a review of Resident 381's Nursing admission Screening/History (NASH), 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.