Lakewood Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure physician's orders were followed for two of five sampled residents (Resident 18 and Resident 36). This deficient practice placed Residents 18 and 36 at risk for complications due to not receiving their medications, supplements, and not being monitored for signs and symptoms of COVID-19. Findings: 1. During a review of Resident 36's admission Record, the admission Record indicated Resident 36 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 36's diagnoses included hypertension (high blood pressure) and schizophrenia (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 36's History and Physical (H&P), dated 9/24/2025, the H&P indicated Resident 36 did not have the capacity to understand and make decisions due to paranoid (feelings of persecution, anxiety, and a strong sense of threat) schizophrenia. During a review of Resident 36'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 remove and separate from current residents' medications 14 discontinued orders for controlled substances (drugs that are regulated by the government because they can be abused or cause addiction) as required by the facility's policy and procedures (P&P), titled, Discontinued Medications and Controlled Medication Storage, affecting nine residents (Residents 24, 29, 45, 59, 63, 127, 237, 257, and 288) in three of five inspected medication carts ([Medcart] (West Station Medcart 1, [NAME] Station Medcart 2, and South Station Medcart 1). This deficient practices increased the risk that Residents 24, 29, 59, 63, 127, 237, 257, and 288, may have received controlled medications without physician orders, more often than prescribed possibly resulting in serious health complications, hospitalization. The availability of discharged Resident 45's controlled medication increased the risk of medication errors, misuse and diversion (when medications are…

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

Based on observation, interview, and record review, the facility failed to ensure kitchen staff were routinely trained and demonstrated competency skills when: a. [NAME] 2 did not follow the recipe when preparing puree (foods that are smooth and pudding like consistency) stir fry vegetables. b. [NAME] 1 did not prepare soft-bite size chopped (foods that can be mashed or broken down with pressure from fork, spoon or chopstick and bite-sized pieces no larger than 1.5 cm [cm., unit of measurement]) stir-fry vegetables in the right size. These deficient practices had the potential to result in 134 of 295 residents on puree/ International Dysphagia Diet Initiative (IDDSI, a framework for categorizing food textures and drink thickness) level 4 and soft bite sized IDDSI level 6 diets at risk of unplanned weight loss, a consequence of difficulty eating and poor food intake, getting food from the kitchen. 1. During a review of the facility's daily cook's spreadsheet (a sheet that contains each diet and what food and portions each diet would get) titled Winter Menus, dated 12/16/2025, the…

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

Based on observation, interview, and record review, the facility failed to prepare food by methods that conserved appearance and temperature for lunch when: 1. Cinnamon apricot was at 64.9 degrees Fahrenheit ( F, a degree of temperature), country baked beans 103.1 F, roast beef melt on soft roll 104 F, lettuce and tomatoes 92.3 F for regular diet (diet with no restrictions) and soft bite sandwich at 113 F, beans at 110 F, onion soup 106.7 F and milk 47.3 F for soft bite-sized diet (food that are soft and chopped to 1.5 centimeters [cm, a unit of measurement]). 2. Plate presentation for double portion servings and extra food was overflowing and tortilla was touching the beans. 3. The soft bite sized stir-fried vegetables were mushy and mashed. These deficient practices had the potential to result in 280 of 281 facility residents at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen.Findings: 1. During a review of the facility's daily cook's spreadsheet (a sheet that contains each diet and what food and portions each diet would get) titled…

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

Based on observation, interview and record review, the facility failed to prepare food in a form designed to meet individual needs for 38 of 295 residents on puree/IDDSI level 4 diet and 96 of 295 residents on soft bite-sized/IDDSI level 6 diet when: a. Residents on puree diet (foods that are smooth with pudding like consistency)/International Dysphagia Diet Initiative ([IDDSI] a framework for categorizing food textures and drink thickness) level four (4) received thick puree fried rice and thick Chinese roasted chicken and watery puree salad. b. Resident on IDDSI Level 6 Soft (foods that can be mashed or broken down with pressure from fork, spoon or chopstick and bite-sized pieces no larger than 1.5 cm [cm., unit of measurement]) in size for oral processing) and bite-sized stir-fried vegetables were not chopped into pieces no larger than 1.5 centimeters x 1.5 cm. These deficient practices had a potential to result in difficulty eating, coughing, choking (to keep from breathing the normal way) and death for 38 of 295 residents on puree/IDDSI level 4 diet and 96 of 295 residents on…

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

Based on observation, interview, and record review, the facility failed to ensure food safety practices and sanitary food storage and food preparation practices when: 1. The refrigerator temperature log indicated temperature at 42 degrees Fahrenheit ( F, a scale of temperature) on 12/10/2025 and freezer temperature log indicated temperature of 10 F on 12/3/2025 and 12/10/2025. 2. Three (3) dented canned foods were stored alongside non-dented canned foods in the dry storage area. 3. The Dietary Supervisor's (DS) was wearing a spiral elastic bracelet touched the plates used in tray line (an area where foods were assembled from the steamtable to resident's plate). 4. Dietary Aide (DA) 1 wore a gold ring with rock while preparing and serving food in the tray line. 5. Ice machine gasket was torn. 6. Two (2) plastic food storage containers on the kitchen shelf had tape and sticker residues. 7. Pots and pans were stacked wet and were not air dried in the storage area. 8. Three (3) cutting boards had scratches. These failures had the potential to result in harmful bacterial growth and cross…

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

Based on observation, interview, and record review, the facility failed to meet the required room size measurement of 80 square feet ([sq. ft.])- a unit of measurement) of room space per resident in rooms with multiple residents. This deficient practice could potentially not provide residents with privacy and could potentially affect residents' health and safety.Findings: During a review of the facility's Room Waiver Request Letter, dated 8/6/2025, the Room Waiver Letter indicated the following rooms did not meet the 80 sq. ft. of space per resident:Room location # of beds Sq. Ft Required Sq. Ft.1. ACU-1A 4 310 3202. ACU-3A 4 310 320 3. ACU-4A 4 310 3204. ACU-4B 2 154 1605. ACU-5B 2 152 1606. ACU-6A 4 310 3207. ACU-7A 4 310 3208. ACU-8A 4 310 320 9. S7 2 141 160 During observations made throughout the course of the survey from 12/15/2025 to 12/18/2025, there were no adverse effects that pertained to the residents' care provided by the facility staff, residents' privacy, health, and safety related to the provided living space of less than 80 sq. ft. per resident. During a concurrent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure translator services or a communication board were provided to two of three sampled residents (Resident 155 and Resident 159). This deficient practice prevented staff from being able to respect Resident 155's and 159's preference to communicate in their respective preferred languages, and to be aware of the care and treatments they were receiving. Cross reference: F-tag F941Findings: 1. During a review of Resident 155's admission Record, the admission Record indicated Resident 155 was initially admitted to the facility on [DATE] and most recently readmitted on [DATE]. Resident 155's diagnoses included metabolic encephalopathy (a brain dysfunction caused by a chemical imbalance or underlying medical issue), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), inability to move the right side of her body, lack of coordination, abnormalities of gait and mobility, 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 ensure one of three sampled residents (Resident 104) was able to exercise her choice to smoke. This deficient practice resulted in a missed or delayed smoking opportunity causing frustration for Resident 104, and had the potential to cause emotional distress. Findings:During a review of Resident 104's admission Record (Face Sheet), the admission Record indicated Resident 104 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 104's diagnoses included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (ongoing feelings of worry or fear that can interfere with daily living), metabolic encephalopathy (any disease, damage, or disorder that affects the brain's function), paranoid schizophrenia (a mental illness that is characterized by disturbances in thought), schizoaffective disorder (a mental illness that can affect thoughts, mood,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident shower rooms and restrooms were maintained in clean, sanitary, and homelike conditions when the grout in the showers and restrooms of Cottages 4, 5, 6, and 7 were observed to have a visible black to brown-colored substance and brown staining, and mosquitoes and gnats were observed along the shower walls, for two of eight sampled residents (Residents 48 and 74). This deficient practice resulted in the reports of discomfort and disgust by Residents 48 and 74, and had the potential to increase the risk of infection, discomfort and diminished quality of life for the residents residing in Cottages 4, 5, 6, and 7.Findings: a. During a review of Resident 74's admission Record, the admission Record indicated Resident 74 was initially admitted to the facility on [DATE]. Resident 74's diagnoses included anxiety (a feeling of uneasiness), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and 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 prevent physical abuse for two out of eight sampled residents (Resident 110 and Resident 45) when the facility failed to ensure one-to-one supervision (a type of supervision that includes a nurse or qualified personnel to be present with a patient at all times to prevent harm) was rendered for Resident 45 who had documented episodes of impulsive, physically aggressive behaviors. This deficient practice resulted in Resident 45 punching Resident 110 on the right side of his nose while he slept at approximately 2:55 a.m. on 12/5/2025.Findings: a. During a review of Resident 45's admission Record, the admission Record indicated Resident 45 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 45's diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), anxiety (a feeling of uneasiness), chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty 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 complete an accurate Minimum Data Set (MDS, a resident assessment tool) assessment addressing the oral and/dental status for one of six sampled residents (Resident 72). This deficient practice resulted in incorrect data transmitted to the Centers for Medicare and Medicaid Services (CMS) regarding Resident 72's missing natural teeth and had the potential to negatively affect resident care plan and delivery of necessary care and services. Findings: During a review of Resident 72's admission Record, the admission Record indicated Resident 72 was admitted to the facility on [DATE]. Resident 72's diagnoses included dysphagia (difficulty swallowing), schizophrenia (a mental illness that is characterized by disturbances in thought), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 72'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 develop an individualized resident centered care plan addressing a language barrier and broken, missing teeth for two of 12 sampled residents (Resident 32 and Resident 13) This deficient practice had the potential for Residents 32 and 13 to not receive the care required for the residents to reach their highest practicable physical, mental and psychosocial well-being.Findings: a. During a review of Resident 32's admission Record, the admission Record indicated the facility admitted Resident 32 on 08/21/2013 and re-admitted Resident 32 on 09/26/2018. Resident 32's diagnoses included schizophrenia (a serious mental health condition that affects how people think, feel and behave), hypertension (high blood pressure), dorsalgia (back pain, with a wide range of discomfort or pain experienced in the back area), and presbyopia (a loss of the eye's ability to focus on close-up objects). During a review of Resident 32'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 implement dietary recommendations for one of three sampled residents (Resident 7) with nutrition concerns by failing to perform weekly weights and accurately document Resident 7's intake for lunch on 12/16/2025. This deficient practice had the potential to result in continued, unmonitored weight loss. During a review of Resident 7's admission Record, the admission Record indicated the facility admitted Resident 7 on 11/12/2025. Resident 7's diagnoses included general muscle weakness, hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) following other cerebral vascular disease (loss of blood flow to a part of the brain) affecting the left non-dominant side, and unspecified psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a review of Resident 7's Minimum Data Set ([MDS] a resident assessment tool), dated 11/12/2025, 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 observation, interview, and record review, the facility failed to ensure that the medication error rate was less than five percent (%). Six medication errors out of a total of twenty-five opportunities contributed to an overall medication error rate of twenty-four percent (%), for one of seven sampled residents (Resident 53) observed for medication administration (med pass) on one of three nursing stations (East Station at Medication Cart 2) reviewed. The medication errors noted were as follows:1. Failure to assess Resident 53's heart rate (HR - how fast the heart beats, measured by taking the pulse, which is the throbbing of the arteries as blood is pushed through them) prior to administering the following medications: Carvedilol (medication used to treat hypertension [HTN - high blood pressure]) Furosemide (medication that helps the body get rid of extra fluid by making the kidneys produce more urine) Sacubitril-Valsartan (medication used mainly for heart failure [when the heart is not pumping blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of seven residents (Resident 53) was free of a significant medication errors. The facility failed to administer carvedilol (medication used to treat hypertension [HTN- high blood pressure]), furosemide (a diuretic medication that helps the body get rid of extra fluid by making the kidneys produce more urine), sacubitril-valsartan (medication used mainly for heart failure [when the heart is not pumping blood as well as it should]), and spironolactone (medication that helps the body get rid of extra fluid without losing too much potassium [a mineral in the blood that helps the heart beat normally, the muscles move, and the nerves work]) in accordance with physician's orders, with a parameter to check the heart rate (HR - how fast the heart beats, measured by taking the pulse, which is the throbbing of the arteries as blood is pushed through them) as a condition to give or hold blood pressure medications, manufacturer'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 ensure staff transcribed the verbal order for Ativan (used to treat anxiety) for one of one sampled resident (Resident 64), who was on Hospice (compassionate care for people who are near the end of life provided at the person's home or within a health care facility). This deficient practice placed Resident 64 at risk for not receiving the prescribed dose.Findings: During a review of Resident 64's admission Record, the admission Record indicated Resident 64 was admitted to the facility on [DATE] and re-admitted [DATE]. Resident 64's diagnoses included encounter for palliative care (a specialized, face-to-face medical visit aimed at providing relief from the symptoms, pain, and physical/psychosocial stress of a serious illness), repeated falls and history of falling, and Alzheimer's dementia (a disease characterized by a progressive decline in mental abilities). During a review of Resident 64's History and Physical (H&P), dated 12/19/2025, the H&P…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement enhanced barrier precautions (EBP - infection control measures required to reduce the risk of infection transmission to residents by limiting the spread of infectious organisms during high-contact care) for two of five sampled residents (Resident 300 and Resident 28). This deficient practice placed Resident 300 and Resident 28 at risk for infection. Findings: a. During a review of Resident 300's admission Record, dated 12/17/2025, the admission Record indicated Resident 300 was admitted to the facility on [DATE]. Resident 300's diagnoses included urinary tract infection (UTI - an infection in the bladder/urinary tract), benign prostatic hyperplasia (BPH - enlarged prostate) with lower urinary tract symptoms, chronic kidney disease (CKD - a long-term condition in which the kidneys do not work as well as they should to filter waste and excess fluid from the blood) and schizophrenia (a mental illness that is characterized by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a privacy curtain to assure full visual privacy for one of 35 sampled residents (Resident 188). This deficient practice had the potential for Resident 188 to be exposed during care. During a review of Resident 188's admission Record, the admission Record indicated Resident 188 was initially admitted to the facility on [DATE]. Resident 188's diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought), Type 2 diabetes mellitus (disorder characterized by difficulty in blood sugar control and poor wound healing), contracture (a stiffening/shortening at any joint that reduces the joint's range of motion) of multiple muscle sites including both ankles and knees. During a review of Resident 188's Minimum Data Set ([MDS] a mandated resident assessment tool), dated 9/25/2025, the MDS indicated Resident 188 had the ability to express ideas and wants, understood verbal content, had clear speech, 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 and interview, the facility did not provide a working call light to one of eight sampled residents (Resident 240). This deficient practice had the potential to cause a delay or the inability in obtaining necessary care and services for Resident 240. Findings: During an observation 12/15/2025 at 1:18 p.m., in Resident 240 room, observed Resident 240's call light button attached to the bed. The call light cord was not attached to the call light system on the wall. During a review of Resident 240's admission Record, the admission Record indicated Resident 240 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 240's diagnoses included schizophrenia (a mental illness that can affect thoughts, mood, and behavior) and epilepsy (chronic brain disorder, causes movements and sensations, like staring spells, confusion, or violent jerking). During a review of Resident 240s History and Physical (H&P) dated 7/13/2025, the H&P indicated Resident 240 did not have the mental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff were aware of and/or trained on the location and/or use of the communication board and language translation line for residents with language barriers. This deficient practice had the potential to impede effective communication between staff and patients with limited English proficiency or communication barriers, which could result in unmet resident needs, delays in care, and compromised resident safety. Cross reference: F-tag F558Findings: 1. During an interview on 12/17/2025 at 10:25 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was not aware of any available translator services and stated she had never been trained to use translator services. During an interview on 12/17/2025 at 10:35 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she had worked in the facility for the last three years and the facility did not have translator services, and she had not been trained to use any. During an interview on 12/17/2025 at 11:29 a.m., with CNA 3, CNA 3 stated she had not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the licensed nurse failed to document the monitoring of signs and symptoms of infection and the amount of urine output, for one of three residents (Resident 1), on the Medication Administration Record on two different shifts in the month of February 2025. This deficient practice had the potential to result in lack of communication between staff and delay and interrupt the provision of care needed to maintain the residents' highest practicable, physical, mental, and psychosocial well-being. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), acute kidney failure (when the kidneys suddenly stop working properly), and malignant neoplasm (cancer) of the prostate (a small gland in men that helped make some of the fluid in semen).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 comprehensive care plan was developed or implemented for one out of three sampled residents (Resident 1) for oxygen administration (medical treatment that delivers oxygen at a concentration higher than room air). This deficient practice resulted in no care plan being created for Resident 1's oxygen administration, which could potentially cause a delay in care and negatively affect the delivery of care. Findings:During a review of Resident 1's admission Record, dated 8/26/2025, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 1's History and Physical (H&P) dated 5/6/2025, the H&P indicated Resident 1 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 administer oxygen safely for one out of three sampled residents (Resident 1) by failing to ensure: 1. Resident 1's nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) was dated with an open date; and2. Resident 1 received oxygen according to doctor's order. These deficient practices had the potential to cause Resident 1 to have lung damage and increased the risk for Resident 1 to develop a respiratory infection.Findings:During an observation on 8/26/2025 at 12:00 p.m. in Resident 1's room, Resident 1 received oxygen at five (5) liters per minute ([LPM] a unit that expresses flow rate). During an observation on 8/27/2025 at 10:09 a.m. in Resident 1's room, Resident 1 received oxygen at three (3) LPM. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure non-pharmacological interventions (NPIs- treatments that do not involve medications) were documented prior to the administration of Ativan (antianxiety medication used to treat anxiety which is the feeling of fear, dread, and uneasiness) for one of six sampled Residents (Resident 5).This deficient practice had the potential to result in Resident 5's cause of anxiety induced behaviors being unaddressed being managed only with medication.Findings:During a review of Resident 5's admission Record (Face Sheet), the Face Sheet indicated Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included anxiety disorder, schizophrenia (a mental illness that is characterized by disturbances in thought), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 5's Minimum Data Set…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow the physician's order for one of three sampled residents (Resident 5), who had an order for one-to-one monitoring ([1:1] assigning a dedicated staff member to continuously observe and monitor a single resident to ensure their safety and well-being).This failure placed the resident at risk of not receiving the care and services necessary to maintain the residents' highest practicable physical, mental and psychosocial well-being.Findings:During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 5's diagnoses included polyarthritis (a medical condition characterized by inflammation and pain in multiple joints) and unspecified dementia (a progressive state of decline in mental abilities), unspecified severity with other behavioral disturbance.During a review of Resident 5's Minimum Data Set ([MDS], a resident assessment 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 interview and record review, the facility failed to implement a care plan intervention to document wandering behavior (a person wandering moving from one place to place without a clear or immediate purpose) for one of seven sampled residents (Resident 1). This deficient practice resulted in Resident 1 leaving the facility unnoticed.Findings: During a review of Resident 1's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought), type 2 diabetes mellitus without complications ([DM] - a disorder characterized by difficulty in blood sugar control and poor wound healing), and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 1's History and Physical (H&P), dated 3/5/2025, the H&P 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 one of seven sampled residents (Resident 1) did not elope (leave the facility unsupervised) by failing to:1. Conduct regular inspection of the facility's exterior gate.2. Document Resident 1's wandering behavior episode as indicated in the care plan.This deficient practice resulted in Resident 1 leaving the facility unnoticed on 7/14/2025. Findings: During a review of Resident 1's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought), type 2 diabetes mellitus without complications ([DM] - a disorder characterized by difficulty in blood sugar control and poor wound healing), and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 1's History…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 notify one of seven sampled residents' (Resident 6) Responsible Party (RP) 1 of Resident 6's abuse allegation with another resident.This deficient practice resulted in RP 1 being unaware of Resident 6's wellbeing and of the facility's interventions to keep Resident 6 safe.Findings:During a review of Resident 6's admission Record (Face Sheet), the Face Sheet indicated Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (persistent and excessive worry that interferes with daily activities). The Face Sheet indicated Resident 6 was self-responsible and RP 1 was Resident 6's first emergency contact.During a review of Resident 6's Minimum Data Set (MDS- a federally mandated resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect one of three sampled resident's (Resident 6) right to be free from physical abuse by another resident (Resident 7). This deficient practice had the potential for Resident 6 experiencing further abuse from Resident 7.Findings:a. During a review of Resident 6's admission Record (Face Sheet), the Face Sheet indicated Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (persistent and excessive worry that interferes with daily activities).During a review of Resident 6's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 4/10/2025, the MDS indicated Resident 6's cognition (process of thinking) was moderately impaired. The MDS indicated Resident 6…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 3) was treated with dignity and respect by Certified Nursing Assistant (CNA) 1 during care. This deficient practice resulted in Resident 3 feeling unvalued or respected and had the potential to negatively affect the resident's sense of self-esteem and self-worth. Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses which included schizophrenia (a mental illness that is characterized by disturbances in thought), hypertension ([HTN]- high blood pressure), and dysphagia (difficulty swallowing). During a review of Resident 3's Minimum Data Set ([MDS] - a resident assessment tool), dated 5/28/2025, the MDS indicated Resident 3's cognition (ability to think, remember, and reason) was moderately impaired. The MDS indicated Resident 3 was dependent (helper does all the effort) on staff for activities of daily…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one of three sampled residents (Resident 2) comprehensive care plan and interventions after a new order from the neurologist (a medical doctor who specializes in the diagnoses, treatment of disorders affecting the brain, and nervous system) which indicated the resident should avoid smoking due to medical risks. This deficient practice had the potential to result in Resident 2's ineffective care, treatment and services which could lead to increased risk in the resident's medical condition due to continued smoking. Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included dementia (a progressive state of decline in mental abilities), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), major depressive disorder (a mood disorder that causes a persistent feeling…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care and services in accordance with professional standards of practice for one of three sampled residents (Resident 2) by failing to: 1. Ensure implementation of physician's orders for dental and podiatry services for Resident 2. 2. Clarify a neurologists' (a medical doctor who specializes in the diagnoses, treatment of disorders affecting the brain, and nervous system) order for drug testing for Resident 2. This deficient practice resulted in Resident 2 not receiving services and treatments as ordered by the physician and had the potential to place the resident at risk for unmanaged health concerns. Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia (a progressive state of decline in mental abilities), schizoaffective disorder (a mental illness that can affect thoughts, mood, 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 implement the physician's orders for one of six sampled residents (Resident 9), who had orders to administer Hydrocortisone cream (a medication used to reduce pain, itching, and swelling because of the body's immune response) for dermatitis (skin inflammation, causing redness, itching, blistering or scaling) and for a Dermatologist (physician who specializes in treating the skin) consultation. This failure had the potential to lead to worsening of Resident 9's skin condition and placed the resident at risk for discomfort and hospitalization. Findings: During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 9's diagnoses included encephalopathy (damage or disease that affects the brain) and cellulitis (a skin infection that causes swelling and redness) of the left and right lower limbs (arm and leg).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an environment free of accident and hazards for two of the four sampled residents (Resident 1 and Resident 2), by failing to ensure: 1.Housekeeping (HK) did not leave Residents 1 and 2, who were cognitively impaired and at risk for falls, in the resident ' s room while the floor was wet, and the room was being deep cleaned. 2.HK did not leave a bottle of Clorox spray (powerful bleach-based cleaner) unattended in Resident 1 and 2 ' s room. These failures had the potential to cause Resident 1and Resident 2 to fall, be exposed to harsh cleaning agents which could result in injuries, hospitalization and death. Findings: 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]. The admission Record indicated Resident 1 ' s diagnoses included Dementia (a progressive state of decline in mental abilities) abnormalities of gait and mobility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement the comprehensive person-centered care plan to 1 of 3 residents, Resident 1, who requested for a female Certified Nursing Assistant (CNA) to provide care. This failure resulted in the resident ' s feelings of fear and anxiety of being abused. Findings: During a review of Resident 1 ' s admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE], with diagnosis of psychosis (a state where a person experiences a significant loss of contact with reality) not due to a substance or known physiological condition, epilepsy (a neurological condition involving the brain that makes people more susceptible to having recurrent unprovoked seizures), and anxiety disorder (a group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation). During a review of Resident 1 ' s Minimum Data Set (MDS -a resident assessment tool) dated April 18, 2025, the MDS indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to revise the care plan to include safety interventions for one of five sampled Residents (Resident 4) who was at high risk for fall and sustained falls at the facility on 4/3/2025 and 4/11/2025. This deficient practice had the potential to place Resident 4 at risk for further falls and injuries including fractures (broken bones). Findings: During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted on [DATE] and re admitted on [DATE]. Resident 4's diagnoses that included abnormalities of gait and mobility (change in walking patterns), lack of coordination (voluntary muscle movements are uncoordinated), and contracture of muscle right forearm (muscles permanently shortened and stiff). During a review of Resident 4's History and Physical (H&P) dated 12/3/2024, the H&P indicated Resident 4 did not have the capacity to understand and make medical decisions. During a review of Resident 4'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 report injury of unknown origin (injuries not observed by any person or the source of the injury could not be explained by the resident) to the California Department of Public Health (CDPH), for one of seven sampled residents (Resident 7), who had bruise on right and left lower side of face and swollen left side of cheek. This failure resulted in a delay of investigation by the CDPH and placed Resident 7 at risk for further injuries. Findings: During a review of Resident 7 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnosis includingunspecified dementia (a progressive state of decline in mental abilities), paroxysmal atrial fibrillation (irregular heartbeat), and other abnormal of gait and mobility (unsteady walking, and difficulty with coordination). During a review of residents 7 ' s Minimum Data Set (MDS – a resident assessment tool) dated 1/20/2025, 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 observation, interview and record review, the facility failed to ensure appropriate skin care, adequate skin reassessment as indicated in the resident's care plan, were provided to one of seven sampled residents (Resident 6), who had generalized body dermatitis (condition of the skin in which it becomes red, swollen, itchy and sore, sometimes with small blisters and rashes) since 12/13/2024. This failure resulted in the resident ' s delayed, non-healing skin condition and had the potential to affect in maintaining the resident ' s highest practicable, physical, mental and psychosocial well-being. Findings: During a review of Resident 6 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], and re-admitted on [DATE] with diagnoses including unspecified dementia (a progressive state of decline in mental abilities), systematic inflammatory respond syndrome (SIRS body's response to an infectious or noninfectious insult.), and dermatitis. 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 interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was free from accident hazards by failing to consult with the Psychiatrist (a medical doctor who specializes in mental health) prior to going out on pass (OOP, temporary leave from the facility), according to its Policy and Procedure (P&P). This failure had the potential to negatively affect Resident 1 psychosocial well-being and cause harm or danger for the resident and others while OOP. Findings: During a review of Resident 1's admission record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood and behavior), anxiety disorder (mental health condition that causes excessive fear, worry, or dread) and presence of cardiac pacemaker (small electronic device is implanted in the chest to regulate the heart's rhythm and rate). During a review of Resident 1's Minimum Data Set (MDS,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) received medications as ordered by the physician by failing to: 1.Provide Resident 1's medications to the resident's Responsible Party (RP) to be given while the resident was Out on Pass (OOP, temporary leave from the facility), according to its Policy and Procedure (P&P). 2.Accurately document medication administration in Resident 1's Medical Records. These failures had the potential to result in worsening of Resident 1's symptoms or condition and lead to medication errors. Findings: During a review of Resident 1's admission record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood and behavior), anxiety disorder (mental health condition that causes excessive fear, worry, or dread) and presence of cardiac pacemaker (small electronic device is implanted in the chest to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify, one of eight sampled residents (Resident 1) doctor, when the resident refused to receive dialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidneys are unable to do so) on 12/13/2024 and missed scheduled dialysis on 12/16/2024 and 12/20/2024. This failure resulted in the doctor not aware and not providing further orders for Resident 1 ' s treatment. This failure placed Resident 1 ' s health and safety at risk for medical 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 diagnoses including end stage renal disease (ESRD, a condition where the kidneys can no longer support your body ' s needs), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and dependency on renal dialysis. 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 complete and send pre (before)-dialysis (a treatment that helps the body remove extra fluid and waste products from the blood when the kidneys are not able to) evaluation to the dialysis center, for one of eight sampled residents (Resident 1). This failure had the potential to cause lack of communication between the facility and the dialysis provider. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including end stage renal disease (ESRD, a condition where the kidneys can no longer support your body ' s needs), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and dependency on renal dialysis. During a review of Resident 1 ' s History and Physical (H&P), dated 11/2/2024, the H&P indicated Resident 1 could make needs known but could not make medical decisions. 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 interview and record review, the facility failed to document in the medical record, the assessment and interventions conducted to one of eight sampled residents (Resident 2), who complained of itchy scalp. This deficient practice had the potential to result in lack of communication among staff involved in the resident's care and the facility's failing to reassess the effectiveness of Resident 2 ' s scalp treatment. Findings: During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including schizophrenia (a serious mental health condition that affects how people think, feel, and behave), major depressive disorder (a mood disorder that causes a constant feeling of sadness and loss of interest), and hyperlipidemia (a condition in which there are high levels of fat in the blood). During a review of Resident 2 ' s history and physical (H&P), dated 12/17/2024, the H&P indicated Resident 2 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 interview and record review, the facility failed to effectively notify both designated emergency contacts listed on a resident ' s admission Record for one out of three sampled residents (Resident 1) when the following occurred: 1) The licensed nurses did not attempt to contact Family Member (FM) 2 listed on Resident 1 ' s admission Record when Resident 1 exhibited a change of condition on 10/17/2024. 2) The licensed nurses did not contact Resident 1 ' s Responsible Party (RP- Family Member [FM] 1) on 10/17/2024 to obtain informed consent for a newly prescribed medication (hydroxyzine hydrochloride – a medication used to help control anxiety and tension caused by nervous and emotional conditions) for the management of Resident 1 ' s anxiety and aggressive behavior. 3) The licensed nurses did not ensure FM 1 or FM 2 were notified when Resident 1 was sent to the General Acute Care Hospital (GACH) on 10/18/2024. These deficient practices caused FM 1 to become upset when she arrived at the facility to visit…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 slept on a pillow with a pillowcase for one out three sampled residents (Resident 1). This deficient practice had the potential to make Resident 1 feel less dignified and feel uncomfortable sleeping or resting in his own bed. Findings: During a review of Resident 1 ' s admission Record, the admission record indicated Resident 1 was originally admitted to the facility on [DATE], and readmitted on [DATE]. Resident 1's diagnoses included paranoid schizophrenia (a mental illness that is characterized by disturbances in thought), dementia (a progressive state of decline in mental abilities), and anxiety (a feeling of dread or uneasiness). During a review of Resident 1 ' s Minimum Data Set ([MDS], a federally mandated resident assessment tool), dated 9/12/2024, the MDS indicated Resident 1 ' s cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was severely impaired.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 for five of 15 sampled residents (Residents 91, 196, 80, 156, and 255) by failing to ensure the call light (a device that residents use to request assistance from staff) was within reach at the bedside. This deficient practice had the potential to negatively impact the psychosocial well-being of Residents 91, 196, 80, 156, and 255 or result in delayed provision of care and services. Findings: a. During an observation on 9/30/2024 at 10:57 a.m., in Resident 91's room. Resident 91 was observed lying in bed. Resident 91's call light was on the floor on the right side of Resident 91's bed. During a review of Resident 91's admission Record (Face Sheet), the Face Sheet indicated Resident 91 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 91's diagnoses including anxiety (feeling of fear, dread, and uneasiness), schizophrenia (a serios mental illness that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide a home like environment for two residents out of eight sampled residents (Resident 211 and 225) by not ensuring, 1. Resident 211 had a bedside table during mealtimes. 2. Resident 225 had a bedside table to use when coloring, and during mealtimes. These deficient practices did not provide dignity to Residents 211 and 225 and it did not provide comfort during mealtimes and activities. Findings: 1. During an observation on 9/30/2024 at 12:52 p.m., in Resident 211 room, Resident 211 was observed sitting on the edge of his bed eating lunch. Resident 211's food tray was resting on Resident 211's walker. Resident 211 did not have a bedside table. During a review of Resident 211's admission Record, the admission record indicated Resident 211 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 211's diagnoses included schizophrenia (a mental disorder characterized by disruptions in thought processes,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a comprehensive care plan with interventions for three out of nine sampled residents (Residents 148, 15, and 274), by failing to: 1. Ensure an individualized care plan for oxygen administration and respiratory therapy was developed for Resident 148 and Resident 15. 2. Ensure an individualized care plan was developed addressing Resident 274's hand tremors. These deficient practices had the potential to negatively affect the delivery of oxygen therapy and interventions for Residents 148 and 15 and potentially delayed the care for Resident 274. Findings: 1. During a review of Resident 148's admission Record, dated 10/2/2024, the admission record indicated Resident 148 was admitted to the facility on [DATE]. Resident 148's diagnoses included schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions), acute kidney failure (the sudden and rapid loss of kidney's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure low-air-loss mattresses ([LALM] a mattress that provides airflow to help keep skin dry, as well as to relieve pressure, and used to treat and prevent pressure ulcers [injuries to the skin and underlying tissue]) were inflated properly for five of 13 sampled residents (Resident 117, 133, 155, 206, and Resident 255) when: 1. Resident 155's LALM was inflated based on a weight of 350 pounds (Lbs., unit of weight). Resident 155 weighed 222.4 Lbs. on 9/15/2024. 2. Resident 206's LALM was inflated based on a weight of 320 Lbs. Resident 206 weighed 147.8 Lbs. on 9/4/2024. 3. Resident 255's LALM was inflated based on a weight of 350 Lbs. Resident 255 weighed 106.2 Lbs. on 9/4/2024. 4. Resident 133's LALM was inflated based on a weight of 200 Lbs. Resident 133 weighed 135 Lbs. 5. Resident 117's LALM was inflated based on a weight of 350 Lbs. Resident 117 weighed 245 Lbs. These deficient practices had the potential to result in pressure ulcer…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 quality Restorative Nursing Aide (RNA) services were provided, as ordered, for three out of eight sampled residents (Residents 132, 166 and 223) by failing to: 1. Ensure enough Certified Nursing Assistants (CNAs) were staffed to ensure RNAs would not be utilized to perform both CNA and RNA duties. 2. Ensure RNA documentation tasks were made accessible in the electronic medical record (EMR) to allow RNAs to review and document RNA services that were ordered. 3. Ensure RNA orders were performed, as ordered by the physician. These failures had the potential to cause a decline in the mobility and range of motion for Residents 166, 132, and 223. Findings: a. During a review of Resident 132's admission Record, the admission Record indicated Resident 132 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 132's diagnoses included Parkinson's Disease (a chronic, progressive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to monitor and record the urine output from the indwelling catheter (a thin, hollow tube that is inserted into the bladder to drain urine) for two of two sampled residents (Residents 71 and 246). This deficient practice had the potential to cause undetected fluid overload (a condition where the body has too much water), or fluid deficit (occurs when the body loses more fluids than it takes in), and an undetected malfunction of the indwelling urinary catheter. Findings: a. During a review of Resident 246's Face Sheet, the Face Sheet indicated Resident 246 was admitted to the facility on [DATE]. Resident 246's diagnoses included dementia (a group of thinking and social symptoms that interferes with daily functioning), major depression, schizophrenia (a serious mental illness that affects how a person thinks feels, and behaves), and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills). 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 two of two sampled residents (Resident 15 and Resident 148) received respiratory care consistent with professional standards of practice by failing to: 1. Ensure Resident 15 received oxygen as ordered. 2. Ensure the nasal cannula (a device used to deliver supplemental oxygen through the nose) tubing, oral suction device (a small plastic tube attached to a suction machine to remove saliva or mucus from the mouth), nebulizer (a device that turns the liquid medicine into a mist which is then inhaled) mask, and respiratory set-up bags (plastic bags used to store oxygen supplies) were changed after seven days. 3. Ensure there was signage indicating oxygen was in use outside of Resident 15 and 148's room. These deficient practices had the potential to result in unsafe use or storage of oxygen equipment, respiratory infection, inability to breathe comfortably, and/or hospitalization, and place Resident 15 and Resident 148 at risk 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 one of five residents (Resident 50) was administered medications in accordance with physician orders to meet the medical needs of the resident by failing to administer Resident 50's medications scheduled for 8 AM administration with a meal as ordered or too close to the next scheduled dose for: (cross reference F759) Metformin (used for diabetes to lower blood glucose/sugar) was documented administered over 60 minutes after the scheduled administration time on 9/28/2024, 9/29/20224, 9/30/2024, and 10/1/2024, and Naproxen (a nonsteroidal anti-inflammatory medication used for pain relief) was documented administered over 60 minutes after the scheduled administration time and within two and one-half hours of the next scheduled dose on 9/27/2024, 9/28/2024, 9/29/20224, 9/30/2024, and 10/1/2024 The deficient practice of failing to administer medications in accordance with the physician orders increased the risk that Resident 50 may…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medication error rate was less than five percent (%). Four medication errors out of 27 total opportunities contributed to an overall medication error rate of 14.81 % for one of five residents (Resident 50) observed during medication administration (MedPass). The facility failed to ensure Resident 50 was administered medications as order with meals, for metformin (used for diabetes [high blood sugar] to lower blood glucose/sugar) and naproxen (used for pain) and within an hour of the prescribed administration time for lactulose (prevent or relieve constipation) and lidocaine patch (for pain relief). The deficient practice of failing to administer medications in accordance with the physician orders increased the risk that Resident 50 may experience adverse reactions, complications, that could lead to a decline in the resident's condition, harm, or hospitalization. Findings: During a review of Resident 50's admission Record (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 ensure a resident was free from significant medication error by administering carvedilol (medicine to treat high blood pressure) outside the parameter (specific instructions that you could measure) as ordered by the physician for one of 11 sampled residents (Resident 30). This deficient practice had the potential to cause complications of hypotension (low blood pressure, dizziness and fainting leading to falls) and low heart rate (leading to lose consciousness). Findings: During a review of Resident 30's admission Record, the admission Record indicated Resident 30 was originally admitted to the facility on [DATE]. Resident 30's diagnoses included hypertension (HTN -high blood pressure), major depressive disorder (a mood disorder that caused a persistent feeling of sadness and loss of interest), schizoaffective disorder (a mental illness that could affect thoughts, mood, and behavior), and bipolar disorder (sometimes called manic-depressive 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.

Based on observation, interview, and record review, the facility failed to ensure one of three medication storage rooms, Advance Care (AC) Unit had a medication room thermometer, and failed to ensure THE refrigerator and room temperatures was properly monitored and maintained as indicated in the facility's policy and procedures (P&P), titled, Medication Storage in the Facility: Storage of Medications. This deficient practice had the potential to result in the loss of strength and integrity of stored medications, and the potential for residents on the AC Unit, requiring medications from the one of three medication storage rooms observed to receive deteriorated or ineffective medications. Findings: During a concurrent interview and observation, on 10/1/2024 at 10:40 AM, in the AC Unit Nursing Station with Licensed Vocational Nurse (LVN) 12 in the presence of LVN 14, and Director of Staff Development (DSD) 1, LVN 12 opened the medication storage refrigerator and stated the temperature was 41 degrees Fahrenheit (°F, temperature scale used to measure temperature). Observed inside of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills when staff: a. Failed to follow puree diet recipes (texture-modified diet where all the foods have a soft pudding-like consistency). b. Failed to demonstrate and verbalized the process of testing Quaternary ammonium compounds ([Quat], group of chemicals used to disinfect and sanitize) sanitizer concentration. These deficient practices had a potential to result in inaccurate food texture, ineffective therapeutic diets, difficulty swallowing, chewing, eating and foodborne illnesses (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) for 281 of 284 facility residents receiving food from the kitchen. Findings: a. During a review of the facilities' daily spreadsheet titled, Fall Menus, dated 9/30/2024), the Fall Menus indicated residents who received puree diets would receive the following food items for lunch: 1. Puree Kung…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow the menu and did not the meet nutritional needs of residents receiving puree diets (diet consisting with soft, pudding like consistency foods) when the seasoned brown rice was runny and the fruit cup was watery. This deficient practice placed 23 of 284 facility residents receiving a puree diet at risk of difficulty in eating, chewing, swallowing and decrease food and nutrient intake resulting to unplanned weight loss. Findings: During a review of the facilities' daily spreadsheet titled, Fall Menus, dated 9/30/2024), the Fall Menus indicated residents receiving puree diets would receive the following food items for lunch: 1. Puree Kung [NAME] pork 3.25 ounces ([oz] a unit of measurement). 2. Puree Seasoned brown rice 3.25 oz. 3. Puree Sesame broccoli ½ cup ([c] a unit of household measurement). 4. Puree Orange slice garnish. 5. Puree Wheat roll 1 piece (pc.). 6. Fresh fruit cup 3.25 oz. 7. Milk 4 oz. During an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor and appearance when, the seasoned brown rice was too sticky, the rice grains were not separated, and the broccoli tasted bland without the sesame taste. This deficient practice placed 260 of 284 facility residents at risk of unplanned weight loss, a consequence of poor food intake, from food the kitchen. Findings: During a review of the facilities' daily spreadsheet titled, Fall Menus, dated 9/30/2024), the Fall Menus indicated residents would the following food items for lunch: 1. Kung [NAME] pork 3.25 ounces ([oz] a unit of measurement). 2. Seasoned brown rice 3.25 oz. 3. Sesame broccoli ½ cup ([c] a unit of household measurement). 4. Orange slice garnish. 5. Wheat roll 1 piece (pc.). 6. Fresh fruit cup ½ c. 7. Milk 4 oz. During an observation on 9/30/2024 at 11:38 a.m., of the tray line (an area where foods are assembled), the seasoned brown rice was observed sticky. During a concurrent…

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

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: a. Four (4) of seven (7) racks in the walk-in refrigerator had cracks, chips, and rust. b. Walk-in freezer floor had dried ice cream drippings, two (2) axes on the floor, a bowl, and the walk-in freezer had ice buildup and torn door gaskets. c. Baking pans had burnt particles. d. Clear storage containers had blue tapes and tape residues and was not air dried prior to stacking. e. Chopping boards in the clean area had scratches and were sticky to touch. f. Three (3) dented cans were stored with non-dented cans. g. Internal parts of the ice machine in the kitchen had black dirt particles. h. Low temperature dishmachine by the preparation area was at 110 degrees Fahrenheit ([°F] a degree of temperature). i. Quaternary ammonium compounds ([Quat], group of chemicals used to disinfect and sanitize) sanitizer was not within an acceptable concentration. j. Resident's refrigerator and freezer temperatures were not following…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dispose garbage and refuse properly by not maintaining the trash area free from trash, plastic, plastic cups, black garbage bags with trash on the floor and completely covering the dumpster (a large trash metal container designed to be emptied into a truck). This deficient practice had a potential to attract birds, flies, insects, pest and possibly spread infection to all 284 facility residents. Findings: During an observation on 9/30/2024 at 3:26 p.m., in the dumpster area, observed that the dumpster was not completely covered. During an observation on 10/1/2024 at 1:57 p.m., in the dumpster area, observed that the dumpster was not completely covered. A black trash bag with trash, used plastic cups, plastic, and other dirt debris were on the surrounding floor. During a concurrent observation and interview on 10/1/2024 at 2:22 p.m. with the Food Service Director (FSD), the FDS stated the kitchen staff took the trash out all day in the dumpster area. The FSD stated the dumpster was not completely covered.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 standard infection control practices were followed for four of eight sampled residents (Residents 62, 246, 132 and 155) by failing to: 1. Ensure Resident 62's oxygen nasal cannula (device used to deliver supplemental oxygen placed directly on the resident's nostrils) and nebulizer mask (nebulizer a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) were properly stored in plastic bag and dated as indicated in the facility's policy and procedure (P&P). 2. Ensure Resident 246's indwelling catheter (a tube that allows urine to drain from the bladder into a bag) drainage bag was not touching the floor. 3. Ensure Resident 155's oxygen tubing, nasal cannula, and humidifier were changed every seven (7) days and dated. 4. Ensure an Enhanced Barrier Precautions ([EBP]-the use of gown and gloves for specific care activities that involve a high change of the spread of infection) sign was posted 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.

During an observation, interview, and record review the facility failed to meet the required room size measurement of 80 square feet ([sq. ft.]- a unit of measurement) of room space per resident in rooms with multiple residents. This deficient practice could potentially not provide residents privacy and could potentially affect residents' health and safety. Findings: During a review of the facility's Client accommodations Analysis form, dated 9/30/2024, the form indicated 9 rooms did not meet the 80 sq. ft. per resident requirement. During a review of the facility's Room Waiver Request Letter, dated 8/15/2024, the Room Waiver Request Letter indicated the following rooms did not meet the 80 sq. ft. of space per resident requirement: Room location # of beds Sq. Ft. Required Sq. Ft. 1. ACU-1 A 4 310 320 2. ACU-3 A 4 310 320 3. ACU- 4 A 4 310 320 4. ACU- 4 B 2 154 160 5. ACU-5 B 2 152 160 6. ACU-6 A 4 310 320 7. ACU-7 A 4 310 320 8. ACU-8 A 4 310 320 9. SW-7 2 141 160 During observations made throughout the course of the survey from 9/30/2024 to 10/4/2024, there were no adverse effects…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 verify the code status (a resident's instructions to a medical team about the type of treatment they want to receive in the event of a cardiac [heart] or respiratory [breathing] arrest) of a resident prior to initiating cardiopulmonary resuscitation (CPR- a lifesaving technique used in emergencies when a resident's breathing or heartbeat has stopped) for one out of one sampled resident (Resident 285). This deficient practice resulted in the administration of CPR and the utilization of an ambu bag (a medical tool which forces air into the lungs of patients who have either ceased breathing completely) for greater than ten minutes before paramedics took over and continued CPR. This deficient practice did not allow Resident 285 to pass comfortably during her last minutes of life. Findings: During a review of Resident 285's admission Record, the admission Record indicated Resident 285 was initially admitted to the facility on [DATE] and readmitted on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to notify the resident's responsible party (RP 1) when there was a room change for one of 11 sampled residents (Resident 101). This deficient practice violated RP 1's right to be promptly informed of changes. Findings: During an observation on 10/1/2024 at 9:32 a.m., outside of room [ROOM NUMBER], Resident 101 was observed sitting down on the bed. During a review of Resident 101's admission Record, The record indicated Resident 101 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 101's diagnoses included dementia (a progressive state of decline in mental abilities), major depressive disorder (a mood disorder that caused a persistent feeling of sadness and loss of interest), anxiety disorder (a condition in which a person had excessive worry and feelings of fear, dread, and uneasiness), and schizophrenia (a mental illness that was characterized by disturbances in thought). The admission Record indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility staff failed to ensure one of seven sampled residents (Resident 115) was free from an unnecessary restraint, as evidenced by: 1. Failing to ensure an appropriate assessment for less restrictive measures were done prior to placing Resident 115's bed against the wall. This deficient practice had the potential to inhibit Resident 115's freedom of movement. Findings: During an observation on 9/30/2024 at 10:43 a.m., in Resident 115's room, Resident 115 was observed lying in bed. Resident 115's bed was observed against the wall on the right side, and a floor mat on the left side of Resident 115's bed. During a review of Resident 115's admission Record (Face Sheet), the Face Sheet indicated Resident 115 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 115's diagnoses included dementia (a group of thinking and social symptoms that interferes with daily functioning, diabetes (abnormal blood sugar), major depression (loss…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to revise the comprehensive care plan intervention for one of 11 sampled resident (Resident 216), after Resident 216 kept wandering into other resident's rooms. This deficient practice had the potential to increase the likelihood of Resident 216 getting injured and harmed from another resident and was a violation of the other residents' privacy. Findings: During an observation on 9/30/2024 at 10:00 a.m., in the facility's East Wing Hallway, Resident 216 was observed wheeling herself into another resident's (Resident 181) room. During an observation on 9/30/2024 at 11:48 a.m., in the facility's East Wing Hallway, Resident 216 was observed wheeling herself into Resident 181's room. During a record review of Resident 216's admission Record, the admission record indicated Resident 216 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 216's diagnoses included encephalopathy (a group of conditions that caused…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff used a communication board and/or interpreter services for one of seven sampled residents (Resident 262) who did not speak the predominant (most spoken or used language) language of the facility. This deficient practice had the potential to negatively affect Resident 262's physical, mental, and psychosocial needs by preventing the resident from communicating with staff and potentially causing missed or delayed care and treatments. Findings: During a review of Resident 262's admission Record (Face Sheet), the Face Sheet indicated Resident 262 was admitted to the facility on [DATE]. Resident 262's diagnoses included major depression (major depression (loss of interest in activities), dementia (a group of thinking and social symptoms that interferes with daily functioning), and hypertension (high blood pressure). During a review of Resident 262's Minimum Data Set ([MDS] a federally mandated resident assessment tool), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one out of eight sampled resident's (Resident 117) blood sugar level was checked prior to administering Glipizide (blood sugar lowering medication). This deficient practice resulted had the potential for adverse reactions for Resident 117, including blood sugar levels that were too high or too low, and could possibly lead to complications including nerve damage, eye disease, kidney disease, heart and blood vessel disease, coma, and hypoglycemia (low blood sugar). Findings: During a review of Resident 117's admission Record, the admission record indicated Resident 117 was admitted to the facility on [DATE]. Resident 117's diagnoses included diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine) and chronic kidney disease (gradual loss of kidney function. Kidneys are unable to filter…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an order for Ativan (a medication used for anxiety- a feeling of fear, dread, or uneasiness) was limited to a 14-day duration for one of 11 sampled residents (Resident 140). This deficient practice had the potential to result in unnecessary or prolonged use of Ativan that could lead to Residents 140 experiencing adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to the medication therapy and may cause impairment or decline in mental, physical condition, functional, and/or psychosocial status of the resident. Findings: During a review of Resident 140's admission Record, the admission record indicated Resident 140 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 140's diagnoses included metabolic encephalopathy (brain dysfunction caused by a chemical imbalance in the blood that affected the brain's normal functioning), major depressive disorder (a mood disorder that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 obtain lithium (a chemical compound found in certain mood stabilizing drugs) blood levels for three months for one out of seven sampled residents (Resident 4), as ordered by the physician. This deficient practice resulted in Resident 4 ' s lithium blood levels to remain unmonitored for three months, which increased the potential for Resident 4 ' s lithium medication to remain subtherapeutic (ineffective). This also increased the potential for Resident 4's behavior disorders to be left untreated, increased the likelihood of Resident 4 to be involved in resident-to-resident altercations, exhibit increased agitation and aggression, and had the potential to lead to undetected lithium toxicity (occurs when too much lithium is found in the blood). Findings: a. During a review of Resident 4 ' s admission Record, the admission Record indicated Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to document the findings related to a change of condition (COC) for three of four sampled residents (Resident 1, Resident 2, and Resident 4). This deficient practice had the potential to result in serious harm such as another episode of aggression towards others, and a delay of necessary treatments. Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to facility on 11/30/2021 and re-admitted on [DATE]. Resident 1's diagnoses included schizoaffective disorder (a serious mental illness that affected how a person thought, felt, and behaved), anxiety (a feeling of fear, dread, or uneasiness), major depressive disorder (a mood disorder that caused a persistent feeling of sadness and loss of interest), and nicotine dependence. During a review of Resident 1's Minimum Data Set ([MDS]- a standardized resident assessment and care screening tool), dated 6/6/2024, the MDS indicated Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident was free from significant medication error by administering carvedilol (medicine to treat high blood pressure) outside the parameter (specific instructions that you could measure) as ordered by the physician for one of four sample residents (Resident 5). This deficient practice had the potential to cause complications of hypotension (low blood pressure, dizziness and fainting leading to falls) and low heart rate (leading to lose consciousness). Findings: During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 5's diagnoses included hypertension (high blood pressure), epilepsy (a brain condition that caused a person to have recurring seizures [a sudden, uncontrolled burst of electrical activity in the brain] over time), schizophrenia (a serious mental illness that affected how a person thought, felt, and behaved),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, facility staff failed to report an allegation of resident-to-resident sexual abuse, for one of two sampled residents (Resident 1), after being made aware of the allegation on 7/30/2024 at 12:53 PM. This deficient practice had the potential to cause a delay in the notification of necessary State and local agencies and the timeliness of their investigations. The failure also increased the potential for additional resident-to-resident sexual abuse incidents to occur. Findings: During a review of Resident 1's admission Record, the record indicated Resident 1 was admitted to the facility on [DATE] and most recently re-admitted to the facility on [DATE]. Resident 1's admitting diagnoses included major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and anxiety disorder (intense, excessive, and persistent worry and fear about everyday…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, facility staff failed to follow their policy and procedure (P&P) titled Abuse Reporting and Investigations , dated 1/2024, following an allegation of resident-to-resident sexual abuse, for one of two sampled residents (Resident 1), after being made aware of the allegation on 7/30/2024 at 12:53 PM; and thoroughly investigate a fall with injury for one of three sampled residents (Resident 8), who was actually physically assulted by Certified Nursing Assistant (CNA) 4 on 7/28/2024. This failure increased the potential for additional resident-to-resident sexual abuse incidents to occur as the alleged perpetrator remained in the room directly across the hall from Resident 1 until the day after the allegation was made, and also caused Resident 1 to report feeling unsafe in her room and unable to sleep. This failure resulted in unidentified physical abuse for Resident 8, and had the potential for reoccuring and undetected physical abuse. Resident 8 reported being…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that quality of care was maintained for two of 11 sampled residents (Resident 4 and Resident 6) when the following occurred: a. Facility staff failed to provide teaching to Resident 6's Responsible Party (RP) 1 about Resident 6's physician orders to immobilize and not put weight on Resident 6's right hip, prior to Resident 6 leaving the facility with RP 1 for the day. b. Facility staff failed to follow their facility protocol prior to allowing Resident 6 to leave the facility with a visitor. 2. Facility staff failed to provide Resident 4 with a splint (a strip of rigid material used for supporting and immobilizing a broken bone), as ordered by the physician, for her ulnar fracture (a broken bone in the forearm). These deficient practices had the potential to cause a worsening of Resident 4's ulnar fracture and Resident 6's right hip fracture because of not receiving the required precautions for their fractures. Findings: 1. During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure fall mats and non-skid footwear were implemented, as indicated in the care plan, for one of two sampled residents (Resident 4). This deficient practice had to the potential to result in an avoidable repeat fall incident, and a worsening of Resident 4's existing ulnar fracture (a broken bone in the forearm) or the occurrence of a new injury. Findings: During a review of Resident 4's admission Record, the admission record indicated Resident 4 was admitted to the facility on [DATE] and most recently re-admitted [DATE]. Resident 4's admitting diagnoses included generalized osteoarthritis (a condition where the flexible, protective tissue at the ends of bones wears down), lack of coordination, symptoms and signs involving the musculoskeletal system, dementia (a group of thinking and social symptoms that interferes with daily functioning). During a review of Resident 4's Minimum Data Set (MDS, a standardized and comprehensive assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide timely update of the care plan when three residents (RES6, RES7, and RES8) were exposed to Candida Auris. This failure resulted in staff not knowing the appropriate interventions to implement to provide care. Findings: During a concurrent interview and record review on 4/18/2024 at 1:58 p.m. with LVN1, LVN1 stated care plans should be created as soon as you see an issue or change of condition. LVN1 could not show a care plan was created for RES6, RES7, or RES8 on 4/12/2024 when the facility was made aware the residents were exposed to Candida Auris. LVN1 stated a care plan is needed for continuity of care. If there is no care plan you may not know something about the resident so you could miss something the resident needs. A care plan lets you know how to care for the resident. During an interview on 4/18/2024 at 2:22 p.m. with RNS, RNS stated care plans should be created/updated on admission, change of condition, and if there is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to initiate contact isolation precautions (action to prevent the spread of germs) for three residents (RES6, RES7, and RES8) known to have been in contact with Candida Auris (type of yeast that causes illness). This failure had the potential to result in Candida Auris being spread to other residents in the Special Care Unit. Findings: During a concurrent observation and interview on 4/16/2024 at 2:55 p.m. with the IP in front of the room containing the exposed residents, there was no isolation set up or signage for precautions. IP stated she is assuming the residents in the room are positive. Stated since no precautions are being used Candida Auris could have spread to other residents. Residents who are positive for Candida Auris are placed in contact precautions indefinitely. During an interview on 4/18/2024 at 11:03 a.m. with DON, DON stated there is a risk someone in the exposed room could be positive for Candida Auris. States exposed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. Follow its policy and procedure (P&P), titled, Abuse-Prevention, Screening, and Training Program, dated 7/2018, which indicated facility did not condone any form of resident abuse or neglect for one of three residents (Resident 12). As a result, this violation delayed the investigation by the State agency and placed Resident 12 and other residents at risk of abuse. Findings: A review of Resident 12 's admission Record (face sheet) indicated the resident was a [AGE] year-old male, admitted to the facility on [DATE] and readmitted on [DATE]. Resident 12 's diagnoses included metabolic encephalopathy (a chemical imbalance in the brain caused by an illness or organs), epilepsy (a brain disorder characterized by recurrent brief episodes of involuntary movement that may involve a part of or the entire body) and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 adequate number of staffs were present to supervise the 12 of 12 residents who were in the patio. This deficient practice resulted in Resident 1 physically assaulting Resident 2, and Resident 1 sustaining laceration on his forehead that required treatment. Findings: a. During a review of Resident 1's admission record, the admission record indicated Resident 92 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included peripheral neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet), metabolic encephalopathy (a chemical imbalance in the brain caused by an illness or organs) and dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment). During a review of Resident 1's Minimum Data Set (MDS- a comprehensive assessment tool) dated 12/22/2023, the MDS indicated Resident 1 was moderately cognitively…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 12 residents (Resident 11), was provided dignity and privacy, by failing to put on resident's clothing, provide privacy curtains and bed linens while on bed. This deficient practice had the potential to negatively affect Resident 11's psychosocial well-being. Findings: During a review of Resident 11's admission record, the admission record indicated Resident 11 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included paranoid schizophrenia (a mental health condition characterized by paranoid delusions and hallucinations), muscle weakness (a decrease in muscle strength) and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life.). During a review of the Minimum Data Set (MDS- a comprehensive assessment tool) dated 12/26/2023, indicated Resident 11 was severely…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its abuse prevention policy by failing to report the unusual occurrence of employee to resident altercation to the State Survey Agency within 24 hours after the allegation occurred for one of twelve residents (Resident 12). This deficient practice placed the resident at risk for further abuse, feelings of intimidation and neglect. Findings: During a review of Resident 12's admission record, the admission record indicated Resident 12 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included metabolic encephalopathy (a chemical imbalance in the brain caused by an illness or organs), epilepsy (a chronic disorder of the brain characterized by recurrent brief episodes of involuntary movement that may involve a part of the body or the entire body) and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report within two (2) hours, resident to resident allegation of physical abuse (Resident 8 hitting Resident 7 on the head and face) to the Department of Public Health, Licensing and Certification unit (CDPH), for one of three sampled residents, Resident 7. This failure resulted in the delay of investigation by the Department of Public Health, and had the potential for the abuse to continue, and cause resident further physical and psychosocial harm. Findings: a). During a review of Resident 7 ' s admission record (Face Sheet), the Face Sheet indicated, Resident 7 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included schizophrenia (a mental condition that affects a person ' s ability to think), depression (feeling sadness and loss of interest), and (loss of memory). During a review of Resident 7 ' s Minimum Data Set ([MDS] a comprehensive standardized assessment and care-screening tool) dated 12/12/2023,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prevent one of three sampled residents (Resident 1) from leaving the facility when the Dietary Aide (DA) allowed Resident 1 to exit a locked door without the DA identifying the resident first. As a result of this deficient practice, Resident 1 left the facility and had the potential to be harmed. Findings: During a record review of Resident 1's admission Record, dated 10/10/2023, the admission record indicated Resident 1 was admit1ted to the facility on 9/21/2023. Resident 1's diagnoses included paranoid schizophrenia (seeing or hearing stimuli that is internal, accompanied by paranoia), major depression disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (persistent and excessive worry that interferes with daily activities), and delusional disorders (having unshakable beliefs in something that is untrue). During a record review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 9/26/2023, the MDS indicated Resident 1 was…

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

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: a. Walk-in freezer pipe had ice buildup and freezer floors with food and dirt debris. b. Mixer attachments were found with dry food debris and food residue. c. Clean area for tray drying were cross-contaminated (transfer of harmful bacteria from one place to another) by wet food residue. d. Dry storage area for coffee and other food items by the tray line area (area for food assembly) was dusty and personal items such as bags were stored. e. Microwave had food debris. f. Clean pots and pans were not air dried and stacked wet. Food Service worker was using towel to wipe off the wet pots and pans. g. Scoops were stored with the handle not facing in one direction. h. Three (3) racks for drying and storage of pots and pans and other kitchen equipment were rusty. i. Fifteen (15) chipped and cracked resident's food trays. j. Drying rack for plate covers was found to have black dirt debris. k. Refrigerator temperature was not…

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

Based on observation, interview, and record review, the facility failed to dispose garbage and refuse (nonhazardous disposable materials) properly by: a. Not covering the dumpster (a large trash container designed to be emptied into a truck) while waiting for trash to be picked up by the garbage truck. b. Not maintaining the garbage storage area free from debris and free of foul odors. This deficient practice attracted flies to the dumpster area, and flies were observed in the kitchen placing two eighty-seven (287) of 287 facility residents receiving food from the kitchen at potential risk of cross-contamination (a transfer of harmful bacteria from one place to another). Findings: During a concurrent observation of the tray line (an area for food assembly) service in the kitchen and interview with the Corporate Registered Dietitian (RD 1) on 9/26/2023 at 12:21 PM, there were two (2) flies observed flying around. The flies were coming around the front door when staff were opening the door for food cart deliveries. The back door was not completely closed. RD 1 stated the doors must be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that three of six sampled residents' belongings were appropriately stored and accounted for per facility policy (Resident 60, 100, and 242). This deficiency had the potential for avoidable theft and loss of the residents' personal property, and to negatively affect the residents' psychosocial well-being. Findings: a. During a review of Resident 60's admission Record, the admission record indicated Resident 60 was admitted to the facility on [DATE]. Resident 60's diagnoses included major depressive disorder (mental disorder causing persistently low mood), lack of coordination, and abnormalities of gait (walking) and mobility. During a review of Resident 60's Minimum Data Set (MDS, a standardized assessment and care-planning tool), dated 8/18/23, the MDS indicated Resident 60 had mild cognitive impairment (ability to think and reason) but could recall information with cueing. During a review of the facility document titled, Dental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 call light device was within reach for four of 48 residents residing on the East and [NAME] Unit of the facility (Resident 5, Resident 262, Resident 226, and Resident 237). This had the potential to result in a delay in or in an inability for the residents to obtain necessary care and services. Findings: a. During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was admitted to the facility on [DATE] with diagnoses including lack of coordination, abnormalities of gait (way of walking) and mobility, and history of falling. During a review of Resident 5's Minimum Data Set (MDS, standardized care and screening tool), dated 7/19/2023, the MDS indicated Resident 5 was moderately impaired with cognitive (processes of thinking and reasoning) skills for decision making. The MDS indicated Resident 5 required limited assistance (resident highly involved in activity; staff provide guided maneuvering 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 follow its Policy and Procedure (P&P) to report allegations of abuse to the State Agency within two hours for four of eight sampled residents (Resident 107, Resident 159, Resident 165, and Resident 288) when: a. Resident 107 reported that Resident 159 hit her in the face with a water pitcher. b. Resident 165 reported that Resident 288 pushed her out of her wheelchair. This deficient practice had the potential to result in a delay for the State Agency to investigate the allegation of abuse and continued abuse for Residents 107 and 165. a. During a review of Resident 107's admission Record, the admission Record indicated Resident 107 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including anxiety (feeling of fear, dread, and uneasiness) disorder, schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves), morbid obesity (more than 80 to 100 pounds above their ideal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prevent further potential abuse or mistreatment of 2 of 45 residents (Resident 107 and 100) residing in the unit when the following occurred: a. Facility staff failed to investigate an alleged physical altercation where Resident 159 hit Resident 107's face with a water pitcher. b. Facility staff failed to document a change of condition for, or update the care plan for, Resident 41 following an alleged physical altercation where Resident 41 hit Resident 100's head with a metal pipe. These deficient practices had the potential to result in unidentified abuse in the facility, and the potential for avoidable further abuse of facility residents. Findings: a. During a review of Resident 107's admission Record, the admission Record indicated Resident 107 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 107's diagnoses included anxiety disorder (feeling of fear, dread, and uneasiness), schizophrenia (serious…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 update and revise the care plan as necessary for three of five sampled residents (Resident 52, Resident 131, and Resident 175,) by failing to: a. Monitor the intake and output ([I&O] recording the amount of fluid that goes into the body and comes out of the body) of Resident 52 who was receiving hemodialysis treatment (a treatment that helps the body remove extra fluid and waste products from the blood when kidneys are unable to due to disease) per the resident's care plan. b. Update Resident 131's care plan to reflect the need for ongoing education due to non-compliance with abiding by the Food Brought in by Visitors policy. c. Develop a care plan for Resident 175 who had a known history of wandering into another resident's room (Resident 256) and invading her privacy. These deficient practices had the potential to cause harm to Resident 52, Resident 131, Resident 175, and Resident 254 by not having a clear plan of care to communicate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Treatment Nurse (TN) 1 provided skin treatments for one of one sampled resident (Resident 241), and Licensed Vocational Nurse (LVN) 12 administered the correct tube feeding flush rate for one of one sampled resident (Resident 205) to maintain the resident's hydration status. These deficient practices placed Resident 241 at risk for further skin complications that could possibly delay skin healing process and placed Resident 205 at risk for inadequate hydration. Findings: a. During a review of Resident 241's admission Record, the admission record indicated Resident 241 was originally admitted to the facility on 8/7/. Resident 241's diagnoses included protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function) and paranoid schizophrenia (characterized by predominantly positive symptoms of schizophrenia, including delusions and hallucinations,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prepare food by methods that conserved flavor and appearance. In addition, food was not delivered at appetizing temperatures and portions were not correct. This deficient practice placed two hundred sixty-seven (267) of two hundred eight seven (287) facility residents at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen. Findings: During an interview with Resident 164 on 9/26/2023 at 10:25 AM, resident 164 stated he doesn't like the food and it doesn't taste good. During a review of Resident 164's admission Record, dated 9/28/2023, the admission record indicated Resident 164 was initially admitted to the facility on [DATE] and then readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD, a lung disease characterized by persistent cough and progressive breathing), essential hypertension (HTN, high blood pressure) and moderate protein-calorie malnutrition (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 lunch at the facility's established mealtime in the facility's East Wing where 64 residents resided. This failure resulted in three of 64 residents (Resident 223, 192, and 121) receiving lunch at least 30 minutes late, causing Resident 223, 192, and 121 to feel hungry. Findings: During a review of Resident 223's admission Record, the admission record indicated the facility admitted Resident 223 on 1/28/2023. Resident 223's diagnoses included diabetes mellitus (high blood sugar), dysphasia (difficulty swallowing), and moderate protein-calorie malnutrition (not getting enough of the right foods to keep the body healthy and growing properly). During a review of Resident 223's Minimum Data Set (MDS, a comprehensive assessment and care planning tool), dated 7/19/2023, the MDS indicated Resident 223 had clear speech, clearly expressed ideas, and wants, and understood verbal content. The MDS indicated Resident 223 required supervision…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement infection control practices for 287 of 287 residents by failing to: a. Accurately and timely test the water for legionella (bacteria that could be present in water which can cause illness) and other water-borne pathogens (bacteria) with a test kit that was not past its expiration date. b. Ensure staff did not remove their N95 respirator (type of mask that provides protection from small particles in the air) during care for five sampled residents (Resident 146, 179, 205, 233, 243) during a COVID-19 outbreak (infectious disease that affects a person's organs and tissues that aid in breathing). c. Ensure hand soap was available to perform effective hand hygiene for 38 sampled residents residing in the South Unit (Residents 3, 18, 21, 27, 29, 30, 33, 37, 41, 44, 58, 60, 61, 62, 63, 80, 83, 86, 93, 96, 98, 100, 110, 126, 135, 138, 151, 155, 187, 197, 221, 230, 244, 259, 267, 285, 541, 542) and 4 sampled residents (Residents 54, 116,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 have a safe, clean, comfortable, and home-like environment for 14 of 48 sampled resident rooms located on the East and [NAME] Unit of the facility. Room A and Room B was observed with dry stool on the toilet seat and dry stool on Room A's bathroom floor, curtains in Room C, Room D, and Room E were not properly hung and were ripped at the bottom, the soap dispenser in Room E was empty, the bathroom in Room A and Room E was not well lit, and the glass sliding door rail was observed sticking out in Room A. These findings had the potential to result in an accident and had the potential to negatively impact the psychosocial wellbeing of the residents. Findings: a. During a concurrent observation and interview on 9/26/2023 at 9:39 a.m., with Certified Nursing Assistant (CNA) 4. Rooom A's toilet seat and bathroom floor was observed with black colored dry stool. CNA 4 stated Room A housed four residents (Resident 262, Resident 97, Resident 125, and Resident 123) residing. CNA 4 stated, Other residents might sit 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 interview and record review, weekend visitation was restricted for one of 36 sampled residents (Resident 242). This deficiency caused avoidable physical and psychosocial harm for Resident 242, who verbalized feelings of depression, frustration, and hopelessness related to his inability to see his family. Findings: During a review of Resident 242's admission Record, the admission record indicated Resident 242 was admitted to the facility on [DATE]. Resident 242's diagnoses included major depressive disorder and bipolar disorder (a brain disorder that causes changes in a person's mood, energy, and ability to function). During a review of Resident 242's Minimum Data Set (MDS, a standardized assessment and care-planning tool), dated 7/12/2023, the MDS indicated Resident 242 had mild cognitive impairment (ability to think and reason) but could recall information with and without cueing. The MDS further indicated Resident 242 did not exhibit any disorganized thinking or acute changes in his mental status.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 241 and Resident 265) were free from the use of restraints for staff convenience. Residents 241 and 265 beds were positioned against the wall enabling the residents to get of the bed from the right side. This deficient practice had the potential to cause harm to Resident 241 and 265 and inhibited Resident 241's and 265's freedom of getting out the bed from either side of the bed. Findings: a. During a review of Resident 241's admission Record, the admission record indicated Resident 241 was originally admitted to the facility on [DATE]. Resident 241's diagnoses included protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function) and paranoid schizophrenia (characterized by predominantly positive symptoms of schizophrenia, including delusions and hallucinations, the debilitating symptoms blur the line between…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 241 and 265), who were assessed as being dependent on staff for positioning, were repositioned daily. This deficient practice had the potential to negatively affect Resident 241 and Resident 265's physical comfort, skin integrity, and psychosocial wellbeing. Findings: a. During a review of Resident 241's admission Record, the admission record indicated Resident 241 was originally admitted to the facility on [DATE]. Resident 241's diagnoses included protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function) and paranoid schizophrenia (characterized by predominantly positive symptoms of schizophrenia, including delusions and hallucinations, often blurring the line between what is real and what isn't, making it difficult for the person to lead a typical life). During a review of Resident 241's History 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 provide adequate supervision for two out of eight sampled residents (Resident 165 and Resident 159) when Resident 165 alleged Resident 159 hit her left arm while both residents waited to be released for a smoke break in Hallway A. This failure had the potential to result in undetected resident to resident altercations, abuse, or episodes of mistreatment in Hallway A. Findings: During a review of Resident 165's admission Record, the admission Record indicated Resident 165 was admitted to the facility on [DATE]. The admission Record indicated Resident 165 had diagnoses of a fracture (broken bone) of the left hip, abnormalities of gait (ability to walk) and mobility, schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves), and bipolar (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) disorder. During a review of Resident 165's Minimum Data Set (MDS-…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store one unopened Novolog FlexPen (a medication used to treat high blood sugar) in the refrigerator per the manufacturer's requirements affecting Resident 68 in one of five inspected medication carts (East Station Medication Cart 1). The deficient practice of failing to store medications per the manufacturers' requirements increased the risk that Resident 68 could have received medication that had become ineffective or toxic due to improper storage possibly leading to health complications. Findings: During a concurrent observation and interview on [DATE] at 1:26 PM of East Station Medication Cart 1 with Licensed Vocational Nurse (LVN) 1, the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as required by their respective manufacturer's specifications: One unopened Novolog FlexPen belonging to Resident 68 was found stored at room…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide one of 28 sampled residents (Resident 226) with assistive devices (special eating equipment and utensils) while eating. This failure had the potential to lead to Resident 226's decreased independence with eating, which could lead to weight loss. Findings: During a review of Resident 226's admission Record, the admission record indicated Resident 226 was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 226's diagnoses included diabetes mellitus (high blood sugar), moderate protein-calorie malnutrition (not getting enough of the right foods to keep the body healthy and growing properly), muscle weakness, and dysphagia (difficulty swallowing). During a review of Resident 226's Minimum Data Set (MDS, a comprehensive assessment and care planning tool), dated 6/21/2023, the MDS indicated Resident 226 had clear speech, expressed ideas, and wants, understood verbal content, and had moderately impaired 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: 1. Ensure staff donned (put on) and doffed (take off) personal protective equipment (PPE) correctly when cleaning Cottage C that housed Coronavirus Disease 2019 (COVID-19, infectious disease that affects a person's organs and tissues that aid in breathing) positive residents. 2. Provide separate restrooms in two cottages, Cottage A and Cottage B, that housed COVID positive residents (Residents 6, 7, 10, and 11) and non-COVID residents (Residents 4, 5, 8, 9, 12, 13, 14, and 15). 3. Provide adequate handwashing areas for staff. 4. Provide hand sanitizer to staff that was not past its expiration date. These failures had the potential to increase the spread the COVID-19 virus to uninfected residents, which could lead to illness requiring medical interventions. Findings: 1. During a concurrent observation and interview, on 9/13/2023, at 12:11 p.m., with the Director of Staffing Development (DSD 1), Certified Nurse Assistant (CNA 1) was observed exiting cottage C and removed her PPE outside of the cottage. DSD 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 develop a care plan with goals and interventions for one of three residents (Resident 1), when Resident 1 had Extended Spectrum Beta-Lactamase (ESBL, germs that are difficult to treat with medication) in her urine. This failure had the potential for delay in Resident 1's treatment. Findings: During a review of Resident 1's admission Record (Face Sheet), the admission Record indicated, Resident 1 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE], with diagnoses including but not limited to metabolic encephalopathy (chemical imbalance in the blood that affects the way the brain functions), hyperlipidemia (increased levels of fat in the blood), and major depressive disorder (MDD, a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). During a review of Resident 1's Minimum Data Sheet (MDS, a standardized assessment 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 meet professional standards of care for one of three sampled residents (Resident 1) when they: 1. Failed to implement Resident 1's physician order to collect urine for laboratory testing. 2. Failed to observe sediment (small substance) in Resident 1's urinary catheter (tube placed into the body to drain and collect urine) and gastrostomy tube (G-Tube, tube placed into the stomach for nutrition) prior to her transfer to the general acute care hospital (GACH). This failure had the potential for a delay in Resident 1's course of treatment. Findings: 1. During a review of Resident 1's admission Record (Face Sheet), the admission Record indicated, Resident 1 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE], with diagnoses including but not limited to metabolic encephalopathy (chemical imbalance in the blood that affects the way the brain functions), hyperlipidemia (increased levels of fat in the blood), and major…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report to the state agency (Department of Public Health) an abuse allegation for one of four sampled residents (Resident 1). This failure resulted in a delay of an onsite inspection by the state agency to ensure the safety of Resident 1. Findings: During a review of Resident 1 ' s admission Record (Face Sheet), the admission Record indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses including but not limited to atrial fibrillation (irregular and fast heartbeat), paranoid schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions), and bipolar disorder (a mental illness that causes unusual shifts in mood, energy, and concentration). During a review of Resident 1 ' s Minimum Data Sheet (MDS, a standardized assessment and screening tool) dated 5/17/2023, the MDS indicated Resident 1 was usually able to make herself understood and was able 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.