Monrovia Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to immediately report an influenza (the flu, a contagious respiratory illness caused by influenza viruses that infect the nose, throat, and lungs) outbreak (the occurrence of influenza cases greater than would normally be expected) to the Los Angeles County (LAC) Department of Public Health (DPH) when 3 of 6 sampled residents (Resident 1, Resident 2, and Resident 3) tested positive for influenza and as indicated in the Influenza and other Respiratory Virus Diseases Outbreak Toolkit.This deficiency had the potential to delay implementation of specific instructions from DPH to prevent the spread of influenza throughout the facility.Findings:During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including displaced fracture of base of the neck of the left femur (hip injury where the bone is broken and separated near the hip joint) and acute…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dignity and privacy for two of three sampled residents (Resident 2 and Resident 3).This deficient practice had the potential to affect Resident 2's and Resident 3's psychosocial wellbeing. a. During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 5/27/2020, with diagnoses that included (a mental illness that is characterized by disturbances in thought) and dementia (a progressive state of decline in mental abilities). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 1/14/2026, the MDS indicated Resident 2's cognitive status (the ability to think and process information) was moderately impaired. The MDS indicated Resident 2 was dependent (helper does all the effort to complete the activity) on staff with shower/bath, toileting and personal hygiene. b. During a review of Resident 3's AR, the AR indicated the facility admitted Resident 3 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 ensure: 1. Certified Nursing Assistant (CNA) 3 changed gloves after transferring Resident 4 back to bed and before preparing supplies and handling clean linens and diaper for Resident 4's diaper change on 2/4/2026. 2. CNA 1 and CNA 2 changed wash cloths and bath water prior to providing Resident 2 and Resident 3 perineal care on 2/5/2026. These deficient practices had the potential to spread bacteria that could lead to urinary tract infection.Findings: 1.During a review of Resident 4's admission Record (AR), the AR indicated the facility admitted Resident 4 on 5/30/2025, with diagnoses that included obstructive and reflux uropathy (a condition in which the flow of urine is blocked which causes the urine to back up and injure one or both kidneys), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 4'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 provide copies of requested medical records within two business days from written request as indicated by the facility's policy and procedure (P&P) titled, Access to Personal and Medical Records for one of three sampled resident (Resident 1). This deficient practice violated Resident 1's right to obtain copies of resident's medical records in a timely manner and had the potential to affect Resident 1's psychosocial well-being. Findings: a) During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included obesity (an abnormal or excessive body fat accumulation), acute respiratory failure without hypoxia (an impairment in oxygenation), basal carcinoma (a type of skin cancer) of skin of right upper limb including shoulder, unilateral primary osteoarthritis (a joint disease where protective cartilage wears down, causing bones to rub, leading pain, stiffness, and swelling)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accommodate the needs four of four sampled residents (Residents 1, 2, 3, and 4 ) in accordance with the facility's Policy and Procedure (P&P) by failing to ensure the call light (a device used by residents to signal his or her needs for assistance) was functioning during the power outage for 11 hours from 10/16/2025 at 9:30 PM to 10/17/2025 at 8:30 AM.These deficient practices had the potential for Residents 1, 2, 3, and 4 who were assessed as high risk of falls to not be able to call the facility staff for help or assistance and placed the residents at risk for harm/injury.Findings: 1. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to facility on 8/19/2024 with diagnoses including morbid obesity (severe obesity- a serious health condition that results from an abnormally high body mass) and history of falling. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow the facility's Policy and Procedure (P&P) titled Medication Orders and Receipt Record to ensure three of three sampled residents (Residents 1, 6 and 7)'s medication delivered by the pharmacy were checked, signed, dated and timed by licensed staff upon receiving. This failure had the potential for missing medication or residents receiving wrong medication.Findings: 1. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to facility on 8/19/2024 with diagnoses including morbid obesity (severe obesity- a serious health condition that results from an abnormally high body mass) and history of falling. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 8/23/2025, the MDS indicated Resident 1's cognitive skills (ability to make daily decisions) was intact. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify Resident 1's doctor of Resident 1's refusals of accuchecks (sampling a drop of blood from the finger to determine the blood glucose [sugar] level) and insulin (a hormone that lowers the level of glucose [a type of sugar] or sugar in the blood) injection on 8/3/2025 and 8/4/2025.These failures had the potential to result in Resident 1 to not receive treatment to address Resident 1's risks for hypoglycemia (a condition where the level of glucose in the blood drops below a healthy range) or hyperglycemia (having too much glucose in the blood) which could negatively affect Resident 1's health and wellbeing.(Cross Reference F686 andF755) Findings:During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to facility on 4/16/2024 and readmitted to the facility on [DATE] with diagnoses including Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and…

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

Based on interview and record review, the facility failed to report an allegation of abuse for one of two sampled residents (Resident 8) to the California Department of Public Health (the Department), the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and to the local law enforcement, within two hours, in accordance with the facility's policy and procedure (P&P), titled Abuse Investigation and Reporting, dated 7/2017.This failure resulted in the delay of notification to the Department and had the potential to result in Resident 8 to be subjected to abuse while at the facilityFindings:During a review of Resident 8's admission Record, the admission Record indicated the facility originally admitted Resident 8 on 7/5/2025, and readmitted the resident on 8/15/2025 with diagnosis that included type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic pulmonary edema (a long-term condition where fluid accumulates in the lungs), and toxic encephalopathy (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 treatment and services to improve one of three (3) resident's (Resident 10) ability to carry out activities of daily living (ADL, basic activities such as eating, dressing, toileting) by failing to offer and assist Resident 10 out of bed into a chair for meals as ordered by the physician. This deficient practice placed Resident 10 at risk for a functional decline in physical functioning and mobility, decreased quality of life, pressure sore (injuries to the skin and underlying tissue resulting from prolonged pressure on the skin) development, and feelings of low self-esteem and self-worth. Findings: During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was admitted to the facility on [DATE] with diagnoses including right-sided hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following a cerebral infarction (blockage of the flow of 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 three sampled residents (Resident 10) received treatment and care in accordance with professional standards of practice by failing to ensure Resident 10's Orthopedic (specialty area in medicine referring to the management of the muscles, bones, and their connective structures) consultation recommendations were implemented. This deficient practice resulted in a delay of care and had the potential for worsening pain and swelling in Resident 10's left hip and left knee and a decline in Resident 10's mobility, range of motion (ROM, full movement potential of a joint), physical comfort and psychosocial well-being. Findings: During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was admitted to the facility on [DATE] with diagnoses including right-sided hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following a cerebral infarction…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a weekly skin check for one of two sampled residents (Resident 1) from 7/5 - 7/18/2025.This failure had the potential for Resident 1's skin wounds to get worse and to not receive timely treatment for the worsening skin wounds.(Cross Reference F580 and F755) Findings:During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), dementia (a group of thinking and social symptoms that interferes with daily functioning), and type 2 diabetes mellitus (DM, a chronic condition that affects the way the body processes blood sugar). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 7/15/2025, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of two sampled resident's (Resident 1) supply of Morphine Sulfate (a medication used to treat pain) was restocked and readily available when the resident needed it. This failure had the potential to result in Resident 1 to experience unrelieved pain.(Cross Reference F580 and F685)Findings:During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to facility on 4/16/2024 and readmitted to the facility on [DATE] with diagnoses including Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), dementia (a group of thinking and social symptoms that interferes with daily functioning), and type 2 diabetes mellitus (DM, a chronic condition that affects the way the body processes blood sugar). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 7/15/2025, 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 provide a Speech Therapy (ST, profession aimed in the prevention, assessment, and treatment of speech, language, communicative, and swallowing disorders) evaluation in accordance with the physician's orders for one of three sampled residents (Resident 10) who had swallowing, communication, and cognitive (mental action or process of acquiring knowledge and understanding) concerns.This deficient practice prevented Resident 10 from receiving ST services to potentially improve swallowing, cognitive, and communication abilities and maintain or achieve the highest practicable level of function. Findings: During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was admitted to the facility on [DATE] with diagnoses including right-sided hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following a cerebral infarction (blockage of the flow of blood brain,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical records for one of three sampled residents (Resident 10) were readily accessible by failing to ensure Resident 10's Orthopedic (specialty area in medicine referring to the management of the muscles, bones, and their connective structures) consultation note, dated 3/20/2025, was readily accessible. This deficient practice had the potential to delay and negatively affect the delivery of necessary care and services. Findings: During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was admitted to the facility on [DATE] with diagnoses including right-sided hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following a cerebral infarction (blockage of the flow of blood brain, causing or resulting in brain tissue death), aphasia (loss of ability to understand or express speech, caused by brain damage), and osteoarthritis (loss of protective cartilage 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.

Based on interview and record review, the facility failed to ensure 1 of 3 sampled resident (Resident 1) was notified of a diagnostic test result that indicated Resident 1 had a mass (a lump) that measured 3.4-centimeter (cm, unit of measurement) on Resident 1's right kidney on 01/29/2025. Additionally, the facility failed to ensure appropriate follow-up was completed by Resident 1's physician (unidentified) to determine whether further interventions were necessary for Resident 1. This failure resulted in a delay in medical treatment and had the potential to result in a physical decline to Resident 1 due to the delayed treatment of a potentially serious medical condition. Findings: During a review of Resident 1's admission Record (AR), the facility initially admitted Resident 1 on 5 /8/2023, and readmitted the resident on 10/6/2024 with diagnoses including diabetes mellitus (DM, long-term disease that results in elevated levels of glucose in the blood), and end stage renal disease (ESRD- a medical condition in which a person's kidneys cease functioning on a permanent basis). 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 the assessment entries on the Minimum Data Set (MDS- a resident assessment tool) related to active diagnoses was accurately documented for one of four sampled residents (Resident 2) when Resident 2's Parkinson's disease (a disorder of the central nervous system [a processing center that manages everything the body does] that affects movement, often including tremors) was not coded (recorded) in Resident 2's MDS. This deficient practice had the potential to negatively affect Resident 2's plan of care and delivery of necessary care and services. Cross Reference F656 Findings: During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE], with diagnoses that included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and dementia (a progressive state of decline in 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan to address medication administration and side effects of Sinemet (a medication commonly used to manage Parkinson's disease [a disorder of the central nervous system (a processing center that manages everything the body does) that affects movement, often including tremors] symptoms, can cause a range of side effects, both mild and serious) for one of four sampled residents (Resident 2). This deficient practice had the potential to result in medication side effects not being identified and addressed for Resident 2. Cross Reference F641 Findings: During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE], with diagnoses that included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and dementia (a progressive state of decline in 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the facility's consultant pharmacist (PharmD) identified the irregularities (includes but is not limited to, use of medications without adequate indication, without adequate monitoring, in excessive doses, and/or in the presence of adverse consequences) related to Sinemet use (medication used to manage the symptoms of Parkinson's disease [a disorder of the central nervous system (a processing center that manages everything the body does) that affects movement, often including tremors) during the monthly medication regimen review (MRR- a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) for one of four sampled residents (Resident 2). This deficient practice had the potential to result in unnecessary use of Sinemet or potential adverse side effects for Resident 2. Cross Reference F757 Findings:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 who was receiving Sinemet (medication used to manage the symptoms of Parkinson's disease [a disorder of the central nervous system (a processing center that manages everything the body does) that affects movement, often including tremors]) was free from unnecessary medication for one of four sampled residents (Resident 2) by failing to: 1. Ensure there was a documented adequate indication for the use of Sinemet medication. 2. Ensure Resident 2 was monitored for effectiveness and/or any potential adverse side effects of Sinemet. These deficient practices had the potential to result in unnecessary use of Sinemet by not monitoring the effectiveness of Sinemet or potential adverse side effects. Cross Reference F641 and F756 Findings: During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE], and then readmitted on [DATE] and 5/8/25 with diagnoses that included…

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

Based on interview and record review, the facility failed for one of four sampled residents (Resident 1) to assist Resident 1in finding her missing personal belongings. This failure had the potential for Resident 1 to feel unheard and/or disrespected. (Cross Reference F842) Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 8/19/2024 with diagnoses including acute embolism (a medical condition where a foreign substance, such as a blood clot, air bubble, or tumor, travels through the bloodstream and blocks a blood vessel) and thrombosis (blood clot) of unspecified deep veins of lower extremities, morbid obesity (excessive amount of body weight), and fall. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 2/23/2025, the MDS indicated Resident 1 had no impairments in cognitive skills (ability to make daily decisions). The MDS indicated Resident 9 required substantial/maximal assistance (helper does more than half the effort) from staff for bathing, lower body dressing, and…

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

Based on interview and record review, the facility failed to accurately document in one of four sampled residents (Resident 1) medical record the facility staff members who were present at Resident 1 ' s quarterly care conference (also known as a care plan meeting, is a scheduled meeting where staff, residents, and family members discuss the resident's care plan, progress, and any concerns) on 2/27/2025. This failure resulted in Resident 1 ' s medical records to contain inaccurate information. (Cross Reference F557) Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 8/19/2024 with diagnoses including acute embolism (a medical condition where a foreign substance, such as a blood clot, air bubble, or tumor, travels through the bloodstream and blocks a blood vessel) and thrombosis (blood clot) of unspecified deep veins of lower extremities, morbid obesity (excessive amount of body weight), and fall. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 2/23/2025, 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 observation, interview, and record review, the facility failed to recognize, assess, and provide effective pain management to two of nine sampled residents (Resident 2 and Resident 3), according to the facility's policies and procedures (P&P) titled, Pain- Clinical Protocol, and Changes in Resident Condition, by failing to: 1. Ensure Resident 2's request to Licensed Vocational Nurse (LVN) 5 to have pain medications of ibuprofen (medication used to treat mild pain rated one to three out of 10) and Tylenol (acetaminophen- pain medication used to treat mild pain rated one to three out of 10) changed from as needed (medication taken when symptoms occur) to scheduled (medication taken at regular intervals) was reported to Resident 2's physician. 2. Ensure LVN 4 accurately documented Resident 3's pain score (pain score indicating level of pain with zero being no pain and 10 being the worst pain) on 3/6/2025 at 1:50 pm when LVN 4 gave Resident 3 Tylenol. 3. Ensure LVN 4 gave the appropriate pain medication to…

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

Based on observation, interview, and record review, the facility failed to ensure one of nine sampled Residents (Resident 5) received prescribed (ordered by a physician) medications in accordance with the facility's policy and procedure (P&P) titled, Administering Medications, by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 6 administered Resident 5's medications as ordered for the following medications: a. calcium (medication or mineral in nutritional supplements and multivitamins used to treat or prevent conditions associated with low calcium levels) 600+D3 (fat-soluble vitamin essential for bone health). b. Freshkote (medication used to relieve dry, irritated eyes) ophthalmic (eye) solution. c. glipizide (medication that stimulates the release of insulin from the pancreas [organ that produces insulin- natural substance that is needed to break down sugar in the body] directing your body to store blood sugar helping to lower blood sugar [BS- also known as blood glucose, is the main sugar found in the blood] and restore the way food is used to make energy). d. metoprolol…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policies and procedures titled, Handwashing/Hand Hygiene (procedures that included the use of alcohol-based hand rubs (containing 60%-95% alcohol) and hand washing with soap and water), and Enhanced Barrier Precautions (EBP- set of infection control measures that use personal protective equipment [PPE- equipment worn to minimize exposure to hazards] to reduce the spread of multidrug-resistant organisms [MDRO- organism that is resistant to most antibiotics] by wearing a gown and gloves) by failing to: 1. Ensure Certified Nurse Assistant (CNA) 2 performed hand hygiene before and after providing care to Resident 8. 2. Ensure CNA 3 performed hand hygiene before and after providing care to Resident 10. These failures had the potential to transmit and spread infection from residents to staff that could result in widespread infection in the facility. Findings: a. During a review of Resident 8 ' s admission Record (AR), the AR…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the assessment entries on the Minimum Data Set (MDS- a resident assessment tool) related to active diagnoses was accurately documented to reflect the resident's medical condition for one of nine resident (Resident 2). This failure had the potential to negatively affect Resident 2's plan of care and delivery of necessary care and services. During a review of Resident 2 ' s admission Record (AR), the AR indicated the facility admitted Resident 2 on 8/19/2024 with diagnoses that included squamous cell carcinoma of skin (a type of cancer that starts as a growth on the skin), acute embolism (an obstacle or blockage in a blood vessel) and thrombosis (the formation of a blood clot inside a blood vessel) of unspecified deep veins of lower extremity (refers to the part of the body that includes the legs and feet) and edema (swelling caused by too much fluid trapped in the body ' s tissues). During a review of Resident 2 ' s MDS dated [DATE] the MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure accurate documentation on the medication administration record (MAR- a report that serves as a legal record of the medications administered to a resident) for one of nine sampled residents (Resident 3), according to the facility's policy and procedure (P&P) titled, Charting and Documentation, by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 4 accurately documented Resident 3's pain score (pain score indicating level of pain with zero being no pain and 10 being the worst pain) when LVN 4 gave Resident 3 Tylenol (acetaminophen- pain medication used to treat mild pain rated one to three out of 10). This failure had the potential to negatively affect Resident 3's plan of care and delivery of necessary care and services for uncontrolled pain management. Cross Reference: F697 Findings: During a review of Resident 3's admission Record (AR), the AR indicated the facility admitted Resident 3 on 4/16/2024 and was readmitted on [DATE] with…

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

Based on interview and record review, the facility failed to ensure a staff member treated one of one sampled resident (Resident 44) with respect and dignity. This deficient practice made Resident 44 feel singled out, embarrassed, emotionally distressed, angry, and belittled. Additionally, the deficient practice had the potential to cause psychosocial harm to Resident 44. Findings: During a review of Resident 44's admission Record (AR), the AR indicated the facility admitted Resident 44 on 5/8/2023, and re-admitted the resident on 10/6/2024, with diagnoses including type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and bipolar disorder (a mental illness that causes extreme mood swings, or shifts from mania [extremely elevated and excitable mood] to depression). During a review of Resident 44's Minimum Data Set (MDS, a resident assessment tool), dated 1/1/2025, the MDS indicated Resident 44's was 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 and interview, the facility failed to ensure a homelike environment for one of one sampled resident (Resident 21) as evidenced by a cracked window in Resident 21's room. This failure resulted in Resident 21 feeling no one cared about the appearance of Resident 21's living space had a cracked window and was described by Resident 21 as ghetto and tacky. Findings: During a review of Resident 21's admission Record (AR), the AR indicated Resident 21 was initially admitted to the facility 10/24/2022 and the resident was readmitted on [DATE] with multiple diagnoses including chronic obstructive pulmonary disease (lung condition that causes long-term breathing difficulties) and depression (feelings of hopelessness, sadness, and a general disinterest in life, which for the most part have no cause and may be the result of a psychiatric illness). During a review of Resident 21's Minimum Data Set (MDS - a resident assessment tool) dated 11/16/2024, the MDS indicated Resident 21 had intact 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 interview and record review the facility failed to develop a care plan (CP - document created that outlines the type of care a patient needs) for one of one sampled resident (Resident 3) for participating in the facility's bowel and bladder program. This failure had the potential to result in unmet bowel and bladder continence (ability to control movements of the bowel and bladder) needs for Resident 3. Findings: During a review of Resident 3's admission Record (AR), the AR indicated Resident 4 was admitted to the facility 1/18/2025 with multiple diagnoses including cellulitis (a skin infection caused by bacteria that can lead to tissue damage and blood poisoning if left untreated; characterized by fever, chills, heat, tenderness, and redness) of the left lower limb (a leg or arm) and depression (feelings of hopelessness, sadness, and a general disinterest in life, which for the most part have no cause and may be the result of a psychiatric illness). During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool) dated 1/22/2025, 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.

Based on observation, interview, and record review, the facility failed to provide an ongoing sensory stimulating activities program designed to meet the interest of Resident 226. This deficient practice had the potential to result in psychosocial decline and a decreased quality of life to Resident 226 due to boredom and loneliness. Findings: During a review of Resident 226's admission R (AR), the AR indicated Resident 226 was admitted to the facility 2/6/2025 with diagnosis that included periprosthetic left hip joint (a break in the bone around a hip replacement), fracture of left radial styloid process (a break at the end of the forearm) and dysphagia (swallowing difficulty). During a review of Resident 26's Activity Interview for Daily and Activity Preferences (AIDAP), dated 2/8/2025, completed by the Activity Assistant (AA), the record indicated Resident 226's previous work experience included, worked at a bookstore and Resident 226's daily pleasure was reading mystery books and doing work search puzzles. During a review of Resident 226's Minimum data Set (MDS, a resident…

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

Based on interview and record review the facility failed to follow the steps outlined in the facility's policy and procedure (P&P), titled, Bladder and Bowel Program, for one of one sampled resident (Resident 3) who was placed in the bladder and bowel program. This failure had the potential to lead Resident 3 being unable to regain bowel and bladder continence. Findings: During a review of Resident 3's admission Record (AR), the AR indicated Resident 4 was admitted to the facility 1/18/2025 with multiple diagnoses including cellulitis (a skin infection caused by bacteria that can lead to tissue damage and blood poisoning if left untreated; characterized by fever, chills, heat, tenderness, and redness) of the left lower limb (a leg or arm) and depression (feelings of hopelessness, sadness, and a general disinterest in life, which for the most part have no cause and may be the result of a psychiatric illness). During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool) dated 1/22/2025, the MDS indicated Resident 3 had intact cognition (ability to understand and…

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

Based on interview, and record review, the facility failed to ensure a code status (an instruction from a patient of the medical team indicating what the medical team should do if the patient has a cardiac or respiratory arrest) was documented on the admission Record, Electronic Health Record (a digital version of a patient's medical history that can be accessed by authorized healthcare providers) dashboard banner, and the physical medical record for one of one sampled residents (Resident 27). This deficient practice had the potential to lead to negative outcomes with failing to honor resident's wishes and improper end-of-life care in a timely manner. Findings: During a review of Resident 27's admission Record (AR), the AR indicated the facility admitted Resident 27 on 1/30/2025, with diagnoses including acute respiratory failure with hypoxia (a sudden and severe condition where your lungs are unable to provide enough oxygen to your body, leading to a dangerously low level of oxygen in your blood), dementia (a progressive state of decline in mental abilities), and failure to thrive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 revise the plan of care and implement new interventions for one of three sampled residents (Resident 1) after Resident 1 first fell on 6/24/2024 at 1:20 AM to prevent Resident 1 from further falls and injuries. This deficient practice placed Resident 1 at risk for further falls and injuries. Cross Reference F689 Findings: During a review of Resident 1's admission Record (AR), the AR indicated, the facility admitted Resident 1 to the facility on 6/7/2024, with diagnoses that included traumatic subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain due to injury) without loss of consciousness, Covid-19 (minor to severe respiratory illness caused by a virus and spread from person to person), fall (on)(from) other stairs and steps, and other abnormalities of gait (manner of walking or moving on foot) and mobility (ability to move). During a review of Resident 1's Fall Risk Evaluation, dated 6/7/2024, the Fall Risk Evaluation indicated, Resident 1 was at high risk for falls. During a…

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

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 5) was free from physical restraints (any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to a resident's body, cannot be easily removed by a resident, and restricts the resident's freedom of movement or access to their body) for use of convenience (the result of any action that has the effect of altering a resident's behavior and requires a lesser amount of care or effort, and is not in a resident's best interest) by failing to ensure Certified Nurse Assistant (CNA) 1 did not tie the bedsheet/fitted sheet to the grab bar and keep Resident 5's arms under the fitted sheet to prevent Resident 5 from moving the resident's arms. This failure violated Resident 5's right and had the potential for Resident 5 to suffer psychosocial (mental, emotional, social, and spiritual effects) harm, and/or physical injury. Findings: During a review of Resident 5's admission Record (AR), the AR indicated the facility admitted Resident 5 on 2/27/24,…

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

Based on observation, interview, and record review, the facility failed to provide a low air loss mattress (LAL mattress, a type of medical mattress designed to reduce pressure on the skin, which helps prevent pressure ulcers ([PU] localized damage to the skin and underlying soft tissue, usually over a bony prominence (areas where bones are close to the surface) or related to a medical or other device, resulting from sustained pressure) as per Physician's Order for one of three sampled residents (Resident 1 This deficient practice had the potential for Resident 1's PU to worsen. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility readmitted Resident 1 on 4/2/24, with diagnoses of acute kidney failure (when kidneys suddenly become unable to filter waste products from your blood), pressure ulcer of sacral ([sacrum] a triangular bone at the base of the spine], region, and muscle wasting and atrophy (a weakening, shrinking, and loss of muscle caused by disease or lack of use). During a review of Resident 1's admission 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 ensure 3 of 3 sampled residents (Residents 14, Resident 61, Resident 67) were made aware of the location of the most recent survey results conducted for resident's review. This failure resulted in violation of resident rights to access the facility's survey results and had the potential to result in the residents not being fully informed about the facility's overall performance and the potential for resident's not being able to make informed choices due to the lack of information. Findings: During a review of Resident 14's admission Record (AR), the AR indicated Resident 14 was readmitted to the facility on [DATE] with diagnoses that included hypertensive heart disease (changes in the left ventricle, left atrium, and coronary arteries as a result of chronic [long standing] high blood pressure), hemiplegia and hemiparesis of left dominant side (one sided paralysis), and chronic pulmonary edema (too much fluid in the lungs). During a review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure resident meals were palatable (refers to the taste and/or flavor of the food) for 3 of 3 sampled residents (Resident 47, 54 and 56) and the facility failed to taste the food prior to serving to the residents (in general) and as indicated in the facility's policy and procedure (P&P). This failure had the potential to result in unplanned weight loss due to poor food intake for Residents 47, 54 and 56. Findings: During a review of Resident 47's AR, the AR indicated Resident 47 was admitted to the facility on [DATE] with diagnoses that included diabetes and obesity (abnormal or excessive fat accumulation). During a review Resident 47's H&P, dated 9/30/23, the H&P indicated Resident 47 had the capacity to understand and make decisions. During a review of Resident 54's admission Record (AR), the AR indicated Resident 54 was admitted to the facility on [DATE] with diagnoses that included diabetes (elevated blood sugar) and hyperlipidemia (elevated fat 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 interview and record review, the facility failed to ensure the signed binding arbitration agreement (BAA, contract between the facility and resident requiring disputes to be resolved by an arbitrator [third party decision-maker] instead of a judge or jury in court) for three of 18 sampled residents (Residents 74, 130, and 56) was provided for the selection of a neutral arbitrator and a convenient venue (location to carry out arbitration proceedings agreed upon and suitable to both parties). This failure had a potential to result in a decline in the Resident 74, 130 and 56's physical and psychosocial condition due to possible hardships related to arbitration proceedings. Findings: a. During a review of Resident 74's admission Record (AR 1), AR 1 indicated the facility initially admitted Resident 74 to the facility on 1/9/2024 with multiple diagnoses including history of joint replacement surgery and infection and inflammation reaction due to internal joint prosthesis (device placed inside the body 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 ensure one of one sampled resident (Resident 56) was included in the resident's discharge planning. This failure resulted in Resident 56 not participating in Resident 56's discharge planning and had the potential to result in Resident 56's personal choices and preferences not included in Resident 56's discharge planning. Findings: During a review of Resident 56's admission Record, (AR), the AR indicated Resident 56 was admitted to the facility on [DATE] with diagnoses that included acute (severe and sudden in onset) and chronic (persistent or long-lasting) respiratory failure (a serious condition that happens when your lungs cannot get enough oxygen into your blood), acute congestive heart failure (CHF, heart doesn't pump enough blood for your body's needs) and generalized muscle weakness. During a review of Resident 56's Social Services Evaluation (SSE) form, completed by the Director of Social Services (DSS), dated 1/10/24 timed at 11:54 am., the SSE…

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

Based on interview and record review, the facility failed to ensure an abnormal urinalysis (urine test to detect and manage some disorders, such as urinary tract infections [UTI] or kidney problems) result of one of one sampled resident (Resident 132) was reported to the physician timely. This failure had the potential to result in a decline in Resident 132's condition due to a delay in the delivery of treatment and services. Findings: During a review of Resident 132's admission Record (AR), the AR indicated the facility initially admitted Resident 132 on 1/23/2024 with diagnoses including obstructive and reflex uropathy (inability of urine to flow through the ureter, bladder, or urethra due to obstruction and with backflow of urine into the kidney/s), congestive heart failure (inefficient pumping of the blood by the heart caused by a weakened or damaged heart), type 2 diabetes mellitus (chronic condition wherein the body has inability to control blood sugar), and alcoholic cirrhosis of the liver (permanent damage of the liver due to scarring due to drinking high alcohol intake).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the necessary care and services for one of one sampled resident (Resident 56) by failing to administer four liters per minute (4L/min, Liters, unit of volume, per minute) of continuous (constant, steady, and reliable oxygen flow) oxygen (O2, gas that the body needs to live) through a nasal cannula [NC, a device that gives you additional oxygen through your nose]) as indicated in the physician's order and the facility's policy and procedures (P&P). This failure had the potential to result in Resident 56 to experience shortness of breath, a delay in treatment, and the potential to result in respiratory distress (oxygen deprivation). Findings: During a review of Resident 56's admission Record, (AR), the AR indicated Resident 56 was admitted to the facility on [DATE] with diagnoses that included acute (severe and sudden in onset) and chronic (persistent or long-lasting) respiratory failure (a serious condition that happens when your lungs cannot…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 transportation was provided for a follow up eye (vision) appointment for one of one sampled resident (Resident 31), who needed eyeglasses. This failure resulted in a delay of necessary care and services for Residents 31 and had the potential to result in worsening eyesight for Resident 31. Findings: During a review of Resident 31's admission Record (AR), the AR indicated Resident 31 was readmitted to the facility on [DATE] with diagnoses that included chronic (long standing) obstructive pulmonary disease (group of lung diseases that block airflow), open angle glaucoma (chronic, progressive, and irreversible loss of peripheral vision and central visual field), and cachexia (general state of ill health involving great weight loss and muscle loss). During a review of Resident 31's History & Physical (H&P), dated 11/19/23, the H&P indicated Resident 31 had the capacity to understand and make decisions. During a review of Resident 31's Minimum Data…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 46) who was a smoker, was assessed quarterly on November 2023 for smoking risk factors and resident safety. This failure had the potential to result in Resident 46 to experience complications from smoking and sustain serious injuries. Findings: During a review of an admission Record (AR) indicated Resident 46 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included muscle atrophy (wasting away of the body tissue) weakness, pylogenic arthritis (an infection in the joint fluid and joint tissues), and difficulty walking. During a review of a Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 11/23/23, the MDS indicated Resident 46 was cognitively (ability to understand and process information) intact, had clear speech, was able to make self-understood, and Resident 46 had the ability to understand others. During a review of Resident 46's…

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

Based on interviews and record review, the facility failed to ensure the medical records of one of one sampled resident's administration of wound treatment was accurately documented (Resident 77). This failure had the potential to result in increased risk for inaccurate treatments being provided to Resident 77. Findings: During a review of Resident 77's admission Record (AR), the AR indicated the facility initially admitted Resident 77 on 1/12/24 with diagnoses including history of benign neoplasm of cerebral meninges (nonmalignant brain tumor) with aftercare following surgery. During a review of Resident 77's History and Physical (H&P), dated 1/13/24, the H&P indicated Resident 77 had the capacity to understand and make decisions. Resident 77 had craniotomy (surgical procedure wherein a part of the skull is temporarily removed to expose the brain and perform a procedure) for tumor resection (tumor removal). During a review of Resident 77's Minimum Data Set (MDS, a standardized resident screening and care-planning tool), dated 1/16/24, the MDS indicated Resident 77 had no 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.

Based on observation, interview, and record review, the facility failed to follow the infection prevention and control practices and implement interventions to prevent and control the spread of infections in the facility for one of 5 sampled residents (Resident 53), who had an indwelling medical device (device embedded in the body that provides a direct pathway for pathogens in the environment to enter the body and cause an infection), in accordance with the facility's policy and procedures (P&P) and national health guidelines. On 2/7/2024, Resident 53 was not identified upon assessment as a resident to be placed on Enhanced Barrier Precautions (EBPs, infection control interventions that require gown and glove use during high-contact resident care activities to reduce transmission of multidrug-resistant organisms [MDROs] in nursing homes) in accordance with the facility's P&Ps on EBPs and Centers for Disease Control and Prevention (CDC) guidelines. This failure had the potential to result in the spread of infections thought out the facility. Findings: During a review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure safe pharmaceutical services and administration of controlled substances (drug or other substance that is tightly controlled by the government because it may be abused or cause addiction), for one of three sampled residents (Residents 1), who received Norco (narcotic, controlled medication used to treat moderate to severe pain and has addiction [physical dependence] properties). On 7/12/2023, Resident 1 did not receive Norco as ordered by her physician. This deficient practice resulted in diversion (theft or illegal distribution of a prescribed drug for purposes not intended by the prescriber) of Norco and had the potential to result in uncontrolled pain to Residents 1. Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included aftercare following joint replacement surgery and difficulty walking. During a review of the facility'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.