San Diego Post-Acute Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to thoroughly investigate two facility reported incidents of physical abuse and take appropriate corrective action.As a result of this deficient practice, there was the potential for further resident-to-resident altercations and abuse to occur. Cross reference F600.The First Reported Incident (12/25/25):A review of Resident 3's admission Record indicated the resident was readmitted to the facility on [DATE] with diagnoses to include anxiety.A review of Resident 5's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses to include traumatic brain injury, post-traumatic stress disorder (PTSD, a mental health condition that develops after exposure to a traumatic event), bipolar disorder (a mood disorder that alternates between depression and mania), and Alzheimer's dementia.A review of the facility's Report of Suspected Dependent Adult/Elder Abuse form (SOC 341, a form submitted to the State agency to report allegations…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 appropriate treatment and services for the behavioral health care of one of three residents (Resident 5) with a diagnosed mental disorder and post-traumatic stress disorder (PTSD, a mental health condition that develops after exposure to a traumatic event) when:1. Resident 5's behavioral triggers were not assessed and care planned.2. Resident 5's PTSD was not assessed and care planned with resident-specific interventions.As a result of these deficient practices, Resident 5 was involved in physical altercations with other residents when triggered. There was also the potential for Resident 5 to be retraumatized when staff were not knowledgeable of the resident's PTSD diagnosis and behavioral triggers. Cross reference F600.A review of Resident 5's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses to include traumatic brain injury, post-traumatic stress disorder, bipolar disorder (a mood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide personalized dementia care for one of two residents (Resident 6) when the resident's behavior of wandering into other residents' rooms was not identified, assessed, and care planned with individualized interventions.As a result, Resident 6 wandered into Resident 5's room, put on Resident 5's clothing which caused a physical altercation. This had the potential to negatively impact Resident 6's ability to achieve his highest level of functioning. Cross reference F600.A review of Resident 6's admission Record indicated the resident was admitted on [DATE] and readmitted to the facility on [DATE] with diagnoses to include unspecified dementia (loss of cognitive functioning) and schizophrenia (a mental disorder characterized by paranoia and delusions). A review of Resident 6's Minimum Data Set Assessment (MDS, a comprehensive assessment tool) dated 12/12/25, indicated the resident scored 5 out of 15 on the brief interview of 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 interview and record review, the facility failed to ensure one of seven residents' (Resident 5) medical record was accurately and completely documented when:1. Resident 5's provider documentation indicated staff reported the resident was being aggressive and having mood swings, but these behaviors were not documented by staff.2. Resident 5's behavioral monitoring on the medication administration record (MAR) was inaccurate.As a result, Resident 5's medical record did not correctly represent the resident's actual behavioral condition.A review of Resident 5's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses to include traumatic brain injury, post-traumatic stress disorder, bipolar disorder (a mood disorder that alternates between depression and mania), and Alzheimer's dementia.A review of Resident 5's IDT (interdisciplinary team) note dated 12/26/25, indicated, .Writer was notified of an incident in the dinning [sic] room [on 12/25/25]. Another 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 develop a discharge care plan for one of three sampled residents (Resident 1).As a result, this deficient practice placed Resident 1 at risk for an unsafe or uncoordinated discharge, unmet care needs, and delays in services during any transition out of the facility.Findings:A review of Resident 1's admission Record indicated, Resident 1 was re-admitted to the facility on [DATE] with diagnoses which included history of Cerebrovascular Disease (conditions that affect blood flow to the brain).A record review of Resident 1's minimum data set (MDS - a federally mandated resident assessment tool) dated 9/5/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of two points out of 15 possible points which indicated Resident 1 had severe cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 12/2/25 at 12:30 P.M., an interview and record review 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 update and revise a person-centered discharge care plan for one of three sampled residents (Resident 3) that reflected their discharge needs, preferences, and goals.As a result, this deficient practice placed Resident 3 at risk for an unsafe or uncoordinated discharge, unmet needs during transition, and delays in needed services.Findings:A review of Resident 3's admission Record indicated Resident 3 was re-admitted to the facility on [DATE] with diagnoses which included history of Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).A record review of Resident 3's minimum data set (MDS - a federally mandated resident assessment tool) dated 11/12/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 15 points out of 15 possible points which indicated Resident 3 had no cognitive (pertaining to memory,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 request, the facility failed to secure medication carts when not in use by staff, for two of eight medication carts (Station 2 and Station 3), when reviewed for Pharmacy Services.This failure had the potential for residents, visitors, and staff, to obtain unauthorized medications that could cause harm.Findings:On 9/5/25, an unannounced visit was made to the facility in response to a complaint. An observation and interview was conducted in the south hall of Station 2 on 9/5/25 at 10:44 A.M., The medication cart was unlocked and unattended, with a resident sitting in a wheelchair next to the medication cart. Resident 1 stated she was waiting for the nurse to return, so she could get her medication. On top of the medication cart, was an opened Control Drug Record (CDR) with a sheet for Resident 2, for antibiotic administration. On the open computer, was the medication record administration for Resident 3. An observation and interview was conducted with Licensed Nurse 1 (LN 1) on 9/5/25 at 10:48 A.M. after she exited a resident room down 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 interview and record review, the facility failed to consistently provide a shower on scheduled shower days for one of three residents (Resident 1) reviewed for Activities of Daily Living (ADL).As a result, Resident 1 was not offered and provided a shower during his first week of admission to the facility. This failure had the potential to negatively affect the resident's well-being.Findings:A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with a diagnosis of generalized weakness, major depressive disorder and cognitive communication deficit.A review of Resident 1's care plan, dated 7/1/25, indicated, ADL/Mobility: Resident.is at risk for ADL/mobility decline and requires assistance.will have no significant declines in ADL's or mobility.On 7/14/25 at 8:55 A.M., an interview was conducted with Resident 1. Resident 1 stated that the facility did not offer him a shower for a full week after admission.On 7/14/25 at 9:08 A.M., an interview was conducted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident's (Resident 2) Low Air Loss mattress (LAL, a mattress that uses a continuous flow of air through tiny laser made air holes in the top of the mattress surface so that the user floats on a soft cushion of air that helps to prevent pressure ulcers) was functioning properly when a plastic inflatable overlay mattress was placed on top of the LAL mattress.As a result, this had the potential for Resident 2 to experience skin breakdown and develop pressure ulcers.Findings:A review of Resident 2's admission Record indicated the resident was re-admitted to the facility on [DATE] with a diagnosis of functional quadriplegia (paralysis of all four limbs), hereditary motor and sensory neuropathy (a condition that affects the nerves), pressure ulcer of sacral region stage 3 (a pressure injury that goes down into the fat and muscle tissue), pressure-induced deep tissue damage of left heel, and pressure-induced deep tissue damage of…

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

Based on observation and interview, the facility failed to ensure staff used the appropriate Personal Protective Equipment (PPE) when entering a room placed on Transmission Based Precautions (TBP – a sign outside of a resident's room which indicated that visitors had to wear PPE to avoid catching an infection from the resident) for two of three staff observed entering rooms on TBP. This failure placed the facility's residents at an increased risk of infection. Findings: On 6/3/25 at 10 A.M., an observation was conducted of Housekeeper (HK) 1 entering the room of resident on TBP. The TBP sign at the entrance to the room directed visitors to wear eye protection before entering the room. HK 1 was not wearing eye protection while he cleaned the floor in the room on TBP. On 6/3/25 at 10:07 A.M., an observation was conducted of Certified Nursing Assistant (CNA) 2 entering the room of a resident on TBP. The TBP sign at the entrance to the room directed visitors to wear eye protection before entering the room. CNA 2 was not wearing eye protection while she went into the TBP room and spoke…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations, interviews, and record reviews the facility failed to ensure sanitary practices in the kitchen were maintained for floor sink drains and the ice machine to prevent debris, slime, mold and other potentially contaminated substances to prevent exposure to unsafe and unsanitary practices that affect foods. These failures had the potential to place residents at risk of developing foodborne illnesses. The facility census was 238. Cross reference F925 Findings: During a record review of the County of San Diego, Department of Environmental Health and Quality, Food Inspection Report dated 5/14/25, the report indicated .Risk Factor/Violation: 23. No rodents, insects, birds or animals Observation: Multiple evidence of rodent infestation (rodent droppings) .behind the oven in the food preparation area. Behind cabinet .Facility using .Pest control company. Last pest control receipt was 5/1/2025 .Corrective Action: Eliminate all rodent activity and harborage immediately. Thoroughly clean and sanitize all food contact surfaces and impacted areas. Facility ordered to cease…

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

Based on observation, interview and record review, the facility failed to ensure the facility's kitchen was free of pests when: 1) the pest control company recommendations were not carried out to prevent rodents, and 2) unsanitary practices with large uncovered openings and holes were found in the kitchen. This failure led to a kitchen closure by the local health department due to sightings of rodent droppings and had the potential to contaminate the residents' food prepared and stored in the kitchen and dining areas. The facility census was 238. Cross reference F812 Findings: During a record review of the County of San Diego, Department of Environmental Health and Quality, Food Inspection Report dated 5/14/25, the report indicated .Risk Factor/Violation: 23. No rodents, insects, birds or animals Observation: Multiple evidence of rodent infestation (rodent droppings) .behind the oven in the food preparation area. Behind cabinet .Facility using .Pest control company. Last pest control receipt was 5/1/2025 .Corrective Action: Eliminate all rodent activity and harborage immediately.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 take appropriate action to protect one (Resident 5) of three residents reviewed for abuse, from his alleged perpetrator (person who inflicts harm). This failure had the potential for Resident 5 for repeat abuse from the perpetrator and placing other residents at risk for a potential abuse. Findings: On 3/19/25 at 9:04 A.M., an unannounced onsite visit at the facility was conducted related to a reported resident to resident altercation. Resident 5 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease (a brain disorder that slowly destroys memory, thinking skills and eventually the ability to carry out simple tasks) and dementia (loss of memory, language, problem solving and other thinking abilities); (an impairment of brain function, such as memory loss and judgment) according to the facility's admission Record. Resident 9 was admitted to the facility on [DATE] with diagnoses including cognitive communication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. The temperature was consistently monitored and documented for one of two medication (med/s) refrigerators, one of one utility room, and one of one utility refrigerator, 2. An opened multi dose flu vaccine was dated with an opened date and an opened inhaler was not labeled and dated, 3. discharged resident medications were kept after more than 30 days and commingled with active resident's medications, and, 4. Loose meds were found in the cycle drawer of the med cart. These failures had the potential to affect the efficacy of medications and effectiveness of treatment, to affect residents to receive expired medications, to affect discharge residents to not have available meds on discharge, and residents' safety. Findings: 1. On 2/24/25 at 3:50 P.M., a joint observation and an interview with Licensed Nurse (LN) 14 was conducted in station 4 med room. The temperature log for the med refrigerator, the utility room and the utility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that food served during lunch was at a palatable temperature for the residents. This failure had the potential to prevent the residents from eating their meals and not receive their daily nutrition. Findings: Review of Resident Council Meeting Minutes from 2/20/25 indicated one resident council member stated .that the food is cold when served . On 2/24/25 between 10 A.M. and 11:15 A.M., a Resident Council Meeting was conducted with eight Resident Council members. At 11:03 A.M., a poll of Resident Council members present indicated seven out of eight members felt food was not hot enough. On 2/24/24 during initial pool screening, residents stated the following about the food: .I have meatball that is raw and felt funny . .I had hamburger- no steam, I touched the bun and it is cold .it frequently happens .I asked the nurse to put in microwave for two minutes- somewhat raw - the burger is still red very visible . .scrambled eggs sometimes cold .sometimes sausage and bacon are cold . On 2/25/25 at 11:45 A.M.,…

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

Based on observation, interview, and record review the facility failed to store the following foods appropriately: 1. Grilled cheese 2. Soy sauce 3. Food thickener This failure had the potential for residents receiving spoiled or contaminated food. Findings: On 2/24/25 an initial tour of the kitchen with the Dietary Manager(DM) and the Registered Dietician (RD) was conducted. During an observation of the walk-in refrigerator at 7:56 A.M., a tray of prepared grilled cheese was observed with a large piece wax paper covering just the top of the grilled cheese on a tray with four small bottles of water weighing down the four corners of the waxed paper. The sides of the grilled cheese were uncovered and open to air. The wax paper was labeled For lunch Prep 2/24/25 for UB (use by) 2/24/25. The DM stated that the grilled cheese should have been sealed with plastic wrap and then disposed of the grill cheese in the trash. On 2/24/25 an initial tour of the dry storage room was conducted at 8 A.M. An opened soy sauce container, dated, opened 1/23/25, and UB date 2/23/25 was observed on sauce…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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's Quality Assessment Performance improvement (QAPI- plan developed by the QAA (Quality Assessment and Assurance committee-committee that oversees facility conditons and trends) failed to identify deficient practices prior to their recertification survey which include; 1) Call light response time from staff and, 2) Identifying food concerns from resident interviews and during the resident council meeting. This failure had the potential for the facility to overlook trends in resident's health and quality of life. Cross reference : F804 A joint interview on 2/27/25 at 2:27 P.M., with the Administrator (ADM) and the Acting Director of Nursing (aDON) was conducted .The ADM stated they were not aware of the call light issues and food concerns. The ADM stated the expectation was the QAA committee should have identified the trends in the facility prior to being identified by the surveyors. A joint interview on 2/27/2025 at 2:27 P.M., with the ADM and the DON was conducted. The DON stated it was important to identify the residents food…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews and facility documents review, the facility failed to ensure a safe discharge for one of four sampled residents, reviewed for closed record (Resident 80). This failure had the potential to compromise Resident 80's health, safety and well-being and, as a result, Resident 80 was admitted to an acute care hospital on 2/16/25. Findings: Resident 80 was readmitted to the facility on [DATE], with diagnoses which included encephalopathy (disease that affects the brain), dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), infection of the skin and subcutaneous tissue and, that he needed assistance with personal care, per the facility's admission Record. On 2/25/25, a review of Resident 80's clinical record was conducted. Resident 80's attending physician completed Resident 80's history and physical (H&P) dated 11/1/24. The H & P indicated Resident 80 did not have the 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 implement a care plan (detailed plan with information about a patient's treatment, goal, and interventions) related to nail care for two of four sampled residents (90 and 131). This failure had the potential to not meet the goals of treatment and needs of Resident 90 and Resident 131. Cross reference to F 677 Findings: 1.Resident 90 was readmitted to the facility on [DATE], with diagnoses which included parkinsonism (a brain disorder that causes unintended or uncontrollable movements) and that he needed assistance with personal care, per the facility's admission Record. Resident 90's attending physician completed Resident 90's history and physical (H&P) dated 12/16/24. The H & P indicated Resident 90 had the capacity to understand and make decisions. On 2/24/25 at 9:44 A.M., an observation and an interview of Resident 90 was conducted in his room. Resident 90 was watching a television show. Resident 90 had a contracted right hand with long fingernails.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 in accordance with the facility's policy and procedure when a Licensed Nurse (LN) 12 did not use warm, purified water and completely diluted a resident's (Resident 141) medications during the administration of medications via a gastrostomy tube (g-tube, a tube inserted through the belly that brings nutrition or medications [med/s] directly to the stomach). This failure had the potential for not meeting Resident 141's therapeutic needs and had the potential of clogging the g-tube. Findings: A review of Resident 141's admission Record indicated Resident 141 was readmitted to the facility on [DATE], with diagnoses which included she had a g-tube for medications and nutrition. During a medication pass observation on 2/26/25, at 7:46 A.M., with Licensed Nurse 12 (LN 12), LN 12 was observed preparing four tablet medications and three liquid medications for Resident 141. LN 12 put gloves on, crushed Resident 141's meds 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 two of four residents (Resident 90 & Resident 131), who were unable to carry out activities of daily living (ADL-self- care activities such as personal hygiene), received assistance with nail care (cleaning, trimming and/or filing of nails). This failure resulted in Resident 98 and Resident 131 having long fingernails which had the potential to negatively impact the residents' hygiene, health and well-being. Cross reference to F 656 Findings: 1.Resident 90 was readmitted to the facility on [DATE], with diagnoses which included parkinsonism (a brain disorder that causes unintended or uncontrollable movements) and that he needed assistance with personal care, per the facility's admission Record. Resident 90's attending physician completed Resident 90's history and physical (H&P) dated 12/16/24. The H & P indicated Resident 90 had the capacity to understand and make decisions. Resident 90's minimum data set (MDS - a federally mandated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 smoking assessment was accurate on 1 out of 8 residents ( Resident 54) reviewed for accidents. This failure had the potential to place Resident 54 at risk for injury. Findings: Resident 54 was admitted to the facility on [DATE] , with diagnoses which included chronic obstructive pulmonary disease (lung disease with difficulty of breathing) and dementia (progressive state of decline in mental abilities) per the admission Record. On 2/27/25 at 9:55 A.M., an interview with Resident 54 was conducted. Resident 54 was alert and was seen on his way walking towards the patio. Resident 54 stated, I was going out to smoke outside, I have been smoking for years. A record review of Resident 54's Minimum Data Set (MDS- a federally mandated assessment tool) dated 2/1/25 with a Brief Interview for Mental Status (BIMS-Cognition assessment used by skilled nursing facilities) score of 09 which indicated Resident 54's cognition was moderately impaired. A record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility staff failed to monitor and document urine output (UO) per the facility's policy, for one of three sampled residents (Resident 141) with a urinary catheter (a tube inserted into the bladder to aid in urine flow). This failure had the potential for Resident 141 to have urinary retention and developed urinary tract infection (UTI). Findings: Resident 141 was readmitted to the facility on [DATE], with diagnoses which included functional quadriplegia (the complete inability to move due to severe disability or frailty caused by another medical condition without physical injury or damage to the spinal cord) and UTI, per the facility's admission Record. On 2/24/25 at 8:15 A.M., an observation of Resident 141 was conducted in her room. Resident 141 was connected to a breathing machine via a tracheostomy (a hole that surgeons make through the front of the neck and into the windpipe) tube. Resident 141 did not respond to her name. Resident 141 had a urinary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 restart Resident 39's (R39) continuous oxygen after transferring her from wheelchair to bed. This failure had the potential to affect the R39's respiratory health. Findings: Review of R39's admission Record indicated that resident was admitted on [DATE] for diagnoses which include Chronic Obstructive Pulmonary Disease (COPD-a group of lung diseases that cause persistent airflow limitation and breathing problems) and Congestive Heart Failure (CHF-chronic condition where the heart muscle is weakened and cannot pump blood effectively.) Review of Minimum Data Set(MDS-Federally mandated assessment tool) section C indicated R39 has a Brief Interview for Mental Status (BIMS- a screening tool that assesses a person's cognitive impairment) Score of 10 which indicates moderate cognitive impairment. Review of physician order from 10/5/25 indicated O2 (Oxygen) 2 Liters NC (Nasal Cannula-a thin, flexible tube that delivers oxygen through the nose)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 unnecessary medication when a resident (Resident 93) was receiving heparin (blood thinner that prevents blood clotting, one side effect is bruising or bleeding) and was not monitored for signs and symptoms of bruising/ bleeding for one of two sampled residents reviewed for anticoagulant. This failure could result in medication related adverse events from inconsistent and poor management of medication therapy for Resident 93. Findings: Resident 93 was readmitted to the facility on [DATE], with diagnoses which included functional quadriplegia (the complete inability to move due to severe disability or frailty caused by another medical condition without physical injury or damage to the spinal cord), per the facility's admission Record. On 2/24/25, a review of Resident 93's clinical record was conducted. There was a physician's order on 10/24/24 for heparin injection 5000 units (unit of measurement) with the direction 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 indicate the appropriate and measurable target behavior of antidepressant (medication used to treat depression, sad mood and lack of interest) for one of five sampled residents reviewed for unnecessary psychotropic (mind-altering medications) medication use (Resident 45). This failure had the potential for unnecessary psychotropic medication use, its side effects, and a decline for residents psychological and mental well-being. Findings: Resident 45's admission Record indicated Resident 45 was readmitted to the facility on [DATE] with diagnoses which included schizoaffective disorder (a mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations [a false perception of objects or events involving your senses: sight, sound, smell, touch and taste] and delusions, and mood disorder symptoms, such as depression, and mania). A review of Resident 45's physician order dated 12/26/24 indicated the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to prevent a medication error for 1 of 38 residents, (Resident 390). This failure had the potential for harm to Resident 390 (R390) from unnecessary medication. Findings: Review of admission Record for R390 indicated resident was admitted on [DATE] for diagnoses which include Type 2 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), morbid obesity (a severe form of obesity characterized by a high body mass index (BMI-a calculation used to estimate body fat percentage based on height and weight) and significant health risks ), cerebral infarction (a medical condition where blood flow to the brain is interrupted, leading to the death of brain cells), and aphasia (a language disorder that affects a person's ability to communicate effectively ). Review of R390's physician orders…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 infection control procedures were followed when a Licensed Nurse (LN) 12 did not perform hand hygiene (the practice of cleaning hands to remove germs, dirt, or other harmful substances) consistently after removing her gloves while passing medications (meds) during medication pass observation for 2 residents (Residents 141, 22). This failure had the potential for cross contamination and spread of infection between the residents. Findings: 1. A review of Resident 141's admission Record indicated Resident 141 was readmitted to the facility on [DATE], with diagnoses which included functional quadriplegia (the complete inability to move due to severe disability or frailty caused by another medical condition without physical injury or damage to the spinal cord) and she had a gastrostomy tube (g-tube, a surgical opening fitted with a device to allow feedings/ meds to be administered directly to the stomach common for people with swallowing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 water from the dishwashing sink drained appropriately onto the drain hole. This failure had the potential for accidents in the dishwashing area and a preventable flooding of the kitchen. Findings: On 2/25/25 at 8:45 A.M. a concurrent observation of dishwashing area and interview with Dietary Aide (DA) was conducted. While DA described the process for washing dishware, water was observed to be draining directly onto the floor beneath the dishwasher sink from the sink pipe and not directly into the drain hole. DA stated that he was not sure how long the water had been draining onto the floor. DA stated that the expectation was the drain water should empty directly into the drain hole and not onto the kitchen floor. DA stated the importance of functioning equipment was for safety of staff washing dishes, as they could slip on the water. On 2/25/25 at 8:50 A.M., a concurrent observation of dishwashing drainpipe and interview with the Dietary Manager (DM) was conducted. The DM stated he was not sure how…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure complete and accurate medical records were documented for two of seven residents (Resident 3 and 7) reviewed for resident records when: 1. Resident 3 and 7's inventory of personal items were not signed by the resident or the resident representative upon transfer to the hospital, 2. There was no documentation regarding following up with Resident 7's responsible party when the resident expired, 3. There was no physician's order to release Resident 7's body to the mortuary. This failure had the potential to result in inaccurate account of residents' belongings. In addition, the RP and md was not aware that Resident 7 expired and there was no physician's order to release Resident 7's body to the mortuary. Findings: 1a. Resident 3 was re-admitted to the facility on [DATE] with diagnoses including congestive heart (a condition in which the heart does not pump blood as well as it should) failure and muscle weakness according to 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 interview and record review the facility failed to ensure a physician's order was followed when nursing staff did not do vital signs every four hours for one COVID-19 (a highly contagious respiratory disease) positive resident (1) who was transferred and later died at the hospital. This deficient practice delayed the gathering of vital information about Resident 1's condition and potentially impacted the transfer of care to the hospital. Findings: Resident 1 was admitted to the facility on [DATE] with a diagnosis of emphysema (a lung condition that causes shortness of breath) per the facility ' s face sheet. Resident 1 tested positive for COVID-19 on [DATE] per the facility's infection control note, dated [DATE]. A review of Resident 1's physician's orders, dated [DATE], indicated Resident 1's vital signs (clinical measurements of essential body functions including: blood pressure, pulse rate, temperature, respiration rate, and oxygen saturation level), were ordered to be monitored every four hours for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to develop a baseline care plan (detailed plan with information about a resident's treatment, goal, and interventions) for one of one sampled resident related to a resident's (Resident 1) multiple episodes of leaving the facility. As a result, the lack of a resident centered care plan with specific interventions had Resident 1 left the facility unnoticed by staff, got hit by a pickup truck and died on [DATE]. Findings: On [DATE], the Department received a facility reported incident (FRI) related to quality of care and resident safety. On [DATE], a follow up, unannounced onsite visit to the facility was conducted. Resident 1 was readmitted to the facility on [DATE], with diagnoses which included schizoaffective disorder (a condition where symptoms of both psychotic and mood disorders are present together during one episode), per the facility's admission Record. On [DATE], [DATE] and [DATE], a review of Resident 1's clinical record was conducted. 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 protect residents' privacy for two of 9 residents reviewed for privacy when male and female residents shared a shower and bathrooms in their room (Resident 5 and 6). As a result, Residents 5 and 6 felt uncomfortable using the bathroom. Findings: Resident 5 was admitted to the facility on [DATE] with diagnoses including need for assistance with personal care according to the facility's admission Record. The admission MDS (a clinical assessment tool) dated 3/21/24, listed Resident 5's cognitive score of 13, indicating cognition was intact. During an observation and interview on 5/9/24, at 10:17 A.M. with Resident 5, Resident 5 stated his bathroom in the room was shared with female residents. Resident 5 walked to the bathroom and showed a shower curtain which separated the female and the male side of the bathroom. The female side had a toilet and a sink. The male side had a walk-in shower, toilet, and sink. Resident 5 stated the shower…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 only authorized personnel had access to the medication storage cart (med cart)'s keys for one of two sampled med carts (1). This failure increased the risk of residents and unauthorized personnel accessing medications. Findings: On 4/24/24 at 9:50 A.M., an observation was conducted of a med cart. There were keys in the lock of the med cart, the cart was unlocked, and it was unattended by staff. After two minutes, an unknown staff member took the keys from the med cart. On 4/24/24 at 10 A.M., an interview was conducted with Licensed Nurse 1. Licensed Nurse 1 stated, he made an error when he left the keys in the med cart instead of locking it and taking the keys with him. On 4/30/24 at 3:25 P.M., an interview was conducted with the Director of Nursing. The Director of Nursing stated, when a nurse left their med cart, they should have locked the cart and taken the keys with them. Per the facility's policy, titled Storage of Medications, revised November 2020, .Drugs and biologicals used in the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe supervision and assistance for one of three sampled residents (1) who was identified as high risk for choking and aspiration (happens when food, liquid, or other material enters a person's airway and eventually the lungs by accident). In addition, the Licensed Nurse (LN) 2 failed to clarify an out on pass order for one resident (4). These failures had the potential for Resident 1 to choke, if not safely assisted and supervised, and there was a potential for Resident 4 to go out on pass without a physician ' s order. Findings: On 2/20/24 at 10:17 A.M., an unannounced onsite to the facility was conducted related to a complaint on quality of care. 1. Resident 1 was readmitted to the facility on [DATE] with diagnoses which included Parkinson ' s disease (movement disorder), and dysphagia (difficulty swallowing), per the facility's admission Record. On 2/20/24, Resident 1's record was reviewed. 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 refer a resident to hospice as ordered for one of two sampled residents (1). As a result, Resident 1 expired without receiving hospice services. Findings: Per the facility ' s admission Record, Resident 1 was admitted to the facility on [DATE] with diagnoses to include kidney cancer. Per the facility ' s Orders for Resident 1, there was an order dated [DATE], .hospice to evaluate resident . Per the facility ' s Progress Notes, there was a note on [DATE], .(Nurse Practitioner) stated that the labs (laboratory tests) shouldn ' t have been drawn because the resident is supposed to be in hospice. Carried out and order placed. SS (Social Services) made aware . Per the facility ' s Orders for Resident 1, there was another order dated [DATE] for, .hospice eval . Per the facility ' s Orders for Resident 1 there was another order dated [DATE] for, .hospice eval: for (kidney cancer) . The order was discontinued on [DATE] due to Resident 1 had expired. Per 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 report to the California Department of Public Health (CDPH- the State Survey and Certification Agency) an alleged abuse violation regarding a resident-to-resident altercation. (Resident 7 and 14). This deficient practice had the potential for incidents of abuse to go unreported and for residents to be unprotected from abuse. Findings: Resident 7 was admitted to the facility on [DATE] with the diagnoses including catatonic schizophrenia (a mental disorder referring to symptoms of hyperactivity to under activity or lack of responsiveness) according to the facility ' s admission Record. Resident 14 was admitted to the facility on [DATE] with the diagnoses including schizoaffective disorder (a mental health disorder with combination of hallucinations or delusions and mood disorder symptoms, such as depression or mania) according to the facility ' s admission Record. An abbreviated survey was conducted at the facility on 12/6/23 and 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 conduct a thorough investigation of an alleged violation of abuse between two residents. (Resident 7 and 14) This deficient practice had the potential to not meet resident ' s needs for safety and well-being. Findings: Resident 7 was admitted to the facility on [DATE] with the diagnoses including catatonic schizophrenia (a mental disorder referring to symptoms of hyperactivity to under activity or lack of responsiveness) according to the facility ' s admission Record. Resident 14 was admitted to the facility on [DATE] with the diagnoses including schizoaffective disorder (a mental health disorder with combination of hallucinations or delusions and mood disorder symptoms, such as depression or mania) according to the facility ' s admission Record. An abbreviated survey was conducted at the facility on 12/6/23 and on 12/20/23 due to an anonymous report regarding Resident 7 ' s complaint of being hit by Resident 14. 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 update nutritional care plans for two residents reviewed for care planning. (Resident 5 and Resident 6). Failure to update a care plan related to nutrition had the potential for residents to not receive appropriate care, treatment, and interventions to provide nutrition and prevent further weight loss. Findings: Resident 5 was admitted to the facility on [DATE] with diagnoses including dysphagia, orophangeal phase (mouth and/or throat swallowing problem) according to the facility's admission Record. A review of Resident 5's weight record was conducted. Resident 5's recorded weights in the facility's electronic medical record were as follows: 8/27/23 106.6 pounds (lbs) 9/8/23 110.8 lbs. 9/15/23 106.2 lbs. 9/22/23 100 lbs. 9/29/23 95.8 lbs. The facility's Weight Variance Progress Notes (PN) dated 9/21/23 was reviewed. The PN indicated Resident 5's weight on 9/15/23 was 106.2 pounds (lbs.) which indicated, A significant weight loss of 4.2% 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, observation and record review, the facility failed to initiate and implement a shower refusal care plan for one of one sampled resident (Resident 1). This failure had the potential for Resident 1 to receive inadequate quality of care and miscommunication among health care providers. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses of chronic pain syndrome, opioid dependence, chronic kidney disease, and chronic obstructive pulmonary disease (lung disease) per her History and Physical. Resident 1 had a Brief Interview Mental Score (method of evaluating mental status) of 14 on 7/28/23, which indicated no cognitive dysfunction. During a concurrent interview and observation, on 9/13/23 at 3:07 PM, Resident 1 was sitting in her bed, calm and cooperative. Resident 1 stated she required assistance to shower, and the facility had not given her a shower in 6 weeks. Resident stated she was unaware there was a shower in her room and she did not know why she had not been…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 physician orders were followed for two of two sampled residents (1,2) when, 1. Resident 1 was not transferred to the hospital after his condition started to worsen, and 2. Resident 2 ' s Methadone medication was not administered as ordered, and facility pharmacy was not notified. Failure to follow a physician ' s order had the potential for residents to suffer severe harm which could result to worsening of the resident ' s health. Findings: 1. Resident 1 was admitted on [DATE] with diagnoses which included Cerebral Infarction (stroke), pneumonitis due to inhalation of food and vomit (infection in the lung), dysphagia (trouble with swallowing), and right hip fracture (broken hip bone) and dementia (. Resident 1 was admitted for custodial care (help with activities of daily living). Per Resident 1 ' s medical record, he was intermittently on 2 lpm (liters per minute) of oxygen (O2). During an interview with the Director 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 notify and account for a physician ' s prescribed Methadone (an addictive narcotic medication used to treat severe pain) order to the facility ' s pharmacy for one of one sampled resident (1). As a result, Resident 1 did not receive a total of 11 scheduled medication doses of Methadone. Due to the missed doses of this medication, Resident 1 had the potential to have increased pain levels, increased use of unnecessary alternative narcotic medication and to suffer from opioid withdrawal (the unpleasant physical and mental effects that can result when you stop taking this class of medication). Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses that included: chronic pain syndrome, opioid dependence, chronic kidney disease, and chronic obstructive pulmonary disease (lung disease) per physician ' s History and Physical. Resident 1 had a Brief Interview Mental Score (method of evaluating mental status) of 14 on 7/28/23,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 measures to keep a resident (Resident 1) safe from elopement (leaving the facility without permission). As a result, Resident 1 eloped and had not been found. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses that included depression and schizoaffective disorder (a condition that causes hallucinations and dramatic mood changes), per the facility ' s admission Record. A review of Resident 1 ' s care plan, dated 6/3/23, indicated Resident 1 was at risk for elopement related to episode of exit seeking and leaving facility. The care plan did not indicate staff or visitor to check and sign in the log before taking the resident and after dropping the resident off. On 8/2/23 at 9:38 A.M. an interview was conducted with certified nursing assistant (CNA) 1. CNA 1 stated Resident 1 had been placed in a room on station 1 (S1, a secured and alarmed unit for residents at risk of wandering) because she was frequently trying to leave…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews and record review, the facility failed to provide a hazard free environment in one of the two stations (Station 1) reviewed for accidents when: - An unattended bucket filled with tools such as a hammer and a trowel (a handheld tool with a flat metal with pointed edges used to apply or spread materials) were left accessible for any residents passing by. - An open bag of powdered building material was left unattended. - A cord laid across the floor of a hallway where ambulatory (able to walk) residents could trip. This failure had the potential for all residents in Station 1 (total of 59 residents) to suffer harm from tripping, falling, and using of construction equipment to harm themselves or others. Findings: During an observation of Station 1 on 08/04/2023 at 10:06 A.M., the nurse's station flooring was removed, and construction tools were stored by the entrance to the nurse's station. The following unattended construction tools and material were observed: · A bucket with tools (hammers, leveling tool-trowel, etc) · An open bag of self-leveling…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews and record review, the facility failed to provide an environment that was free from abuse for one of two residents (Resident 1) reviewed for abuse, when Resident 1 and Resident 2 were not permanently separated after Resident 2 threatened Resident 1. This failure resulted in Resident 2 slapping Resident 1 on the face. Findings: During an interview on 08/04/2023, at 09:30 A.M., with the Director of Nursing (DON), the DON stated Resident 2 slapped Resident 1 because Resident 2 was annoyed of Resident 1's singing. The DON stated that both residents were separated. The DON stated Resident 2 was out of the facility with family. A record review of Resident 1's facesheet indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses that included Dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A record review of Resident 2's facesheet indicated that Resident 2 was admitted to the facility on [DATE]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews and record review, the facility failed to implement their abuse policy and procedure for one of two residents (Resident 1) reviewed for abuse when: - Resident 1 and Resident 2 were not separated after continued threats were made by Resident 2 against Resident 1. - The abuse incident that involved Resident 1 and Resident 2 was not thoroughly investigated. These failures resulted in Resident 1 being slapped by Resident 2. In addition, staff who witnessed the threats made by Resident 2 towards Resident 1 were not interviewed in order for the facility to identify areas of improvement that may have contributed to the abuse incident. Findings: During an interview on 08/04/2023, at 09:30 A.M., with the Director of Nursing (DON), the DON stated Resident 2 slapped Resident 1 because Resident 2 was annoyed of Resident 1's singing. The DON stated that both residents were separated. The DON stated Resident 2 was out of the facility with family. A record review of Resident 1's facesheet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews and record review, the facility failed to ensure that one of two residents' (Resident 1) medical record was complete when incidents involving Resident 1 and her roommate were not documented in Resident 1's medical record. This failure resulted in staff not knowing the altercations that occurred between Resident 1 and Resident 2, which could lead to delayed interventions and further incidents of altercation between the two residents. Findings: During an interview on 08/04/2023, at 09:30 A.M., with the Director of Nursing (DON), the DON stated Resident 2 slapped Resident 1 because Resident 2 was annoyed of Resident 1's singing. The DON stated that both residents were separated. The DON stated Resident 2 was out of the facility with family. A record review of Resident 1's facesheet indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses that Dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). 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 interviews and record review, the facility failed to conduct a thorough investigation and a root cause analysis on the abuse incident involving Resident 1 and Resident 2. As a result, the facility did not identify, during their investigation, areas of improvement that may have led to the altercation between Resident 1 and Resident 2. This could lead to further incidents of altercation between Resident 1 and Resident 2. (Cross reference F-tag 600, F-tag 607, and F-tag 842) Findings: During an interview on 08/04/2023, at 09:30 A.M., with the Director of Nursing (DON), the DON stated Resident 2 slapped Resident 1 because Resident 2 was annoyed of Resident 1's singing. The DON stated that both residents were separated. The DON stated Resident 2 was out of the facility with family. During an interview on 08/08/2023, at 09:42 A.M., with the ADON, the ADON stated the Director of Staff Development (DSD) called her to report the incident. The ADON stated she spoke to CNA 2 and LN 3. The ADON stated she did not identify areas improvement during her investigation of the abuse incident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 infection control practices when urinary Foley (brand name) catheter bags were in contact with the floor for six of six of six residents, (Residents 24, 25, 59, 164, 411, 412), reviewed for urinary catheter care. As a result, there was the potential for Residents 24, 25, 59, 164, 411, 412 to be at risk for a facility acquired infection, which would negatively impact the resident's quality of life. Findings: 1. Resident 24 was admitted to the facility on [DATE], with diagnoses that include Respiratory Failure (a condition affecting the lungs), per the facility's admission Record. On 6/13/22 at 10:08 A.M., a concurrent observation and interview was conducted with CNA 12. Resident 24 was observed laying in bed. CNA 12 stated, she did not know the foley bag on the left side of the bed touching the floor. CNA 12 stated, she was not sure of the facility policy regarding urinary catheter care and stated the urinary bag should not 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 the dignity of four of four residents (Resident 24,164, 411, 412) when foley catheter bags (collects urine from the bladder into a bag) did not have dignity cover. These failures had the potential for the resident(s) to not be treated with dignity and suffer emotional and psychosocial distress. Findings: 1. Resident 24 was admitted to the facility on [DATE] per the facility's admission Record. On 6/12/22, a review of Resident 24's Minimum Data Set (MDS- a health status screening and assessment tool), dated 3/11/22, indicated a Brief Interview for Mental Status (BIMS- a test for cognitive function) was 15 out of 15, indicating cognition was intact. On 6/13/22 at 10:08 A.M., a concurrent observation and interview was conducted with CNA 12. Resident 24 was observed sitting up in bed a foley catheter bag, hanging off the right side of the bed draining yellow-colored urine. CNA 12 stated, the resident's foley catheter bag did not have 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 the Physicians Orders for Life Sustaining Treatment (POLST) forms were accurate and matched the facility's code status (the level of medical interventions a person wishes to have if their heart or breathing stops) for three of five residents reviewed for Advanced Directives (Residents 71, 77, and 177). This failure had the potential for Residents 71, 77 and 177 to receive the incorrect care in the event of a medical emergency. Findings: 1. Resident 71 was admitted to the facility on [DATE], with diagnoses to include dementia (a progressive loss of memory and the ability to think), per the facility admission Record. On [DATE] at 9:17 A.M., a record review was conducted. A. Resident 71's electronic medical record (EMR) listed the code status as full code (prolong life by all medically effective means). B. A physician's order, dated [DATE], indicated full code. C. A POLST, dated [DATE], was scanned into the EMR. The POLST listed Do Not Attempt…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 conduct a physical assessment based on standards of care for one of 11 residents (Resident 201) with a gastrostomy tube (GT- a surgical opening into the stomach). As a result, there was potential for Resident 201 to have complications related to GT care including infection and/or occlusion (blockage). Findings: A review of Resident 201's admission Record dated [DATE] was conducted. Resident 201 was admitted to the facility on [DATE] with diagnoses which included encounter for gastrostomy. A review of Resident 201's record was conducted. The record indicated a physician's order dated [DATE] to flush GT with 50 milliliters (ml) of water every shift. On [DATE] at 12:06 P.M., a concurrent observation and interview was conducted with LN 4. LN 4 stated Resident 201 did not have a GT. LN 4 stated she had been caring for Resident 201 for the past 2 weeks. LN 4 asked permission from Resident 201 to look at his abdomen to verify if he had a GT 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 communication tools were provided to two of two non-English speaking residents (Residents 20 and 187). As a result, there was a potential the residents needs were not met. Findings: 1. Resident 20 was admitted to the facility on [DATE] with Arabic as her primary language per the facility's admission Record. On 6/13/22 at 9:44 A.M., an interview with CNA 41 was conducted. CNA 41 stated she was the CNA for Resident 20 and she was just a Registry. CNA 41 stated Resident 20 only spoke Arabic and was not interviewable because Resident 20 did not speak English. CNA 41 stated she had not used any communication tools or any translator services to speak to Resident 20. On 6/13/22 at 9:50 A.M., a concurrent observation and interview of Resident 20 was conducted. Resident 20 was in her room and was heard talking on the phone speaking in a foreign language. There were no communication board or tools inside the room. Resident 20 stated she spoke…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 3. A review of Resident 135's admission Record was conducted. Resident 135 was admitted to the facility on [DATE] with diagnoses which included end stage renal (kidney) disease, dependence on dialysis (machine used to remove waste from the blood when a person has kidney failure), and diabetes (inability to manger blood sugar in the body). On 6/15/22 at 11:45 A.M., a concurrent observation and interview was conducted with Resident 135. Resident 135 used a pad of paper and pen to communicate. While observing Resident 135, both hands were noted to have very long fingernails. Resident 135 stated he would like his fingernails cut because they were too long. Resident 135 stated the facility had not offered to cut his nails. Resident 135 stated he was going to ask his son to cut his nails next week when he comes to visit. On 6/15/22 at 12:29 P.M., a concurrent observation, interview and record review were conducted with LN 2. LN 2 stated while observing Resident 135's fingernails, his nails were too long and needed to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the physical environment was free from hazards when unprescribed medications were left within reach of 2 of 2 residents reviewed for accidents and hazards (Resident 185, 164 ). This failure had the potential for accidental ingestion. and The facility also failed to ensure 1 of 1 sampled residents (415) was assessed as a fall risk, and interventions were in place to ensure thes resident's safety from falls. This failure had the potential to put Resident 415 at risk for injury due to unnecesay falls. Findings: 1. Resident 185 was admitted to the facility 8/24/19 with diagnoses to include traumatic brain injury (brain dysfunction caused by an outside force), per the facility admission Record. On 6/13/22 at 11:04 A.M., a concurrent observation and interview was conducted with Resident 185. Resident 185 was in bed, awake and alert. A plastic bottle, labeled Ammonium lactate 12% lotion, was on a bedside table within reach of the 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 2. A review of Resident 201's admission Record was conducted. Resident 201 was admitted to the facility on [DATE] with diagnoses which included end stage renal (kidney) disease, dependence on dialysis (machine used to remove waste from the blood when a person has kidney failure), and encounter for gastrostomy (hole in the abdomen into the stomach wall to introduce feeding or fluids via a tube). A review of Resident 201's record was conducted. The record indicated a physician's order dated [DATE] to flush GT with 50 milliliters (ml) of water every shift and (if used for meds (medications) give 50 ml before meds and 50 ml after meds). On [DATE] 3:30 P.M., a concurrent record review and interview was conducted with LN 2. LN 2 stated there was a flush order for Resident 201's GT. LN 2 stated the physicians order for Resident 201's GT flush was to flush GT with 50 ml of water every shift. On [DATE] 9:57 A.M., a concurrent interview and record review were conducted with the ADON/IP. The ADON/IP stated it was her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 oxygen was administered per physician's order for one of two residents reviewed for oxygen use (Resident 185). This failure had the potential to affect the health and well-being of Resident 185. Findings: Resident 185 was admitted to the facility on [DATE] with diagnoses to include pulmonary disease (a disease of the lungs), per the admission Record. On 6/13/22 at 11:05 A.M., a concurrent interview and observation was conducted with Resident 185. Resident 185 stated the oxygen was for a breathing problem. Resident 185 wore a nasal cannula (NC, a device used to deliver oxygen). The oxygen was set at three liters per minute (LPM). The NC did not have a label or date to indicate when it was changed. On 6/15/22 at 9:13 A.M., an observation was conducted with Resident 185. The oxygen was set at 2.5 LPM. The NC and oxygen tubing was not labeled or dated. On 6/15/22 at 9:03 A.M., a record review was conducted. Per Resident 185's physician…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 of 1 resident (Resident 59) was medicated for pain when requested by the resident. This failure had the potential for the resident to experience unnecessary pain. Findings: Resident 59 was admitted to the facility on [DATE], with diagnoses that include Rectal Abcess (a collection of fluid near the opening of the rectum), per the facility's admission Record. On 6/15/22, a review of Resident 59's MDS (a health status screening and assessment tool), dated 3/23/22, indicated a BIMS (Brief Interview for Mental Status-test for cognitive function) was 15 out of 15, indicating cognition was intact. On 6/15/22 at 10:57 A.M., an interview was conducted with Resident 59. Resident 59 stated, he just told the nurse he was in pain allover; dull aches and rated his pain an 8/10 (a rating scale to determine level of pain). Resident 59 stated, I always have pain and I have to ask for my pain medication. Resident 59 stated, he was not offered any…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 properly care for a dialysis access site for one of three dialysis patients (Resident 135). As a result, this had the potential to increase Resident 135's risk for a dialysis access site infection and clotting of the access. Findings: A review of Resident 135's facility admission Record was conducted. Resident 135 was admitted to the facility on [DATE] with diagnoses which included end stage renal (kidney) disease and dependence on dialysis (machine used to remove waste from the blood when a person has kidney failure). On 6/13/22 at 9:30 A.M., a concurrent observation and interview was conducted with Resident 135. Resident 135 had a dressing on his left upper arm that appeared frayed with yellow drainage on the outside of the dressing. Resident 135 stated it was his dialysis access where the dressing was and his last dialysis was on Friday 6/10/22. Resident 135 stated the last time he had the dressing changed on his left upper arm was on 6/10/22. 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 Food and Nutrition Services department failed to provide nutritional supplements (NS, a shake or food product added to a diet, usually for additional calories or protein) as ordered by the physician, for two of six residents reviewed for nutrition (Residents 82, 168). This failure had the potential for the residents to not receive adequate nutrition, further compromising their medical status. Findings: 1. Resident 82 was admitted to the facility on [DATE] with diagnoses to include adult failure to thrive (a decline in medical condition resulting in poor nutrition and weight loss), per a facility admission Record. On 6/13/22 at 12:43 P.M., an observation was conducted of Resident 82. Resident 82 had finished lunch but had eaten less than 25% of the foods on the tray. Resident 82 did not respond to questions. Resident 82's tray ticket indicated she was to receive a NS. No NS was on the tray or at the bedside. On 6/13/22 at 12:46 P.M., an interview 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 a safe and sanitary environment that mitigated the risk for foodborne illness and cross contamination when: 1. a countertop-mounted can opener holder was not clean, and, 2. a wall in a food production area was not clean or repaired. These failures had the potential to place residents at risk for foodborne illness as well as bacterial, chemical and foreign object contamination of foods. Findings: 1. On 6/13/22 at 8:36 A.M., a kitchen tour was conducted with Registered Dietitian Nutritionist (RDN) 1. A countertop-mounted can opener holder was observed to be food/debris encrusted. Per RDN 1, breakfast had just been served and food service staff would be cleaning and sanitizing all areas, including the can opener and the holder. On 6/15/22 at 10:35 A.M., a concurrent observation and interview was conducted with RDN 1. The can opener and holder were again observed to be food/debris encrusted. RDN 1 removed the can opener from the holder, and stated, This should have been sanitized each day. There is 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 document review, the facility failed to conduct a COVID-19 (a type of infection) test for two of five sampled unvaccinated employees per the facility's policy. As a result, residents, employees, and visitors were at risk for contracting a COVID-19 infection. Findings: On 6/15/22 at 9:34 A.M., a concurrent document review and interview was conducted with the facility's ADON/IP. The ADON/IP identified LN 6, LN 7, Registered Dietitian Nutritionist (RDN) 2, Physical Therapist (PT) 1, and CNA 3 were unvaccinated employees. The ADON/IP stated per their policy, unvaccinated employees were tested for COVID-19 twice a week . On 6/16/22 at 7:49 A.M., a concurrent document review and interview was conducted with the facility's ADON/IP. The facility assignment sheets and COVID-19 testing logs for May and June 2022 were reviewed. Per the ADON/IP, PT 1 worked the week of 6/12/22 but was not tested that week, and CNA 3 was not tested per policy on six of the eight weeks reviewed. The ADON/IP stated if the unvaccinated employees were not tested per the facility's policy, all…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record and document review, the facility failed to have a policy which included resident screening for COVID-19 vaccination (a preventative measure for an infection) status, offering the vaccination and vaccinating residents against COVID-19. As a result, residents, staff and visitors were at risk for COVID-19 infection. Findings: A review of Resident 135's facility admission Record was conducted. Resident 135 was admitted to the facility on [DATE] with diagnoses which included end stage renal (kidney) disease, dependence on dialysis (machine used to remove waste from the blood when a person has kidney failure), and diabetes (inability to manage blood sugar in the body). On 6/15/22 at 11:45 A.M., an interview was conducted with Resident 135. Resident stated the facility never offered him the COVID-19 vaccine since he had been at the facility, but he would take it if they gave it to him. On 6/16/22 at 7:49 A.M., a concurrent record review, interview and document review were conducted with 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 consistently offer bedtime snacks to all residents. This failure had the potential to result in residents not having nourishment between evening meals and breakfast the following day. Findings: On 5/21/19, an interview of confidential residents (CRs), was conducted. Four CRs voiced concerns over bedtime snacks. CR 6 stated once in a while he received a bedtime snack. CR 11 stated residents needed to be on a list in order to receive a bedtime snack, or residents had to ask for a snack. CR 7 stated staff did not offer bedtime snacks. CR 8 stated she did not receive bedtime snacks. On 5/21/19 at 3:41 P.M., an interview was conducted with CNA 7 from Station 2. CNA 7 stated evening snacks were delivered to the nursing unit at 8 P.M. CNA 7 stated the snacks would have stickers with residents' names on them and staff would deliver the snack to those residents. CNA 7 stated the snacks usually consisted of sandwiches, pudding, applesauce, and cheese sticks. CNA 7 further stated if other residents requested a snack…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations, interviews, and record reviews, the facility failed to ensure safe and sanitary practices were met in the Food and Nutrition Services Department when: 1. Hand hygiene was not correctly practiced during garbage disposal, 2. Food temperatures were not taken for food on the trayline steamtable, and 3. A plate warmer with clean plates had brown and black dirt inside. These failures had the potential to cause widespread foodborne illness in the residents who consume food from the facility's kitchen. The facility census was 215. Cross reference 802 Findings: 1. On 5/20/19 at 2:40 P.M., an observation and interview was conducted with DA 2 about the trash removal from the kitchen. DA 2 emptied trash from a medium-sized red trash can into a large grey trash can with gloves on. DA 2 then washed the red trash can and sanitized it without changing gloves or washing hands. DA 2 then took the trash bag from the grey trash can out to the dumpster. After DA 2 tossed the trash into the dumpster and closed the lid, he brought the grey trash can back into the kitchen. DA 2 then…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 communication aids (language boards with pictures and the resident's native language or translation service via phone) were available and utilized for two of two residents (492, 494) reviewed for language/communication who did not speak English. As a result, Residents 492 and 494 had the potential to not have their needs met. Findings: 1. Resident 492 was admitted to the facility on [DATE] per the facility's Resident Face Sheet. On 5/20/19, a record review was conducted. Resident 492's native language was documented incorrectly on the Resident Face Sheet. On 5/20/19 at 8:27 A.M., an observation and interview of Resident 492 was conducted with CNA 11. Resident 492 was observed lying in bed banging on the bedside table and yelling in a foreign language. Per CNA 11, language aids and translation services were absent from the resident's room and he did not know the language Resident 494 spoke. On 5/20/19 at 12:13 P.M., an interview 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 did not ensure one of five residents (100) reviewed for advanced directives (a written document giving instructions for an individual's end of life wishes) had a completed Physician's Order for Life-Sustaining Treatment (POLST) form, when: 1. Resident 100's physician had not signed the POLST; and 2. Resident 100's POLST was signed by someone other then the listed Responsible Party (RP-a designated person responsible for making healthcare decision on behalf of the resident). As a result, there was a potential for end-of-life choices not being discussed by the physician with the RP, and Resident 100 could have received treatment not in accordance with the resident's wishes. Findings: Resident 100 was admitted to the facility on [DATE], with diagnoses which included vascular dementia (impaired blood flow to the brain, resulting in poor memory and judgment), per the facility's Resident Face Sheet. 1. On 5/20/19, a clinical record review was conducted for Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, clean, and homelike environment for three of 11 residents (100, 135, 82) reviewed for resident rights when: 1. Resident 100's window curtain was suspended from a curtain rod with zip ties, a cable wall plate was unattached and hanging from the wall, duct tape was unraveling from the edges of a mirror, and one wall was scuffed and dented with chipped paint. 2. Resident 135 did not have clear, easy access to his bathroom. 3. Resident 82 did not have any personal belongings kept at the bedside. These failures resulted in the residents or RP not being happy with their rooms. Findings: 1. Resident 100 was admitted to the facility on [DATE], per the facility's Resident Face Sheet. On 5/20/19 at 9:56 A.M., an observation and interview was conducted with Resident 100 in his room. Resident 100's left window curtain panel was hanging from the curtain rod with four white zip ties. A cable wall plate below the television was hanging…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and implement care plans for two of five residents reviewed for care plans (82, 52). These failures had the potential to result in inconsistent treatment and care. Findings: 1. Resident 82 was admitted to the facility on [DATE] with diagnoses that include Down Syndrome (disorder arising from a chromosome defect, mental and physical delays) and quadriplegia (loss of the ability to move all four limbs) per the facility's Resident Face Sheet. On 5/20/19 at 9:20 A.M., an observation in Resident 82's room was conducted. Resident 82 was lying in bed, with the left leg flexed at 45 degrees and a pillow under her left ankle. Resident 82's feet both extended with all toes curled down. On 5/20/19 at 9:25 A.M., an interview with RP 1 was conducted. RP 1 stated Resident 82 had RNA ordered for five times a week. RP 1 stated one week, Resident 82 received RNA only three times. RP 1 stated there were not enough staff to provide Resident 82 with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to promptly identify and intervene when a change in condition occurred for one of 35 residents reviewed for quality of care (96). This failure had the potential to result in a life-threatening allergic reaction for Resident 96. Findings: Resident 96 was admitted to the facility on [DATE] with diagnoses which include chronic respiratory failure (long-standing lung disease) per the facility's Resident Face Sheet. A review of Resident 96's MDS, Section C, dated 3/13/19, indicated the resident's BIMS Summary Score (an assessment of mental status) was 14 out of 15, indicating attention, level of orientation, and ability to recall information was intact. On 5/23/19 at 11 A.M., Resident 96 was observed sitting in bed in her room. Resident 96 was scratching a rash on her left leg. Large areas of red, raised rashes were on Resident 96's chest, legs, and arms. Multiple scratches were on both Resident 96's legs. On 5/23/19 at 11:01 A.M., an interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to reposition one of eight residents reviewed for pressure ulcers (92). This failure had the potential for worsening of Resident 92's pressure ulcer. Findings: Per the facility's Resident Face Sheet, Resident 92 was admitted to the facility on [DATE] with diagnoses which included persistent vegetative state (a long-lasting unresponsive, dependent condition) and pressure ulcer (damage to the skin and underlying tissue). On 5/20/19 at 7:55 A.M., Resident 92 was observed lying in bed on his back. The head of the bed was angled up about 30 degrees and the resident was in a semi-sitting position. On 5/20/19 at 11:34 A.M., and interview was conducted with Resident 92's family member. The family member stated she visited seven days each week, usually about six hours a day. She stated Resident 92 was often soiled brief when she arrived to visit him. She stated the resident was always in bed. The family member stated Resident 92 does not get turned…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 RNA for one of five residents reviewed for limited range of motion (82). This failure had the potential to result in further decline of Resident 82's range of motion. Findings: Resident 82 was admitted to the facility on [DATE] with diagnoses which include Down Syndrome (disorder arising from a chromosome defect, mental and physical delays) and quadriplegia (loss of the ability to move all four limbs) per the facility's Resident Face Sheet. On 5/20/19 at 9:20 A.M., an observation in Resident 82's room was conducted. Resident 82 was lying in bed with the left leg flexed at 45 degree and a pillow under her left ankle. Resident 82's feet both extended with all toes curled down. On 5/20/19 at 9:25 A.M., an interview with RP 1 was conducted. RP 1 stated Resident 82 had RNA ordered for five times a week. RP 1 stated one week, Resident 82 received RNA only three times. RP 1 stated there were not enough staff to provide Resident 82 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 2. Per the Resident Face Sheet, Resident 52 was admitted to the facility on [DATE] with diagnoses to include chronic respiratory failure (long-term inability of the lungs to take in enough oxygen) and dysphagia (swallow difficulty). On 5/20/19, a record review of Resident 52's medical chart was conducted. Per a physician's order, dated 4/14/19, Peek-a-boo mittens Special instructions: on q 2hr (every two hours) and off for circulation and hygiene related to pulling out life sustaining devices . On 5/20/19 at 8:55 A.M., an observation of Resident 52 and an interview was conducted with a visitor. Resident 52's mittens were off. The visitor stated she was a family member, and she had taken the mittens off. On 5/20/19 at 2:55 P.M., an observation of Resident 52 alone in his room was conducted. Resident 52's mittens were not on his hands. On 5/20/19 at 3 P.M., an interview was conducted with CNA 26. CNA 26 stated Resident 52 wore peek-a-boo mittens on and off. CNA 26 stated, Yes, it's a restraint. CNA 26 stated 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 interview and record review, the facility failed to ensure there was adequate staff to provide the necessary care for 8 of 16 residents reviewed (75, 82, CR4, 6, 8, 10, 11, 14) for sufficient staffing when: 1. Call lights were not answered in a timely manner; or when answered, care was not provided, and; 2. RNA services were not provided as ordered. These failures had the potential to result in physical and emotional harm. Findings: 1. In an interview, CR 4 stated call lights not being answered was an ongoing problem. The resident stated a CNA came into the room in response to a call light, turned it off, and left without addressing CR 4's needs. The resident also stated it took up to half an hour for the call light to be answered. In an interview, CR 11 stated, the CNAs won't say a word when answering call lights, they just turn off the call light without the need being met. In an interview, CR 6 stated on one occasion, a CNA peeked his head into his/her room in response to a call light, turned it off,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 IDT team (health care team managing resident care) did not fully assess the psychotropic medication regime (medications affecting the nervous system and mental state of an individual) for one of three sampled residents reviewed for psychotropic medications (220). This failure had the potential for a decrease in function for Resident 220. Findings: Resident 220 was admitted to the facility on [DATE] with diagnoses which included dementia (memory loss), per the facility's Resident Face Sheet. On 5/20/19, Resident 220's record was reviewed. The physician's History and Physical, dated 4/20/19, indicated Resident 220 suffered from acute delirium (confusion with fluctuating awareness, delusions-false impressions). The physician's orders, dated 4/22/19, indicated staff should monitor for psychotropic medication side effects, which included sedation, limitation of functional capacity, confusion, and lethargy (diminished energy and mental capacity). Per the nursing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 secure one of six medication carts reviewed for medication storage. This failure had the potential for residents, visitors, and staff to have access to unauthorized medications. Findings: On 5/21/19 at 4:12 P.M., a medication cart was observed unlocked on station four. The medication cart was backed up against the wall, in the hallway between room [ROOM NUMBER] and 422. No staff were visible in the hallway. Next to the medication cart was a side table, which contained two empty plastic medication dispensing cups and a laptop computer. On 5/21/19 at 4:14 P.M., an unidentified female staff member was observed walking past the medication cart. On 5/21/19 at 4:16 P.M., an observation and interview was conducted with LN 6. LN 6 exited a resident's room and walked toward the medication cart. LN 6 confirmed he was the medication nurse assigned to the cart. LN 6 stated he went to answer a call light and forgot to lock the medication cart. LN 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.

Based on observations, interviews, and record reviews, the facility failed to ensure the Food & Nutrition Services staff effectively carried out the functions of the department for sanitizer testing of dish machine equipment and red buckets. This failure in staff competency had the potential to cause foodborne illness in the residents who consumed food from the facility's kitchen. The facility census was 215. Cross reference F812 Findings: On 5/20/19 at 2:30 P.M., an observation and interview was conducted with DA 1, RD 1 and RD 2 about the sanitizer buckets and dish machine sanitizer levels. DA 1 tested the sanitizer level in a red bucket. DA 1 dipped an ammonia test strip in the bucket for 15 seconds and stated the color should be green on label test strip container. DA 1 then went to the dish machine and dipped a chlorine test strip into the tank solution to test the chlorine level. DA 1 stated the dish machine was a low-temperature machine and the test strip color should be light purple and match 50 ppm (parts per million). RDs 1 and 2 acknowledged the incorrect sanitizer…

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

Based on interview and record review, the facility failed to ensure the staff had the knowledge of proper food storage and heating time of foods brought into the facility by visitors for resident consumption. These failures had the potential for foodborne illness. Findings: On 05/21/19 at 3:41 P.M., an interview was conducted with CNA 7. CNA 7 stated if family brought in food from home, the food would be labeled with the resident's name, room number and the date it arrived, then stored in the resident refrigerator. CNA 7 stated he did not know how long food could be stored in the refrigerator. CNA 7 stated he did not know how long the food should be heated in the microwave and he would have to ask the licensed nurse for guidance. On 5/21/19 at 3:48 P.M., an interview was conducted with LN 9. LN 9 stated the charge nurse was responsible for checking the refrigerator temperature each shift, along with discarding any resident food over three days old. LN 9 stated coffee should be heated for one minute and heavier foods like lasagna should be heated for two minutes. LN 9 stated she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure a hospice agency's written documentation of visits were present in the health record for one of five sampled hospice residents (104). As a result, there was the potential to put Resident 104 at risk for delayed or uncoordinated care between the facility's healthcare team and the hospice agency. Findings: Resident 104 was admitted to the facility on [DATE] on hospice (comfort care at the end of life), per the facility's Resident Face Sheet. On 5/22/19 at 8:28 A.M., Resident 104's health record and separate hospice binder were reviewed with LN 1. According to the hospice visit calendar and visit sign-in sheets, the hospice nurse (HN) had visited Resident 104 multiple times between 2/18/19 and 5/22/19. LN 1 was unable to find documentation of the hospice visits between those dates. LN 1 stated the visit sheets should have been in Resident 104's hospice binder. On 5/22/19 at 9:20 A.M., the DON was interviewed. The DON stated the hospice agency should…

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

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 system was working properly for one of 35 sampled residents (64). As a result, there was the potential Resident 64 would be unable to communicate his needs to the staff. Findings: Resident 64 was re-admitted to the facility on [DATE], per the facility's Resident Face Sheet. A review of Resident 64's MDS (resident assessment tool), dated 3/6/19, indicated the resident's cognitive and decision-making skills were intact. Resident 64 required extensive staff assistance with bed mobility, transfers, dressing, toileting, personal hygiene and bathing. On 5/20/19 at 3:20 P.M., during an observation and interview, Resident 64 tested his call light, and it was not working. Resident 64 demonstrated by pressing the call light button several times. There was no audible alarm heard, nor was there a blinking light observed on the call light indicator, located above the door outside the resident's room. Resident 64 stated, It comes…

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