Fidelity Health Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a Notice of Proposed Transfer/Discharge (NPTD) and failed to inform the long-term care Ombudsman (a representative who assists residents with issues related to day-to-day care, health, safety, and personal preferences) of a transfer for one of three sampled residents (Resident 1), when Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) on 2/24/2026.This deficient practice placed Resident 1 at risk for an inappropriate and unsafe discharge and violated Resident 1's rights.Findings:During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was initially admitted to the facility on [DATE] with diagnoses which included chronic pain syndrome (pain that lasts longer than three months).During a review of Resident 1's History and Physical (H&P), dated 8/25/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS, a resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect the residents' right to be free from verbal, mental(emotional) and physical abuse for two of three sampled residents (Residents 1 and 2).This deficient practice resulted in Resident 1 being subjected to physical abuse and Resident 2 being subjected to verbal and mental abuse. Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), Chronic atrial fibrillation (AFib- a condition where the upper chambers of the heart (atria) beat irregularly and rapidly ), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control). During a review of Resident 1's Nursing admission Assessment (NAA) dated 1/17/25, the NAA indicated Resident 1had clear speech, normal hearing, and level of consciousness was oriented,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Residents 4 and 34) were treated with dignity when Certified Nursing Assistant 2 (CNA 2) and CNA 4 stood over Residents 4 and 34 while assisting Residents 4 and 34 to eat. This deficient practice had the potential to result in psychosocial (mental and emotional well-being) decline and lowered self-esteem and self-worth for Residents 4 and 34. Findings: a. During a review of Resident 4's admission Record (AR), the AR indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) without dyskinesia (uncontrolled, involuntary muscle movement), without mention of fluctuations and unspecified dementia (a progressive state of decline in mental abilities), mild, without behavioral disturbance, psychotic disturbance (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 observation, interview, and record review, the facility failed to follow safe food handling and proper storage practices for one of one facility kitchen in accordance with professional standards of food service safety and the facility's Policy and Procedure (P&P) by failing to: 1. Label/date food items. 2. Store dishware and kitchenware under sanitary conditions. 3. Wear hair restraints in the kitchen food preparation area. These deficient practices could result in a risk for serious complications from food borne illness (illness caused by the ingestion of contaminated food or beverage) and/or affect the quality and palatability (taste) of food for the residents. Findings: During a concurrent observation and interview on 4/1/25 at 9:22 a.m. with the Dietary Supervisor (DS), during the initial tour of the kitchen, Freezer 2 had a signage posted on the door indicating a Reminder: . Observed inside Freezer 2 were: 1. One opened box of 24 count of individual three oz (ounce, a unit of weight) cups of frozen pineapple sherbet and one three oz cup of frozen pineapple sherbet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement infection control guidelines by failing to: a. Ensure to change the nasal canula (NC, a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) weekly for one of one sampled resident (Resident 76). b. Ensure personal toiletry was labeled and not stored inside the [NAME] and [NAME] restroom (a restroom that has two doors and is sandwiched between two bedrooms and is accessible by both bedrooms) of Residents 65, 48, 30, 78, 43 and 23. These failures had the potential to result in the spread of infection in the facility. Findings: a. During a review of Resident 76's admission Record (AR), the AR indicated Resident 76 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing) and Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control). During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the call light was within reach for one of three sampled residents (Resident 47). This failure had the potential for Resident 47 not to receive necessary care or receive delayed services, placing the resident at risk for falls or injury. Findings: During a review of Resident 47's admission Record (AR), the AR indicated Resident 47 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), dementia (a progressive state of decline of mental abilities), and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 47's Fall Risk Assessment (FRA) dated 1/31/2025, the FRA indicated Resident 47 was assessed as high risk for fall. During a review of Resident 47's Minimum Data Set (MDS, a resident assessment tool) dated 2/26/2025, the MDS indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its Policy and Procedure (P&P) on Advance Directives (AD, a legal document indicating resident preference on end-of-life treatment decisions) for one of one sampled resident (Resident 76) by failing to ensure the Advance Directive Acknowledge (ADA) Form was completed on admission for Resident 76. This failure had the potential risk for facility staff to provide medical treatment and services against the will of Resident 76. Findings: During a review of Resident 76's admission Record (AR), the AR indicated Resident 76 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing) and Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control). During a review of Resident 76's Minimum Data Set (MDS, a resident assessment tool) dated 1/29/2025, the MDS indicated Resident 76 had an intact cognition (ability 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 designate a member of the facility's Interdisciplinary Team (IDT- a group of health care professionals who work together toward the goals of their patients) who was responsible for working with Hospice (a program designed to provide comfort care and emotional support to the terminally ill) representatives to coordinate care for one of one sampled resident (Resident 3). This deficient practice had the potential to affect Resident 3's quality of while on Hospice Care. Findings: During a review of Resident 3's admission Record (AR), the AR indicated Resident 3 was readmitted to the facility on [DATE] with diagnoses including adult failure to thrive (a decline in physical and cognitive function) and rhabdomyolysis (a medical condition characterized by the breakdown of muscle tissue, leading to the release of harmful substances into the bloodstream). During a review of Resident 3's active Physician Order (PO) dated 3/19/2025, the PO indicated Resident 3 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 observation, interview, and record review, the facility failed to keep an electric fan (a powered machine used to create a flow of air to cool and ventilate rooms and control humidity) in a safe, operating, and sanitary condition for one of one sampled resident (Resident 17). This failure had the potential to affect Resident 17's quality of life and health. Findings: During a review of Resident 17's admission Record (AR), the AR indicated Resident 17 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hypertension (HTN, high blood pressure), anxiety (intense, excessive, and persistent worry and fear), and osteoarthritis (a progressive disorder of the joints). During a review of Resident 17's Minimum Data Set (MDS, a resident assessment tool) dated 2/5/2025, the MDS indicated Resident 17 had moderately impaired cognition (ability to understand and process information). The MDS indicated Resident 17 required setup or clean-up assistance (helper sets up or…

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

Based on interview and record review, the facility failed to implement its written policies and procedures for screening potential employees for a history of abuse, neglect, exploitation or misappropriation of property by failing to: 1. Obtain information from previous employers and/or current employers for four out of four sampled employees (Certified Nursing Assistants [CNA] 1, 2, 3, and 4). 2. Inform the previous employer and/or current employer of facility's intention to make reasonable efforts to uncover information about any past criminal prosecutions, allegations of abuse, etc. These deficient practices had the potential for residents to be exposed to abuse, neglect, exploitation or misappropriation of property from staff. Findings: During an interview on 3/7/2025 at 10:03 AM, with the Director of Staff Development (DSD), the DSD stated when completing reference checks, the DSD would ask the previous employer of the applicant/potential employee if the potential employee would be hirable or not and the DSD would write hirable or not hirable on the applicant's reference checks.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of nine sampled residents (Resident 1) was free from verbal and physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) according to the facility's policy and procedure (P&P) titled, Abuse Prevention. Resident 1 was yelled and scratched on the right hand by Resident 2, resulting in an open cut on Resident 1's right hand. This deficient practice resulted in Residents 1 to experience physical and verbal abuse from Resident 2. Findings: a. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was re-admitted to facility on 4/25/2024, with multiple diagnoses including osteoarthritis (joint disease) of both knees and anxiety (a feeling of worry, nervousness, or unease). During a review of Resident 1's History and Physical (H&P), dated 1/7/2025, the H&P indicated Resident 1 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 observation, interview, and record review, the facility failed to report an allegation of abuse to the California Department of Public Health (CDPH- a government agency that promotes and protects the health of all people and their communities), the police department and the Ombudsman (advocates for residents of nursing homes) within the two-hour time frame as indicated in the facility's policy and procedure (P&P) titled, Abuse Prevention. On 3/6/2025, Resident 5 reported to the Social Services Assistant (SSA) that Resident 6 hit Resident 5. This deficient practice had the potential to compromise the safety of Resident 5 and exposed Resident 5 to further physical, mental, and emotional abuse. Findings: a. During a review of Resident 5's admission Record (AR), the AR indicated Resident 5 was re-admitted to the facility on [DATE], with diagnoses that included diabetes (elevated blood sugar in the blood), hypertension (elevated blood pressure), and abnormalities in gait and mobility (walking). During a…

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

Based on interview and record review, the facility failed to ensure Payroll Based Journal (PBJ, a nurse staffing and non-nurse staffing data sets that provide information submitted by nursing homes including rehabilitation services on a quarterly basis) staffing data report was submitted quarterly as required by the Centers for Medicare and Medicaid Services (CMS, a federal agency within the United States Department of Health and Human Services that administer Medicaid, the Children's Health Insurance Program, and health insurance portability standards) for quarter one of year 2023, from 10/1/2023 to 12/31/23. This failure had the potential to result in CMS not receiving accurate and timely staffing data which could negatively affect the quality of care in the facility. Findings: During a review of the facility's Certification and Survey Provider Enhanced Reports (CASPER) 1705D (PBJ Staffing Data Report), for quarter one of year 2023, the CASPER PBJ Staffing Data Report indicated the result was triggered for failing to submit data and one star staffing rating. 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 ensure the resident's call light was within reach for two of two sampled residents (Resident 7 and 31) when: a. Resident 31's bathroom did not have a call light cord. b. Resident 7's call light was not within reach for Resident 7 and the call light was stuck behind Resident 7's roommate's walker. These deficient practices had the potential for Resident 7 and Resident 31 not to receive or received delayed care to meet the resident's needs and could result in a fall or accident. Findings: a. During a review of Resident 31's admission Record (AR), the AR indicated Resident 31 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but are not limited to syncope (passing out) and collapse, chronic pain syndrome (pain lasting three to six months or more), and generalized anxiety disorder (persistent feelings of anxiety that can interfere with daily life). During a review of Resident 31'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 observation, interview, and record review, the facility failed to supervise two of five sampled residents (Resident 67 and 70) when: a. Resident 67 had a history of wandering into other resident rooms to look for cigarettes since 12/8/2023, the facility failed to implement specific interventions that addressed this behavior and Resident 67 continued to wander into other resident rooms. b. Resident 70 who was assessed as high risk for falls was not provided continuous one to one monitoring (continuous visual supervision) in accordance with the resident's plan of care. These failures had the potential to result in serious injuries to Resident 67 and Resident 70. Cross reference F656 Findings: a. During a review of Resident 67's admission Record (AR), the AR indicated Resident 67 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medications were administered and disposed according to the facility's policy and procedure (P&P) by failing to: a. Administer Depakote (medication used to treat seizure disorder [sudden burst of uncontrolled electrical activity in the brain]) Extended Release (ER) as ordered during medication pass observation for one of one sampled resident (Resident 6). Licensed Vocational Nurse 2 (LVN 2) split Depakote Extended Release 500 milligram (mg) tablet in half and administered to Resident 6 on 4/25/2024. This failure had the potential to result in Resident 6 to not receive full effect of the medication. b. Ensure two licensed nurses witnessed the disposition of discontinued medication as indicated in the facility policy and procedure titled Medication Destruction for one of one Medication Storage Room (MS room [ROOM NUMBER]). This failure had the potential risk for medication diversion (illegal distribution or abuse of prescription…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 monitor and provide a Gradual Dose Reduction (GDR, tapering of a dose for psychotropic medications [used to treat mental health disorders, alter neurotransmitters (transmit messages from neurons to muscles) in the brain] to determine if symptoms, conditions, or risks can be managed by a lower dose or if the medication can be discontinued altogether) for two of five sampled residents (Resident 67 and 7) when: a. For Resident 67, a GDR was not completed on 3/2/2024 for the use of Trazodone (medication used to treat depression) 100 milligrams (mg, unit of measurement) and a clinical rationale was not indicated in Resident 67's clinical record. b. For Resident 7, behaviors were not monitored from 4/2/2024 to 4/6/2024 during 11 pm to 7 am shift and from 4/9/2024 to 4/13/2024 during 11 pm to 7 am shift for the use of Zyprexa (medication to treat schizophrenia [mental illness that affects how a person thinks, feels, and behaves]). These failures had 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 follow required food sanitation and handling practices by failing to discard six glasses of expired milk inside one of one kitchen refrigerator. This deficient practice had the potential to result in food-borne illnesses (illness caused by consuming contaminated food or beverages) to the residents. Findings: During an initial kitchen tour on 4/23/2024 at 9:14 am, with the Dietary Supervisor (DS), there were six glasses of milk in the facility's refrigerator dated 4/21/2024-4/22/2024. The DS stated the milk was outdated/expired and should not be left inside the refrigerator after the expiration date. The DS stated, consuming expired milk could cause food borne illness like diarrhea and vomiting. The DS stated expired food inside the refrigerator needed to be removed and discarded by the end of the expiry date. During a review of the facility's Policy and Procedure (P&P) titled, Food Receiving and Storage of Cold Foods, dated 2018, the P&P indicated, Poured beverages such as milk or juice, should be labeled 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 follow infection control policy and procedures (P&P) by failing to: a. Ensure Certified Nursing Assistant 1 (CNA1) wore the required personal protective equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) prior to entering a Contact Isolation (used for residents with diseases caused by bacteria and viruses that are spread through direct and indirect contact) room for one of one sampled resident (Resident 54). b. Ensure staff did not store food in one of one sampled Medication Storage Room (MS room [ROOM NUMBER]). There was one box of doughnut in MS room [ROOM NUMBER]. These failures had the potential to result in the spread of infection and cross contamination (transfer of harmful bacteria from one object or place to another). Findings: a. During a review of Resident 54's Record of admission (AR), the AR indicated Resident 54 was readmitted to the facility on [DATE] with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure privacy curtain was drawn close to provide privacy while checking gastrostomy tube (G-tube, feeding tube that is surgically placed through an opening into the stomach from the abdominal wall) site for one of one resident (Resident 42) in accordance with the facility's policy titled Privacy During Activities of Daily Living (ADL) Policy, and resident's plan of care. This deficient practice had the potential to cause psychosocial (mental and emotional well-being) decline in Resident 42's self-esteem and self-worth. Findings: During a review of Resident 42's admission Record (AR), the AR indicated the facility admitted Resident 42 on 8/28/2017 and readmitted on [DATE] with diagnoses that included chronic obstructive disease (COPD- a long-term exposure to irritants that damage the lungs and airways), epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a care plan for one of one sampled resident (Resident 67) when Resident 67 wandered into other residents' rooms. This failure had the potential to result in unmet individualized needs for Resident 67 and the potential to affect the resident's physical and psychosocial well-being. Cross Reference F689 Findings: During a review of Resident 67's admission Record (AR), the AR indicated Resident 67 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday tasks), schizophrenia (serious mental disorder in which people interpret reality abnormally), and anxiety. During a review of Resident 67's Minimum Data Set (MDS, a standardized comprehensive assessment of each resident's functional capabilities and identifies health problems) dated 3/25/2024, the MDS indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to conduct an Interdisciplinary Team (IDT, a team brings together knowledge from different health care disciplines to help the residents receive the care they need) care planning (a conversation between the person and the healthcare practitioner about the impact their condition has on their life, and how they can be supported to best meet their health and wellbeing needs) conference for one of one sampled resident (Resident 184) in accordance with the facility's Policy and Procedure (P&P) titled Care Planning Interdisciplinary Team. This failure had the potential for Resident 184 not to receive the necessary person-centered care, treatment, and services. Findings: During a review of Resident 184's admission Record (AR), the AR indicated Resident 184 was admitted to the facility on [DATE], with diagnoses that included type 2 diabetes mellitus (elevated blood sugar level) and anemia (not having enough healthy red blood cells to carry oxygen to the body's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 5) selected for activities of daily living (ADL) was assessed and monitored during mealtime as indicated in the resident's care plan (CP). This failure had the potential to result in Resident 5 not to receive necessary care and treatment services. Findings: During a review of Resident 5's admission Records (AR), the AR indicated, the facility initially admitted Resident 5 to the facility on 6/4/2018, and readmitted on [DATE], with diagnoses that included Parkinson's disease (a disorder of the central nervous system that affects movement often including tremors) and osteoarthritis (occurs when the flexible, protective tissue at the ends of bones wears down). During a review of Resident 5's untitled CP dated 8/4/2023, the CP indicated Resident 5 had a potential for injury from tremors and involuntary movements due to Parkinson's disease. The CP interventions included to assure the resident 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 observation, interview, and record review, the facility failed to implement intervention on the resident's care plan (CP) for one of two sampled residents (Resident 23) selected for position/mobility (ability to move freely) care area. This failure placed Resident 23 at risk to develop skin breakdown (damage to the skin's surface). Findings: During a review of Resident 23's admission Records (AR), the AR indicated, Resident 23 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included cerebral infarction (type of ischemic [deficient supply of blood] stroke [sudden death of brain cells in a localized area due to inadequate blood flow] resulting from a blockage in the blood vessels supplying blood to the brain), hemiplegia (paralysis that affects one side of the body) and hemiparesis (loss of strength on one side of the body). During a review of Resident 23's untitled CP dated 3/26/2024, the CP indicated Resident 23 was at risk for alteration in skin integrity…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 13)'s nasal cannula tubing (flexible plastic tubing used to deliver oxygen through the nostrils) was not touching the trash bin, in accordance with professional standards of practice and the facility's policy and procedure titled Infection Control Policy: Oxygen Use. This deficient practice had the potential to increase the risk of infection to Resident 13. Findings: During a review of Resident 13's admission Record (AR), the AR indicated the facility admitted Resident 13 on 4/7/2017 and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, disease that causes blockage of airflow in the lungs) and heart failure (condition when the heart is unable to pump sufficiently to maintain blood flow to meet the body's needs) During a review of Resident 13's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 4/3/2024, the MDS indicated…

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