Madera Post Acute Center

Based on observation, interview and record review, the facility failed to ensure safe storage for one medication by: 1. Not ensuring medications were stored in a secure and locked manner. 2. Not ensuring medications were discarded after resident was discharged from facility. These deficient practices had the risk of medication theft and diversion of medication (redirection of prescription medication from its intended path (manufacturer to patient) for unauthorized use). Findings: During an observation on 3/11/2026 at 2:22 p.m. in the shed for nursing supplies, there was one box of lidocaine patches (topical, adhesive, local anesthetic products designed to treat pain by numbing specific areas of skin and underlying nerves) five percent (5%). During a concurrent observation and interview on 3/11/2026 at 2:26 p.m. with the Director of Maintenance (DOM) in the shed for nursing supplies, a box of lidocaine patches 5% was on a shelf on top of some diaper boxes. The DOM stated the DOM had never seen that box and the DOM did not know why it was there. The DOM stated medications should not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to follow their smoking policy and procedure (a structured framework of rules and guidelines that ensure consistency, legal compliance, and operational efficiency within an organization) for one of one sampled resident (Resident 3) by: 1. Not ensuring Resident 3 had a current smoking assessment on medical record. 2. Not reassessing Resident 3's ability to smoke safely quarterly or after a significant change. These deficient practices placed Resident 3 at risk of fire or burn injuries. Findings: During a review of Resident 31's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) and heart failure (progressive heart disease that affects pumping action of the heart muscles, causes fatigue and shortness of breath). During a review of Resident 3'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 7), received hydration through the gastrostomy tube (GT - a tube inserted into a surgical opening to allow feedings to be administered directly to the stomach common for people with swallowing problems) as ordered by the physician.This failure resulted in Resident 7 receiving insufficient hydration.Findings:During a review of Resident 7's admission Record (AR), the AR indicated Resident 7 was admitted on [DATE] with diagnoses that included cerebral palsy (group of conditions that affect movement and posture caused by damage to the brain before birth), quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), and dysphagia (difficulty swallowing). The AR also indicated Resident 7 had a GT.During a review of Resident 7's Minimum Data Set (MDS - a resident assessment tool), dated 12/9/2025, the MDS indicated Resident 7 had severely impaired…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report allegations of abuse for three of five sampled residents (Resident 3, Resident 4, and Resident 9) to the State Agency within two hours, in accordance with the facility's policy and procedure (P&P) titled, Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment, revised April 2025.These failures resulted in the delay of notification to the State Agency and had the potential for Resident 3, Resident 4, and Resident 9 to be subjected to abuse while at the facility.Findings: a. During a review of Resident 3's admission Record (AR), the AR indicated the facility admitted Resident 3 on 6/2/2025 and readmitted Resident 3 on 7/3/2025 with diagnoses which included acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood), chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), and urinary tract infection (UTI, an infection…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement its policy and procedure (P&P) titled, Fall Management System, for two of three sampled residents (Resident 6 and Resident 7) when: a. Resident 6's bed sensor pad alarm (an assistive electronic device that makes alerts/sounds to warn caregivers when the resident tries to get up from the bed) was in the off position while Resident 6 was in Resident 6's bed. b. The facility's Interdisciplinary Team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of the resident) failed to implement new interventions to address Resident 7's falls on [DATE] and on [DATE]. The IDT also failed to update Resident 7's care plan following Resident 7's falls on [DATE] and [DATE]. These failures had the potential to result in Resident 6 and Resident 7 sustaining injury and/or harm due to falling while in the care of the facility.Findings: a. During a review of Resident 6's admission Record (AR),…

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

Based on observation, interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Labeling and Dating of Foods, and Refrigerated Storage Guide, by failing to ensure: 1. A box of orange-colored, shredded cheese was labeled with an open date, a use by date or expiration date, and labeled with what kind of cheese was in the box.2. A box of Parmesan cheese was labeled with an open date and a use by date or expiration date.3. A plastic bag which contained three (3) blocks of orange-colored cheese was labeled with a use by date or expiration date. These failures had the potential to result in food borne illnesses (any illness resulting from eating contaminated/spoiled foods) for all residents in the facility who received food from the facility kitchen. Findings: During a concurrent observation and interview on 12/31/2025 at 10:59 AM with the Dietary Supervisor (DS) inside the kitchen walk-in refrigerator, the following were observed inside the walk-in refrigerator:a) A plastic box full of orange-colored, shredded cheese labeled with a date 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 interview and record review, the facility failed to provide necessary care and services to one of three sampled residents (Resident 1) by failing to:A. Ensure Resident 1's physician's orders were followed when Licensed Vocational Nurse 1 (LVN 1) held administration of Tresiba (a once-daily medication used to manage high blood sugar).B. Ensure accurate medication administration documentation for Resident 1, when LVN 2 did not document the Tresiba administration for Resident 1 on 8/9/2025.These deficient practices had the potential to result in serious health complications for Resident 1.Findings:A. During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 11/4/2018 and readmitted the resident on 8/12/2025 with a diagnosis including type 2 diabetes mellitus (a chronic [persistent or long-lasting] disease characterized by high blood sugar levels due to insufficient insulin [a hormone which regulates the amount of sugar in the blood] production) and unspecified hypoglycemia (body's blood sugar level goes below 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 promote and treat four of four sampled residents (Residents 10, 34, 61 and 102) with respect, privacy and dignity by failing to ensure:a. The Director of Staff and Development (DSD) close the privacy curtain while checking Resident 102's Gastrostomy tube (G-tube, feeding tube that is surgically placed through an opening into the stomach from the abdominal wall) site. b. Resident 34's nephrostomy (a thin catheter that drains urine from kidney into a bag) drain was covered and provided Resident 34 with privacy. c. Certified Nursing Assistant 8 (CNA 8) and Restorative Nursing Assistant 2 (RNA 2) closed the privacy curtain completely while providing care to Resident 61.d. Resident 10 was offered to get up to go to the bathroom between 7:30 am and 11:02 am on 7/9/2025. As a result, Resident 10 was sitting in Resident 10's urine-soaked brief from 8:13 am to 11:02 am. Resident 10 felt sore, mad, and angry that facility staff did not offer…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 promote continence (ability to control the bladder and bowels) for one of two sampled residents (Resident 10), according to the facility's policies and procedures (P&P) titled, Bowel and Bladder Assessment, and Resident Assessment and Associated Processes, by failing to:1. Ensure Resident 10 was placed on a scheduled toileting program (taking resident on a planned schedule to the toilet) after Resident 10 was assessed to not be a candidate for bowel and bladder retraining on 4/18/2025 and 6/18/2025. 2. Ensure Resident 10's bowel and bladder assessments (BBA) dated 6/18/2025 and Minimum Data Set (MDS- a resident assessment too) dated 6/18/2025 provided an accurate assessment of Resident 10's continence level based off the facility staff's observations. Licensed nurses assessed Resident 10 as always incontinent of bowel and bladder.As a result of these failures, Resident 10 was not placed on a scheduled toileting program on 4/18/2025 and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan (CP) for four of four sampled residents (Residents 4, 335, 61 and 44).a. Resident 4's CP was not initiated and implemented for the use of Buspirone (anxiolytic - medication used to treat anxiety disorders).b. Resident 335's CP was not initiated and implemented to address chronic abdominal pain.c. Resident 61 CP was not initiated and implemented to address recurrent Urinary Tract Infection (UTI - common infections that happen when bacteria, often from the skin or rectum, enter the urethra and infect the urinary tract).d. Resident 44's CP was not initiated and implemented for the use of Hydrocodone (narcotic pain medication).These deficient practices had the potential to not provide adequate care and services to address specific needs of Residents 4, 335, 61 and 44.Findings: a. During a review of Resident 4’s admission Record (AR), the AR indicated Resident 96 was admitted to the facility on…

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

Based on observation, interview and record review, the facility failed to ensure 20 cups of milk were maintained at temperature of 41 degrees Fahrenheit (41 F) during the meal service (Food Service- Meal service may include, but is not limited to, the steam table where hot prepared foods are held and served, and the chilled area where cold foods are held and served.This deficient practice had the potential to affect microbial (germs) growth that could lead to food poisoning (Food poisoning can happen to anyone who swallows food or water that's contaminated by 'germs).Findings:During a kitchen observation on 7/7/2025 at 7:59 AM, of the meal service which had already started, there were 20 cups of thickened milk and boxed milk placed on top of the plastic trays at room temperature. The temperature of the thickened milk of a cup was 57. F and the temperature of the boxed milk was 47.8 F.During an interview on 7/7/2025 at 8:01 AM, the Dietary Services Supervisor (DSS) stated the DSS would put the milk cups and boxed milk on ice now during the meal service.During an interview on 7/7/2025…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policies and procedures (P&P) on Infection Prevention and Control were implemented for five of five sampled residents (Residents 105, 122, 61, 53, and 34) by failing to:a. Ensure Resident 105's urinal was stored appropriately and labeled with a resident identifier.b. Ensure staff wore proper personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) for Enhanced Barrier Precautions (EBP- an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs] that employs targeted gown and glove use during high contact resident care activities and were indicated for residents with infections, wounds, and indwelling medical devices) while providing range of motion (ROM) exercises to Resident 122.c. Ensure staff changed PPE in between Resident 61 and Resident 53's care.d. Ensure staff placed EBP signage and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 109) had a bedroom wall that was not missing part of the baseboard.This failure had the potential to result in the exposure of Resident 109 and Resident 109's visitors to dust and other unknown contaminants and failed to provide a safe, clean, comfortable, and homelike environment.Findings:During a review of Resident 109's admission Record (AR), the AR indicated Resident 109 was admitted to the facility on [DATE] with diagnoses including sepsis (a life-threatening blood infection), lack of coordination, and dysphagia (difficulty swallowing).During a review of Resident 109's History & Physical (H&P), dated 6/7/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 109's Minimum Data Set (MDS, a resident assessment tool), dated 6/17/2025, the MDS indicated Resident 109 had moderately impaired cognition (ability to understand), used a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a change of condition was developed and the physician was notified for one of one resident (Resident 335) who had an alert notification for no bowel movement for three days.This deficient practice had the potential to lead to a bowel obstruction, bowel rupture and/or death.Findings:During a review of Resident 335's admission Record (AR), the AR indicated the facility admitted the resident on 5/1/2025, with diagnoses that included enterocolitis due to clostridium difficile (is an inflammation of the intestines that is predominantly associated with antibiotic use), irritable bowel syndrome (a condition that causes abdominal discomfort and altered bowel movements).During a review of Resident 335's MDS dated [DATE], the MDS indicated Resident 335 had intact cognition. The MDS indicated Resident 335 was dependent in toileting hygiene, bed mobility; rolling left and right, sit to lying, lying to sitting on the side of the bed,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a physician order and an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) were obtained before the installation of side rails for one of two sampled residents (Resident 83).This failure placed Resident 83 at risk for entrapment (an event in which residents were caught, trapped, or entangled in a tight space around the bed) and injury from use of side rails.Findings:During a review of Resident 83's admission Record (AR), the AR indicated Resident 83 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hemiparesis (weakness on one side of the body) and dysarthria (a speech disorder that results in slurred, slow, or imprecise speech).During a review of Resident 83's Minimum Data Set (MDS, a resident assessment tool), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a resident with a physician order to have a plate guard (a dining aid that can help people with limited control, grip, or dexterity eat with one hand and reduce the risk of spills) during meals for one of one sampled resident (Resident 83).This failure had the potential to result in Resident 83's decline in nutritional status and inability to maintain independence during mealtimes.Findings:During a review of Resident 83's admission Record (AR), the AR indicated Resident 83 was admitted to the facility on [DATE], with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hemiparesis (weakness on one side of the body), dysarthria (a speech disorder that results in slurred, slow, or imprecise speech) and adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity).During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the bed alarm was functioning properly for one of two sampled residents (Resident 10), to alert staff when Resident 10 attempted to get up unassisted.This deficient practice had the potential to result in residents being at risk for further falls.Findings:During a review of Resident 10's admission Record (AR), the AR indicated the facility originally admitted the resident on 3/22/2023, and readmitted the resident on 4/18/2025, with diagnoses that included Parkinson's disease (is a brain condition that causes problems with movement, mental health, sleep, pain and other health issues), encephalopathy (brain disease or brain damage.) and abnormality of gait and mobility, During a review of Resident 10's Minimum Data Set (MDS) dated [DATE], the MDS indicated Resident 10 had intact cognition. The MDS indicated Resident 10 required moderate assistance (helper does less than half the effort) with mobility in chair/bed-to chair transfer,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow the facility ' s policy and procedure (P&P) titled, Significant Change of Condition, Response, for one of three sampled residents (Resident 1) by failing to: 1. Ensure Certified Nursing Assistant (CNA) 1, reported to a charge nurse or supervisor an incident involving Resident 1 ' s left leg that got caught on the shower chair during 7 am – 3 pm shift. 2. Ensure Resident 1 ' s left leg was assessed by a charge nurse or supervisor during 7 am – 3 pm shift. These deficient practices had the potential to delay the necessary care and services for Resident 1. Findings: During a review of Resident 1 ' s admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 10/27/2023 and recently admitted on [DATE] with diagnoses that included hemiplegia (paralysis that affects only one side of the body) and hemiparesis (one-sided weakness or inability to move) following cerebral infarction (damage to tissues in the brain due to a loss…

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

Based on interview and record review, the facility failed to follow the facility ' s policy and procedure (P&P) titled, Charting and Documentation, by failing to have complete documentation for one of three sampled residents (Resident 2). Resident 2 was found with purplish discoloration (any alteration in the skin's color, texture, or pigmentation) on the right great toe. This deficient practice resulted in not providing complete information about how Resident 2 sustained the purplish discoloration on the right great toe which had the potential to put Resident 2 ' s safety at risk. Findings: During a review of Resident 2 ' s admission Record (AR), the AR indicated the facility originally admitted Resident 2 on 2/2/2023, and readmitted Resident 2 on 12/11/2024, with diagnoses that included chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), acute kidney failure (when the kidneys suddenly cannot filter waste products from the blood), and chronic systolic (congestive) heart failure (when the heart cannot pump blood well enough to give…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 promptly (quickly/with little or no delay) notify the physician for one of eight sampled residents (Resident 8) who experienced a change of condition (COC- a sudden clinically important deviation from a resident/patient's baseline in physical, behavioral, or functional domains) as indicated in the facility's policy and procedure (P&P) titled, Significant Change of Condition, Response, by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 3 promptly notified Resident 8's Primary Care Provider/Medical Doctor (MD) 2 when LVN 3 observed an increase in swelling in Resident 8's left leg and foot on 1/15/2025. 2. Ensure LVN 3 promptly notified MD 2 on 1/20/2025 when Resident 2's left leg and foot condition did not improve. These deficient practices resulted in a delay in providing the care and treatment for Resident 1 and placed Resident 1 at risk for further skin breakdown. Cross Reference F684 Findings: During a review of Resident 8's admission Record (AR), the AR indicated the facility initially admitted Resident 8 on…

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

Based on interview and record review, the facility failed to monitor and document a change of condition for one of eight sampled residents (Resident 8) as indicated in the facility's policy and procedure (P&P) titled, Significant Change of Condition, Response, by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 3 completed a Situation-Background-Assessment-Recommendation (SBAR- a written communication tool that helps provide essential, concise information, usually during crucial situations)/Change of Condition (COC) form when LVN 3 observed an increase in swelling in Resident 8's left leg and foot on 1/15/2025. 2. Ensure LVN 3 completed an SBAR/COC form on 1/20/2025 when Resident 2's left leg and foot condition did not improve after 72 hours. These deficient practices resulted in a delay in providing the care and treatment for Resident 1 and placed Resident 1 at risk for further skin breakdown. Cross Reference F580 Findings: During a review of Resident 8's admission Record (AR), the AR indicated the facility initially admitted Resident 8 on 6/15/2025, and readmitted Resident 8…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 skin treatment in accordance with the professional standards of practice for one of three sampled residents (Resident 1) by failing to: a. Ensure a Licensed Vocational Nurse (LVN) instead of a Certified Nursing Assistant (CNA) 1 applied ointments to Resident 1. b. Ensure there was a physician's order for the ointments being applied to Resident 1. These failures had the potential to result in improper use and application of skin treatment for Resident 1. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 10/27/2023 and recently admitted on [DATE] with diagnoses of hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or paralysis on one side of the body) following cerebral infarction (a medical condition where blood flow to the brain is interrupted, leading to the death of brain cells) affecting…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 involving one of ten sampled residents (Resident 1) and a family member of Resident 2 (FM 1) to the California Department of Public Health (CDPH), the local law enforcement, and the Ombudsman (an official appointed to advocate for residents of nursing homes) within two hours as indicated in the facility's policy and procedure (P&P) titled, Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment. This deficient practice violated Resident 1's rights, had the potential to compromise Resident 1's safety, and could subject Resident 1 to potential further verbal, mental, and emotional abuse. Findings: 1. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was readmitted to the facility on [DATE] with diagnoses that included diabetes (elevated blood sugar in the blood), hypertension (elevated blood pressure), and anemia (low iron levels in the blood). During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) with psychotropic medication (any drug that affects the brain activities associated with mental processes and behavior) order was free from unnecessary drugs, according to the facility's policy and procedure (P&P) titled, Psychotropic Medications, by failing to: Ensure Resident 1 was not ordered Seroquel (medication used to treat symptoms of psychosis [severe mental condition in which thought and emotions are so affected that contact is lost with external reality] and other mental health disorders) 25 milligrams (mg- unit of measurement) for false accusations towards staff for unspecified psychosis not due to a substance (drug) or known psychological condition on 8/23/2024 when Resident 1 was not diagnosed by Psychiatrist/Medical Doctor (MD) 2 with unspecified psychosis. This deficient practice had the potential to result in significant adverse consequences from the use of unnecessary medications.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide reasonable accommodation of need for three of three sampled residents (Residents 32, 84 and 89) who were assessed as at risk for fall, by failing to ensure the residents call light was within reach as indicated in the facility's Policy and Procedure (P&P), titled Call Light and resident's plan of care. These deficient practices had the potential for Residents 32, 84 and 89 not to receive or received delayed care that could result in a fall or accident. Findings: a. During a review of Resident 89's admission Record (AR), the AR indicated the facility admitted Resident 89 on 1/23/2024 with diagnoses that included abnormalities of gait (a person's manner of walking) and mobility (the ability to move), need for assistance with personal care and dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning). During a review Resident 89's History and Physical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents were provided with a communication device with the language that the resident understood for two of three sampled residents (Residents 50 and 80). These deficient practices had the potential to prevent Residents 50 and 80 from communicating with the staff and had the potential to receive delayed care, treatment, and services. Findings: a. During a review of Resident 50's admission Records (AR), the AR indicated, Resident 50 was admitted to the facility on [DATE] with diagnoses that included dementia (loss of cognitive functioning, thinking, remembering, and reasoning that interferes with a person's daily life and activities), and cognitive communication deficit (occurs when someone has difficulty with communication due to impaired cognition). During a review of Resident 50's untitled Care Plan (CP), dated 1/4/2024, the CP indicated Resident 50 was at risk for communication problem related to language barrier. The CP…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident's environment was free from accidents for two of four sampled residents (Residents 12 and 339) by failing to: a. Implement Resident 12's Medical Doctor (MD) order and care plan to place floor mats at the edge of Resident 12's bed to prevent injury for fall. Implement Resident 12's Care Plan (CP) and Policy and Procedure (P&P) on Seizure Precaution to pad the bed side rails to prevent injury during a seizure (uncontrolled electrical activity in the brain that causes temporary abnormalities in muscle tone or movements) b. Implement the facility's P&P on smoking when Resident 339 was observed to have cigarettes on Resident 339's position on 7/16/2024. These failures had the potential to result in accident and hazard for Residents 12 and 339. Findings: a. During a review of Resident 12's admission Record (AR), the AR indicated Resident 12 was admitted to the facility on [DATE] with diagnoses that included epilepsy (brain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow the facility's Policy and Procedure (P&P), titled Resident with Indwelling Catheter in Placed and the resident's Care Plan (CP) for three of three sampled residents (Residents 30, 106, and 128) by failing to: a. Ensure Resident 30's indwelling catheter (known as foley catheter [FC], a tube that allows urine to drain from the bladder into a bag that is usually attached to the thigh) was assessed and monitored for the presence of white sediments (visible particles in the urine that may contain red or white blood cells, casts, bacteria, fungi, parasites in the urine that could indicate infection or dehydration [fluid deficit]) in the urine. b. Ensure Resident 106's FC was assessed and monitored for the presence of white sediments in the urine and tubing and was not kinked. c. Ensure Resident 128's FC was assessed and monitored for the presence of white sediments in the urine. These deficient practices had the potential for Residents…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 30 and 128 ) who had gastrostomy tube (GT- a tube inserted through the abdomen that delivers nutrition directly to the stomach) received appropriate treatment and services as indicated in the facility's Policy and Procedure (P&P) titled Enteral Formulas, Administration of Closed System, Gastrostomy Tube Care Management, and the resident's plan of care by: a. Failing to ensure Resident 30's GT formula bottle was labeled with time started. b. Failing to ensure Resident 128 received the recommended amount of GT water flush, as ordered. These deficient practices had the potential to result in adverse consequences for Residents 30 and 128. Findings: a. During a review of Resident 30's admission Record (AR), the AR indicated the facility admitted Resident 30 on 4/28/2024 with diagnoses that included urinary tract infection (UTI, condition in which bacteria invade the urinary system) and encounter…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 attempt the use of appropriate alternatives to bed rails before its installation for two of two sampled residents (Residents 26 and 99). These deficient practices placed Residents 26 and 99 at risk for entrapment and injury from the use of bed rails. Findings: a. During a review of Resident 99's admission Record (AR), the AR indicated the facility readmitted the resident on 6/10/2024, with diagnoses that included diabetes mellitus (a condition that happens when the blood sugar [glucose] is too high) and anxiety disorder (a type of mental condition that cause fear, panic and other symptoms that are out of proportion to the situation). During an observation and concurrent interview on 7/18/2024 at 9:10 a.m., Resident 99 was lying on her back in bed with half-length bed rails up on both sides. Resident 99 was watching the television, alert and coherent. Resident 99 stated she did not know why both sides of her bed rails were always up since the first day of readmission to the facility. Resident 99 was able to get…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 proper food sanitation and safe handling practices by: a. Placing a container of raw meat for thawing next to the container of ready to eat carrots, at the lowest shelf inside one of one facility walk-in refrigerator. b. Placing spoons with food particles in one of one clean knife holding rack. These failures had the potential to result in contamination and food borne illnesses (illness caused by consuming contaminated food or beverages) to the residents. Findings: During an observation on 7/16/2024 at 8:32 am, in the facility's kitchen, there was one container with raw meat placed on the lowest shelf inside the facility's walk-in refrigerator. There was a container with ready to eat chopped carrots next to the meat container. During a concurrent interview, Certified Dietary Manager (CDM) stated, the packed meat inside the container was raw ground turkey for defrosting. CDM stated ready-to-eat food should be placed above the thawing meat. The CDM stated, kitchen staff should not place ready to eat 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 interview and record review, the facility failed to provide information on Advance Directive (AD, a written preferences regarding treatment options, a process of communication between individuals and their healthcare agents to understand, reflect on, discuss, and plan for future healthcare decisions for a time when individuals are not able to make their own healthcare decisions) for one of three sampled residents (Resident 48). This failure had the potential for facility staff to provide treatment and services against the resident's will. Findings: During a review of Resident 48's admission Record (AR), the AR indicated Resident 48 was readmitted to the facility on [DATE] with diagnoses that included dysphagia (difficult swallowing) and dementia (loss of thinking abilities severe enough to interfere with daily life). During a review of Resident 48's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 6/6/2024, the MDS indicated Resident 48 had unclear speech, rarely/never…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 apply elbow splint as ordered by the physician for one of four sampled residents (Resident 27) This failure had the potential risk to result in the resident's decline in Range of Motion (ROM, full movement potential of a joint) that cause stiffness (inability to move easily and without pain) and contractures (deformity and joint stiffness). Findings: During a review of Resident 27's admission Record (AR), the AR indicated Resident 27 was readmitted to the facility on [DATE] with diagnoses that included joint contracture and dysphagia (difficult swallowing). During a review of Resident 27's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 4/23/2024, the MDS indicated Resident 27 had unclear speech, rarely/never understood others, and rarely/never made self-understood. Resident 27 was dependent (helper does all of the effort) for personal hygiene, dressing and rolling left and right. During a review of Resident…

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

Based on observation, interview and record review, the facility failed to ensure a resident with breathing problem receive continuous oxygen therapy as ordered by the physician for one of one sampled resident (Resident 4) This deficient practice placed Resident 4 at risk for severe difficulty of breathing. Findings: During a review of Resident 4's admission Record (AR), the AR indicated the facility readmitted the resident on 8/7/2023, with diagnoses that included chronic obstructive pulmonary disease ([COPD]a group of lung diseases that block airflow and make it difficult to breathe) and diabetes mellitus (a condition that happens when the blood sugar [glucose] is too high). During a review of Resident 4's untitled Care Plan (CP) for oxygen therapy dated 10/12/23, the CP indicated Resident 4 will not have signs and symptoms of poor oxygen by providing continuous oxygen at two liters per minute through nasal cannula to keep oxygen saturation above 92 percent. During a review of Resident 4's Physician Order Sheet (POS) dated 6/20/2024, the POS indicated an order for licensed staff 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 hospice (program that gives special care to residents who are near the end of life and have stopped treatment to cure or control disease) diet order for one of two sampled residents (Resident 68). Resident 68 had an order of puree diet (food that has been ground, blended, or chopped into a thick paste or liquid for easier swallowing and digestion) with thin liquids from the hospice physician but Resident 68 was currently receiving mechanical soft diet (foods that are soft in texture) with thin liquids. This failure had the potential to result in adverse consequences for Resident 68 including weight loss. Findings: During a review of Resident 68's admission Record (AR), the AR indicated Resident 68 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included leukemia (cancer that causes large numbers of abnormal blood cells that enter the bloodstream), Alzheimer's disease (progressive disease affecting…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain a complete and accurate clinical record for one of one sampled residents (Resident 1) when Registered Nurse Supervisor (RNS) 3 did not document that RNS 3 flushed with saline (a solution of salt in water), clamped, and capped Resident 1's permanent catheter (Permacath- a type of central venous catheter [CVC- an indwelling device inserted into a large, central vein to administer fluid, medication, and/or treatment] used for short-term or long-term hemodialysis [a treatment to filter wastes and water from the blood, as the kidneys did when the kidneys were healthy]) after the completion of Resident 1's intravenous (IV, within a vein) infusion (a method of putting fluids into the bloodstream) on Resident 1's clinical record. This deficient practice had the potential to cause inconsistencies and errors in providing the necessary care and treatment to Resident 1. Cross Reference F694 Findings: During a review of Resident 1's admission Record (AR), the AR indicated, the facility originally admitted Resident 1 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 follow its own policy and procedure to ensure there was sufficient staff available to assist one of five sampled residents (Resident 1) who required assistance with feeding in a timely manner. Resident 1 had to wait 30 minutes to be fed after his meal tray was placed at the bedside. This failure had the potential to result in the food getting cold and to not be appetizing to the resident and could result in potential risk of weight loss for Resident 1. Findings: During a review of Resident 1's admission record, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dysphagia (difficulty swallowing), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and schizophrenia (mental illness that affects how a person thinks, feels, and behaves). During a review of Resident 1's Mini Nutritional…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 five sampled residents (Resident 2) by failing to ensure the call light was not wrapped to the top of the left side of Resident 2's bed frame. This failure had the potential to result in Resident 2 being unable to notify staff of Resident 2's needs, and possibly, sustain an injury. Findings: During a review of Resident 2's admission record, the admission record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia (one-sided muscle paralysis or weakness) and hemiparesis (weakness or inability to move one side of body) after a cerebral infarction (occurs as a result of disrupted blood flow to the brain) affecting the right dominant side, muscle wasting and atrophy (decrease in size), and dementia (problems with thinking, remembering, and reasoning to an extent that interferes with a resident's daily life and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the right to formulate Advance Directives were exercised for eight of 14 sampled residents (Residents 79, 104, 99, 55, 41, 5, 34, and 217). This deficient practice has the potential for residents future health care decisions or wishes not be determined and identified by the facility staff to implement in the event of medical emergency. Findings: a. A review of Resident 79's admission Record indicated the resident was originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included: Type 2 diabetes mellitus (high blood sugar), morbid obesity (excessive body fat), hypertension (high blood pressure), muscle weakness, lack of coordination, and heart failure. A review of Resident 79's Minimum Data Set (MDS, standardized assessment and care screening tool) dated 8/2/21 indicated cognition was moderately impaired and was usually able to understand and be understood by others. A review of Resident 79's History and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow safe food storage and food handling practices in accordance with professional standards for food service safety and the facility's policy and procedure (P&P) by failing to: 1. Label/date prepared food items in the kitchen's refrigerator. 2. Label opened/used dry food item stored in the kitchen dry storage pantry. 3. Discard opened/used dry food item on the shelf in the kitchen dry storage pantry within the time specified. 4. [NAME] (put on) gloves during food preparation in the kitchen. These deficient practices had the potential for food borne illness (illness caused by the ingestion of contaminated food or beverage) and/or affect the palatability of the meal to the residents. Findings: 1. During an initial tour observation of the kitchen, and interview on 10/18/2021, at 9:12 am, Dietary Supervisor 3 (DS 3), stated there was a tray with two small bowls of cottage cheese, two small bowls of yogurt, and a small bowl of cut up…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain proper infection control practices when: a. Resident 109's percutaneous cholecystostomy catheter (tube placement for gallbladder, small organ that helps with digestion, content drainage) bag was observed touching the floor. b. During initial tour, there was trash and dark spots on the floor in Resident 6's room. In addition, Resident 6 hung one of two urinals (urine plastic bottle) on the trash bin and his urinals were unlabeled. c. Laundry staff (unidentified) were eating and drinking in the clean linen laundry area. d.Water temperature was not maintained at 150 degrees Fahrenheit for washing linens, the gauge read 115-125 degrees F. e.The facility staff (Certified Nursing Assistant 1 [CNA 1]) failed to wear a face shield while caring for Resident 28 in the [NAME] Zone (area where there are no Coronavirus-19 [COVID-19, a new infectious viral disease that can cause respiratory illness cases]). f. The facility's Activities…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 informed consent for the use of psychotropic medication (any medication capable of affecting the mind, emotions, and behavior) was obtained from the resident who had the capacity to make decisions and not from the family member, for one of 23 sampled residents (Resident 167). This failure had the potential to violate the Resident 167 rights to be informed of the adverse effects of taking the psychotropic medication and to choose the type of care or treatment to be received, or alternatives the resident preferred. Findings: A review of the admission Record indicated Resident 167 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (fear characterized by behavioral disturbances), hypertension…

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

Based on observation, interview, and record review, the facility failed to provide a communication board (a device that displays photos, symbols, or illustrations to help people with limited language skills express themselves) for one of one sampled residents (Resident 34). Resident 34 had a language barrier, and the facility did not provide the resident with a communication board as indicated in the facility's Language/Communication Barriers policy. This deficient practice had the potential for Resident 34 not to communicate effectively with staff. Findings: A review of Resident 34's admission Record indicated the facility readmitted the resident on 9/23/2021 with diagnoses of Type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), benign prostatic hyperplasia age-associated prostate gland enlargement that can cause urination difficulty), and unspecified dementia without behavioral disturbance (mental disorder in which a person loses the ability to think, remember, learn, make decisions and solve problems). A review of Resident 34'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 privacy for one of one sampled resident (Resident 104). Certified Nursing Assistant 3 (CNA) 3 was providing care to Resident 104, and left the room. Resident 104 was left lying on her bed with her gown up to her hip area, and both legs were exposed. This deficient practice has the potential to violate the resident's right for personal privacy. Findings: A review of the admission Record indicated Resident 104 was admitted to the facility on [DATE] with diagnoses that include: urinary tract infection (infection in the urine), heart failure, dysphagia (difficulty swallowing), lack of coordination, dementia (a decline in mental ability), schizophrenia (mental disorder characterized by loss of contact with the environment). A review of the History and Physical Examination, dated 9/24/21, indicates Resident 104 does not have the capacity to understand and make decisions. A review of the Minimum Data Set (MDS, standardized assessment and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop an individualized care plans for three of 23 sampled residents (Residents 109, 6, and 417) as indicated on the facility policy and procedure. a. Resident 109 who had a percutaneous cholecystostomy catheter (tube placement for gallbladder, small organ that helps with digestion, content drainage) with a drainage bag did not have a care plan developed for the care of the catheter. b. Resident 6 did not have a care plan with appropriate interventions to address resident's consistent behavior of hanging his urinal on a trash bin and propelling himself on the wheelchair with no foot rest. c. Resident 417 did not have a care plan upon admission for grieving and emotional distress due to the loss of her son. These deficient practices had the potential to result with Residents 109, 6, and 417 not receiving interventions to address resident specific needs, which can result to decline in well-being. Findings: a. A review of the admission…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 modify the care plan for one of 23 sampled residents (Resident 3) to address impaired vision. This deficient practice had the potential for Resident 3 not to receive specific interventions to address needs, which can result in falls and injury and decline in functional ability. Findings: A review of the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of blindness on the right and left eye and unspecified intellectual disabilities. A review of the History and Physical, dated 8/30/2021, indicated Resident 3 did not have the capacity to understand and make decisions. A review of the Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 6/21/2021, Resident 3 had clear speech, usually understood and had the ability to understand others. MDS also indicated Resident 3 had severely impaired vision (no vision or sees only light colors or shapes)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assist one of two sampled residents (Resident 98) to obtain an ppointment with an audiologist (a physician who evaluates hearing disorders) for the need of a hearing device (a device used to improve hearing). This deficient practice had the potential to result in increased hearing loss, difficulty with communication and decline in Resident 88's quality of life. Findings: A review of Resident 98's admission Record indicated the facility readmitted the resident on 8/23/2021 with diagnoses of metabolic encephalopathy (a problem in the brain caused by chemical imbalance in the blood), benign prostatic hyperplasia age-associated prostate gland enlargement that can cause urination difficulty), and unspecified dementia without behavioral disturbance (mental disorder in which a person loses the ability to think, remember, learn, make decisions and solve problems). A review of Resident 98's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 9/10/2021, indicated he was moderately cognitively…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide treatment to prevent the development of a pressure ulcer (localized injury to the skin and or underlying tissue usually over a bony prominence as a result of pressure or pressure in combination with shear and/or friction) for one of one sampled Residents (Resident 28) by failing to ensure the low air loss mattress (LAL, special type of mattress used for both the prevention and treatment of pressure ulcer) was set on the correct setting as indicated on the facility policy. This deficient practice had the potential to result in the development of new pressure ulcers or result in reoccurrence of pressure ulcer, which could lead to complications and affect Resident 28's total well-being. Findings: A review of the admission Record indicated Resident 28 was initially admitted on [DATE] and readmitted on [DATE] with multiple diagnoses including unspecified dementia without behavioral disturbance (a mental disorder in which a person loses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safety measures for one of two sampled residents (Resident 104). On 10/18/2021 at 9:39 am, Certified Nursing Assistant 3 (CNA 3) left Resident 104 unattended in bed during perineal (involves cleaning private areas) care and did not lower Resident 104's bed when she left the room. This deficient practice had the potential for Resident 104 to experience injuries and or a fall. Findings: A review of Resident 104's admission Record indicated Resident 104 was admitted to the facility on [DATE] with diagnoses of urinary tract infection (infection in the urine), heart failure, dysphagia (difficulty swallowing), lack of coordination, dementia (a decline in mental ability), schizophrenia (mental disorder characterized by loss of contact with the environment). A review of Resident 104's Fall Risk Assessment, dated 9/23/2021, indicated Resident 104 was at high risk for falls and had one or more falls in the past three months. 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 one of one sampled residents (Resident 23) who required an ileostomy (where the small intestine is diverted through an opening in the tummy to move waste out of the body) received care in accordance with the resident's physician's order by failing to: 1. Address Resident 23's ileostomy defective bag in a timely manner. This deficient practice resulted in Resident 23's emotional well-being to be affected and had the potential to develop breakdown to the resident's skin surrounding the ostomy (or stoma, an artificial opening in the body, created during an operation such as a colostomy or ileostomy). Findings: A review of Resident 23's admission Record, indicated, Resident 23 was initially admitted to the facility on [DATE] and readmitted last on 5/11/2021 with diagnoses of end stage renal disease (the final permanent stage of chronic kidney disease where kidney function has declined to the point that the kidneys can no longer function…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide adequate pain management for three of four sampled residents (Resident 270, Resident 218, and Resident 267), according to the residents' plan of care. This deficient practice resulted for the residents to experience pain, and had the potential to decline in function. Findings: a. A review of Resident 270's admission Record indicated the facility admitted Resident 270 to the facility on [DATE] with diagnoses of malignant neoplasm (cancerous tumor) of anus, pathological (not cause by force or impact) fracture, and high blood pressure. A reveiw of Resident 270's physician order dated 10/9/2021, indicated for the resident to receive oxycodone (medication to relief pain) tablet, 10 milligrams (mg, a unit of measurement), one tablet by mouth every eight hours as needed for severe pain (7-10). A review of Resident 270's physician order dated 10/9/2021, indicated for the resident to receive acetaminophen (Tylenol) 500mg two tablets by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to document and account for controlled medications (medications that can cause physical and mental dependence), as indicated in the facility's Medication Administration policy and procedure, for two of two sampled residents (Resident 57 and Resident 100). This deficient practice had to potential for the loss of controlled medications. Findings: a. A review of Resident 57's admission Record indicated Resident 57 was admitted to the facility on [DATE] with diagnoses of seizures (abnormal behavior, sometimes including loss of consciousness), and narcolepsy (a chronic sleep disorder). A review of Resident 57's Physician's Orders dated 2/8/2019, indicated for the resident to receive Vimpat (a federally controlled anticonvulsant medication used to treat seizures) 100 milligrams (mg, a unit of measurement) daily. A review of Resident 57's History and Physical, dated 2/7/2021, indicated Resident 57 had fluctuating capacity to understand and make decisions. During…

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

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 167) had a self-administration assessment for the use of albuterol inhaler (inhaled spray to treat narrowing of the airways). The facility was not aware Resident 167 was self-administering an albuterol inhaler brought from home. This deficient practice had the potential to result with unsafe administration of the inhaler for Resident 167. Findings: A review of Resident 167's admission Record indicated the facility admitted the resident on on 10/5/2021 with diagnoses of chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), major depressive disorder, anxiety disorder, hypertension (high blood pressure), and history of falling. A review of Resident 167's History and Physical Examination, dated 10/8/2021, indicated Resident 167 has the capacity to understand and make decisions. During an observation and concurrent interview on 10/18/2021 at 11:40 am, Resident 167 was awake and alert lying in bed and an…

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

Based on observation, interview, and record review, the facility failed to provide rehabilitative services (help people return to daily life and live in a normal or near-normal way) to one of one sampled residents (Resident 55). Resident 55 did not receive rehabilative services for 13 days (10/9/21 to 10/21/21), while waiting for his insurance company to approve physical therapy (focuses on helping improve your movement, mobility, and function), and occupational therapy (focuses more on how clients perform activities and roles that are most important to their daily lives). This deficient practice had the potential for Resident 55 to decline in functional ability or deterioration of muscle strength. Findings: A review of Resident 55's admission Record indicated the facility admitted admitted the resident on 7/6/2021 with diagnoses of chronic kidney disease (longstanding disease of the kidneys in which waste builds up as the kidneys fail to filter waste and excess fluid from the body), difficulty walking, gout (a form of arthritis characterized by severe pain, redness, and tenderness…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 coordination of care between the hospice (care designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than cure) team and the facility for one of two sampled residents (Resident 167) by not having a calendar hospice staff sign in sheet and no documented evidence of scheduled Licensed Vocational Nurse (LVN) and Registered Nurse (RN) visits were conducted in accordance with the facility policy and procedure. This failure had the potential for Resident 167 not to receive the hospice services necessary to promote comfort and quality of life. Findings: A review of the admission Record indicated Resident 167 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), major depressive disorder (mood disorder that causes a persistent feeling of sadness…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement the antibiotic stewardship (refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use) policy for two of three sampled residents (Resident 22 and Resident 55) for the use of antibiotics (a medication used to treat bacterial infections). a. For Resident 22, regarding the use of Doxcycline Monohydrate (antibiotic) b. For Resident 55, regarding the use of Cephalexin (antibiotic). This deficient practice had the potential to result in the development of antibiotic-resistant organisms (organisms not affected to antibiotics). Findings: a. A review of Resident 22's admission Record indicated Resident 22 was admitted to the facility on [DATE] with diagnoses of dementia (a disorder that affect the brain) and diabetes (blood glucose, or blood sugar, levels are too high). A review of Resident 22's History and Physical dated 4/16/2021, indicated Resident 22…

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