Penn Mar Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 9)'s target behavior was monitored for the use of Lithium Carbonate Oral Capsule (medication that treats bipolar disorder (mental disorder with periods of depression and periods of elevated mood) and the indication for use of Benztropine Mesylate Oral Tablet (Cogentin, medication used to treat symptoms of Parkinson's disease, such as tremors and stiffness, as well as involuntary movements caused by certain antipsychotic drugs [antipsychotic medication - drugs that are used to treat symptoms of psychosis]) was accurate for one of five sampled residents (Resident 9) as indicated in the facility's Policy and Procedure (P&P) titled Psychotherapeutic Drug Management. This deficient practice had the potential to result in the use of unnecessary psychotropic drug, which may result in significant adverse (harmful) consequences to Resident 9.Findings: During a review of Resident 9's admission Record (AR), the AR…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of one sampled resident's (Resident 6) Minimum Data Set (MDS - a federally mandated resident assessment tool) assessment related to medications was accurately documented to reflect the resident's use of an antidepressant (medication used to treat depression). This failure had the potential to negatively affect Resident 6's plan of care and delivery of necessary care and services.Findings: During a review of Resident 6's admission Record (AR), the AR indicated Resident 6 was admitted to the facility on [DATE] with diagnoses that included schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 6's History and Physical (H&P), dated 7/18/2025, the H&P indicated the resident had fluctuating capacity to make medical decisions. During a review of Resident 6's Minimum Data Set assessment, dated 10/22/2025, the MDS indicated Resident 6 was cognitively intact (ability to think) and was taking 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that medication regimen review (MRR, a comprehensive evaluation of a resident's medications by a pharmacist to ensure the drugs are appropriate, effective, and safe) irregularity identified by the facility's Pharmacy Consultant was acted upon for one of five sampled resident (Resident 31). This deficient practice had the potential for resident harm due to the missed opportunity by the physician and the licensed staff to act upon the reported irregularities. Findings: During a review of Resident 31's admission Record (AR), the AR indicated Resident 31 was admitted to the facility on [DATE] with diagnoses that included anxiety and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 31's History and Physical (H&P), dated 7/24/2025, the H&P indicated the resident had fluctuating capacity to make medical decisions. During a review of Resident 31's Minimum Data Set (MDS - a federally mandated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect one of three sampled residents (Resident 1) from physical abuse (aggressive or violent behavior with the intention to cause physical harm) as indicated in the facility's policy and procedure (P&P) titled, Abuse Prevention and Prohibition Program.This failure resulted in Resident 2 hitting Resident 1 on 3/1/25, 4/12/25, 5/7/25, and on 6/27/25 and resulted in Resident 1 feeling unsafe in the facility.A. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included schizophrenia (a mental illness that is characterized by disturbances in thought).During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1's cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact and was independent with activities of daily living (ADLs) and with walking.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 interview and record review, the facility failed to ensure annual performance evaluations were completed for three of four Certified Nursing Assistants (CNAs) as indicated in the facility's policy and procedure (P&P) titled, Performance Evaluations. This failure had the potential to result in unrecognized skill deficiencies, placing residents at risk for receiving subpar care from staff. Findings: During an interview on 5/14/2025 at 2:20 PM with the Director of Staff Development (DSD), the DSD stated that CNA skills evaluations had not been completed consecutively or annually as required. The DSD stated, I just started last week and haven't had a chance to review everyone's (performance) evaluations. I know they haven't been done consistently. The DSD stated that performance evaluations were essential to identify gaps in understanding and ensure staff were competent to provide quality care. During a review of the personnel files for the following CNAs on 5/14/2025 indicated: 1. CNA 2 had no performance evaluation completed or 2024. 2. CNA 4 had no performance evaluations…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 perform neurological (of, relating to, or affecting the functioning of the brain, spine or nerves) assessments for two of three sampled residents (Residents 5 and 6) following an incident with potential head trauma per facility's policy and procedure (P&P) titled, Neurological Assessments. This failure had the potential to result in delayed identification and treatment of neurological changes, placing Resident 5 and Resident 6 at risk for harm. Findings: 1. During a review of Resident 5's admission Record (AR), the AR indicated the facility admitted Resident 5 on 3/28/2025, with diagnoses including Schizophrenia (chronic mental health condition characterized primarily by symptoms of hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression) and seizures (a sudden, temporary disturbance of the brain's electrical activity, leading to involuntary movements, changes in awareness, or sensory experiences).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a complete, individualized, and comprehensive plan of care (outlines specific care needs, preferences, and goals for individuals receiving care) for one of four sampled residents (Resident 1). This failure resulted in Resident 1 not receiving individualized care and had the potential to affect Resident 1's quality of life. 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 paranoid schizophrenia (a type of mental disorder associated with feelings of being persecuted or plotted against) and insomnia (difficult to fall asleep). During a review of Resident 1's History & Physical (H&P) dated 2/19/25, the H&P indicated Resident 1 did not have the capacity to make medical decisions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 3/11/25, the MDS indicated Resident 1 was cognitively intact (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 ensure one of seven sampled residents (Residents 1) had a complete neurological (of, relating to, or affecting the functioning of the brain, spine or nerves) assessment check (neurocheck - evaluates brain and nervous system [network of cells, tissues, and organs that controls and coordinates bodily functions) for the 72-hour monitoring period after a resident-to-resident altercation. This failure resulted in incomplete neurological assessments for Resident 1 after a change in condition and had the potential to negatively affect the delivery of necessary care and services in assessing for possible neurological complications. 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 schizophrenia (a mental illness that is characterized by disturbances in thought) and depression (a mood disorder that may cause persistent sadness or loss of interest in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) was not physically assaulted (someone had been attacked or harmed through physical violence) by another resident (Resident 2) on 3/17/2025. This failure resulted in Resident 1 sustaining bleeding from the nose, discoloration (any change in natural skin tone) on the face and redness on the nose. Findings: a. During a review of Resident 1's admission Records (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included schizophrenia (a mental illness that is characterized by disturbance in thought), diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control) and hyperlipidemia (a condition characterized by abnormally high levels of fats in the blood). During a review of Resident 1's Minimum Data Sheet (MDS, a resident assessment tool) dated 2/27/2025, the MDS indicated Resident 1 had an intact cognition (ability to understand…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three Certified Nursing Assistants (CNA 6) had an active CNA certification when CNA 6 worked for 30 days ([DATE] - [DATE]) with an expired CNA certification. This failure had the potential to put the safety of the residents under the care of CNA 6 at risk. Findings: During a review of CNA 6's undated L&C Verification Detail Page (VDP), the VDP indicated CNA 6's CNA certification expired on [DATE]. During an interview on [DATE] at 9:31 AM with the Director of Staff Development (DSD), the DSD stated CNA 6's CNA certification expired in 11/2024. During a concurrent interview and record review on [DATE] at 11:09 AM with the facility's Bookkeeping staff (BK), CNA 6's Timecard Report (TCR) from 11/2024 to 12/2024 were reviewed. The BK stated CNA 6 worked on the following days: [DATE] to [DATE] [DATE] [DATE] [DATE] [DATE] to [DATE] [DATE] [DATE] [DATE] [DATE] to [DATE] [DATE] [DATE] [DATE] [DATE] to [DATE] [DATE] [DATE] [DATE] [DATE] to [DATE]…

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

Based on interview and record review, the facility failed to ensure all in-services for the year 2024 were maintained, kept and readily accessible in accordance with the facility's policy on record retention for three of three sampled Certified Nursing Assistants (CNAs 3, 4 and 5). This failure had the potential to result in CNAs not receiving necessary training that could affect the resident care and safety. Findings: During an interview on 1/16/2025 at 6:24AM with CNA 3, CNA 3 stated CNA 3 was unsure if CNA 3 received dementia care in-services in 2024. CNA 3 stated the risk of not receiving in-services was that it could impact the delivery of care because staff would not be updated on current practices to ensure the residents were safe. During an interview on 1/16/2025 at 6:30 AM with CNA 4, CNA 4 stated CNA 4 did not receive an in-service on dementia care in 2024. During an interview on 1/16/2025 at 6:45 AM with CNA 5, CNA 5 stated CNA 5 received three in-services in 2024 and stated in-services were not provided regularly. CNA 5 stated CNA 5 would have benefited from a regular…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a care plan (CP) for one of four sampled residents (Resident 1) who was identified as a high risk for elopement (leaving without permission or supervision). Consequently, Resident 1 eloped while attending a court hearing on 12/18/2024. This failure had the potential to result in Resident 1 sustaining a serious injury. 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 schizophrenia (serious mental disorder in which people interpret reality abnormally). During a review of Resident 1 ' s History and Physical (H&P, formal document of a medical provider ' s examination of a patient) dated 7/28/2024, the H&P indicated Resident 1 lacked capacity to make medical decisions. During a review of Resident 1 ' s Minimum Data Set (MDS, a standardized comprehensive assessment of each resident's functional capabilities and identifies health problems)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 on wandering and elopement (leaving without permission or supervision) and perform an elopement risk assessment upon admission for one of four sampled residents (Resident 1). This failure resulted in Resident 1 eloping on 12/18/2024 when Resident 1 attended a court hearing with Resident 1's public conservator. This failure had the potential to result in Resident 1 sustaining a serious injury during elopement. 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 schizophrenia (serious mental disorder in which people interpret reality abnormally). During a review of Resident 1's History and Physical (H&P, formal document of a medical provider's examination of a patient) dated 7/28/2024, the H&P indicated Resident 1 lacked capacity to make medical decisions. During a review of Resident 1's Minimum Data Set (MDS, a standardized…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Medical Doctor's (MD) notification of a change of condition (COC) was documented in the resident's medical record for one of four sampled residents (Resident 1) when Resident 1 eloped (leaving without permission or supervision) from a court hearing on 12/18/2024. This failure had the potential to negatively impact the delivery of services for Resident 1. Findings: During a review of Resident 1's admission Record (AR) the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included schizophrenia (serious mental disorder in which people interpret reality abnormally). During a review of Resident 1's History and Physical (H&P, formal document of a medical provider's examination of a patient) dated 7/28/2024, the H&P indicated Resident 1 lacked capacity to make medical decisions. During a review of Resident 1's Minimum Data Set (MDS, a standardized comprehensive assessment of each resident's functional capabilities…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 three of three sampled residents (Residents 2, 20 and 41) by failing to: a. Ensure the Advance Directive Acknowledge (ADA) Form was completed on admission for Resident 41. b. Ensure the ADA Form was completed on admission for Resident 2. c. Ensure the ADA form was completed on admission for Resident 20. These failures had the potential for the facility staff to provide medical treatment and services against the will of the residents. Findings: a. During a review of Resident 41's admission Record (AR), the AR indicated, Resident 41 was admitted to the facility on [DATE] with diagnoses that included pain in the left ankle and joints, alcohol use, and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 41'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 interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool) quarterly assessment was completed within federal time frames per Center of Medicare and Medicaid Services (CMS) requirement to participate for three of three sampled residents (Residents 1, 7 and 14). These failures had the potential risk to affect Residents 1, 7 and 14's care by not providing CMS specific resident information and assessment on a quarterly basis. Findings: a. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted on [DATE] with diagnoses that included, major depression disorder (a serious mood disorder that an affect how people fee, think, and behave), Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 1'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 interview and record review, the facility failed to ensure the initial face-to-face visit (in person meeting between a patient and a physician) was made by a physician (a person qualified to practice medicine) for two of two sampled residents (Residents 41 and 247). These failures had the potential for Residents 41 and 247 not to receive necessary care or receive delayed treatment and services to meet the residents' needs. Findings: a. During a review of Resident 41's admission Record (AR), the AR indicated Resident 41 was admitted to the facility on [DATE] with diagnoses that included pain in the left ankle and joints, alcohol use, and schizophrenia (a mental illness characterized by disturbances in thought). During a review of Resident 41's History and Physical (H&P) dated 10/3/2024, the H&P indicated Resident 41 was seen face-to-face in the facility by a physician assistant (PA, a licensed health professional who works with physicians to provide patient care). During a review of Resident 41's Minimum…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the services of a Registered Nurse (RN) for at least 8 consecutive hours a day for three of seven days a week (4/7/2024, 5/5/2024 and 6/9/2024). This failure had the potential to affect the quality of care, quality of life, health, and safety of all the residents who resided in the facility. Findings: During a review of the facility's Assignment/Sign-In Sheet for all shifts, dated 4/7/2024, 5/5/2024 and 6/9/2024, the Sign-In Sheet indicated, there was no RN coverage for these three days. During an interview on 12/5/2024 at 9:26 am, the Director of Nursing (DON) stated, there was no RN working on 4/7/2024, 5/5/2024 and 6/9/2024. The DON stated, it was important to have a RN coverage because the RN could perform resident assessment while Licensed Vocational Nurse (LVN) did not have the legal scope of practice to perform resident assessment. The DON stated without proper assessment, the resident might not receive proper treatment and that could lead to hospitalization. The DON stated, the facility did not have a…

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

Based on interview and record review, the facility failed to complete a performance review of Certified Nursing Assistant (CNA) at least once every 12 months for two of three CNAs (CNA 2 and CNA 3). These failures had the potential for nurse aides not having competent skills when taking care of the residents. Findings: During an interview and concurrent review of CNAs 2 and 3's personal files on 12/4/2024 at 2:54 pm, with the Director of Staff Development (DSD), the personal files indicated CNA 2's last performance review was done on 9/6/2022, and CNA 3's last performance review was done on 9/9/2022. The DSD stated, there was no performance review completed after those days for CNA 2 and CNA 3. A review of CNA 2's Evaluation of Employee indicated CNA 2 had a performance review, dated 9/6/2022. A review of CNA 3's Evaluation of Employee indicated CNA 3 had a performance review, dated 9/9/2022. During an interview on 12/5/2024 at 3:38 pm, the Director of Nursing (DON) stated, the facility should complete a performance evaluation for all staffs on a yearly basis. The DON stated there…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain safe food storage and handling practices in one of one facility kitchen, by failing to: a. Label one sealed frozen roast beef with received date in Freezer 1. b. Discard one opened bag of expired frozen raspberry and one unopened and expired bag of frozen raspberry in the dairy freezer. c. Discard two bags of expired toasted bread (thick-cut white bread) and three bags of expired hamburger buns in the dry storage area. These failures had the potential to result in food-borne illnesses (illness caused by ingesting contaminated food or beverages) to the residents. Findings: a. During an observation in the kitchen on 12/3/2024 at 9:26 am with the Dietetic Services Supervisor (DSS), one sealed frozen roast beef at the bottom shelf of Freezer 1 did not have a date when it was received. b. During an observation in the kitchen on 12/3/2024 at 9:30 am with DSS, one opened bag of frozen raspberry with no opened date labeled and one sealed, unopened bag of frozen raspberry with no received date labeled were in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of one sampled resident (Resident 33) for the diagnosis of post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event). This deficient practice had the potential to negatively affect the delivery of necessary care and services for Resident 33. Findings: During a review of Resident 33's admission Record (AR), the AR indicated Resident 33 was admitted to the facility on [DATE] with diagnoses that included mood disorder (a mental health condition with extreme mood swings or changes, depressive or manic episodes), anxiety, and PTSD. During a review of Resident 33's History & Physical (H&P) dated 7/11/2024, the H&P indicated the resident had a diagnosis of PTSD. During a review of Resident 33's Minimum Data Set (MDS, a resident assessment tool), dated 10/22/2024, the MDS indicated Resident 33 had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interventions were implemented to address the resident's limited range of motion (ROM, distance and direction a joint or body part could move around a fixed joint) and leg edema (also known as fluid retention, swelling caused by fluid buildup in the body's tissues) for one of one sampled resident (Resident 41). This failure had the potential to cause further decline in Resident 41's range of motion, mobility, and physical functioning. Findings: During a review of Resident 41's admission Record (AR), the AR indicated Resident 41 was admitted to the facility on [DATE] with diagnoses that included pain in the left ankle and joints, alcohol use, and schizophrenia (a mental illness characterized by disturbances in thought). During a review of Resident 41's Order Summary Report (OSR) dated 10/3/2024, the OSR indicated Resident 41 had an order for staff to elevate bilateral (both) lower extremity (BLE) due to left ankle swelling. 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 five sampled staffs [Certified Nurse Assistant 3 (CNA 3)] had an active Basic Life Support/Cardiopulmonary Resuscitation (BLS/CPR, a training course that teaches individuals how to respond to breathing and cardiac emergencies in adults. The CPR certification is intended for healthcare professionals) certificate before assigned CNA 3 to care for residents in the facility. This failure had the potential to place the residents at risk for not having their needs meet safely and in a manner that promotes the residents' rights, physical, mental, and psychosocial well-being by competent staff. Findings: During a review of the facility's Personnel Action Request (PAR), the PAR indicated CNA 3 was hired on [DATE]. During a review of the facility's [DATE] 's CNAs monthly schedule, the monthly schedule indicated CNA 3 was scheduled to work four days a week. During a review of CNA 3's CPR Certificate of Completion, The CPR Certificate of Completion…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 act upon the pharmacist's medication regimen review (MRR, a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication.) recommendation for one of five sampled residents (Resident 24). This deficient practice had the potential for Resident 24 receiving unnecessary mediations and not maintaining the resident's highest practicable level of physical, mental, and psychosocial well-being and prevents or minimizes adverse consequences related to medication therapy to the extent possible. Findings: During a review of Resident 24's admission Record (AR), the AR indicated Resident 24 was admitted on [DATE] with diagnoses that included, depression disorder (a mood disorder that an affect how people fee, think, and behave and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 24's Order Summary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 physician's psychotropic medication (any drug that affects brain activities associated with mental processes and behavior) order for Ativan (a psychotropic drug to treat anxiety disorders), had a specific indicated behavior for its use for one of five sampled residents (Resident 1). This deficient practice had the potential for Resident 1 receiving unnecessary mediations, experiencing side effects of medications, not maintaining the resident's highest practicable level of physical, mental, and psychosocial well-being, and preventing or minimizing adverse consequences related to medication therapy to the extent possible. Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted on [DATE] with diagnoses that included, major depression disorder (a serious mood disorder that an affect how people fee, think, and behave), Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 three of three sampled residents (Residents 1, 2, 3) were provided with their own deodorant for personal use. This deficient practice had the potential to increase the risk of spreading infection among Residents 1, 2, 3. Findings: a. During a review of Resident 1 ' s admission Record (AR), the AR indicated the facility admitted Resident 1 on 6/12/2024 with diagnosis of schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 1 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/25/2024, the MDS indicated Resident 1 was understood by others and had the ability to understand others. The MDS indicated Resident 1 was independent (resident completes the activity by himself or herself with no assistance from a helper) in oral hygiene, toileting hygiene, upper body dressing, lower body dressing, putting on/taking off footwear, and personal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for four of seven sampled residents (Residents 2, 3, 6 and 7) as indicated in the facility's policy and procedure on Abuse Prevention and Prohibition Program, when: a. Resident 1 kicked and hit Resident 2 on the face and arms on 8/12/2024 at 11:15 pm and a few minutes later (undetermined time) hit Resident 2 again. Resident 2 sustained abrasion (scraping of skin) of the bridge of the nose, right side of jawline and right side of the neck and discoloration of Resident 2's right knuckle. b. Resident 1 stabbed Resident 3 with a broken plastic plate on 8/13/2024 at 7:20 am. Resident 3 sustained one wound to the left forearm (front of arm) measuring 1.8 centimeters (cm, a unit of measurement) in length, 0.5 cm in width and 0.2 cm in depth, one wound on the scalp measuring 9.6 cm in length, 5.9 cm in width…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 appropriate plans of actions under its Quality Assurance and Performance Improvement (QAPI) program after identifying 31 resident-to- resident altercations from January to July 2024. This deficient practice had the potential to result in negative outcomes for the residents' quality of care. Findings: During a review of the facility's Quality Assurance/Risk Management Committee Meeting minutes, dated 4/17/24, the minutes indicated the following: January: 4 resident-to-resident altercations February: 1 resident to resident altercation March: 10 resident-to-resident altercations. The minutes indicated, Nursing will continue to monitor resident behavior to prevent altercations to occur. There was no specific plan of action with expected outcome noted in the minutes, except Resident to Resident Altercation: 15; QAPI Topic for April 2024: Resident to Resident Altercations. During a review of the facility's Quality Assurance/Risk Management Committee Meeting minutes dated 7/17/24, the minutes did not indicate how many…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the resident while receiving Clozaril (medication used to treat mental and or mood disorders) for auditory and visual hallucinations (hearing or seeing things that do not exist in reality) as ordered by the physician, for one of nine sampled residents (Resident 5). This deficient practice had the potential for Resident 5 to inflict harm to others. Findings: During a review of Resident 5's admission Record (AR), the AR indicated Resident 5 was admitted to the facility on [DATE] with diagnoses that included schizophrenia (mental disorder that is characterized by abnormal thought processes and an unstable mood) and tobacco use. During a review of Resident 5's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 4/12/2024, the MDS indicated Resident 5's cognitive abilities (ability to think, learn, and process information) were intact. During a review of Resident 5's Order Summary Report (OSR) dated 2/2/2024, the OSR…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the Medical Doctor (MD) of a physical altercation on 5/24/2024 for two of nine sampled residents (Residents 5 and 6). Resident 6 punch Resident 5 in the left eye and forehead. This failure had the potential to result in serious injury to the residents. Findings: During a review of Resident 5's admission Record (AR), the AR indicated Resident 5 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder (mental disorder that is characterized by abnormal thought processes and an unstable mood) and insomnia (inability to sleep). During a review of Resident 5's History and Physical (H&P, formal document of a medical provider's examination of a patient) dated 11/29/2023 at 12:44 PM, the H&P indicated Resident 5 was alert and oriented to name, place, date of birth , and situation. During a review of Resident 5's untitled care plan (CP), dated 5/24/2024, the CP indicated Resident 5 was pushed on the forehead with two…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents were supervised and monitored in accordance with Medical Doctor's (MD) order for one of nine sampled residents (Resident 6) by failing to: 1. Monitor Resident 6's behavior on 5/10/2024, 5/13/2024, and 5/27/2024 when Resident 6 was receiving Depakote (medication used to stabilize mood) for behavior problems of auditory hallucinations (hearing noises or voices that do not exist in reality). 2. Provide one-to-one monitoring (continuous observation to protect a resident from harm) for Resident 6 for on 6/3/2024. These failures had the potential to result in serious injury to Resident 6 and/or others. Cross reference F684 Findings: During a review of Resident 6's admission Record (AR), the AR indicated Resident 6 was admitted to the facility on [DATE] with diagnoses that included schizophrenia (mental disorder that is characterized by abnormal thought processes and an unstable mood) and insomnia (inability to sleep). During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow its Policy and Procedure (P&P) on Abuse Reporting and report an alleged physical abuse for one of nine sampled residents (Resident 5) to the California Department of Public Health (CDPH). Resident 9 hit Resident 5 on the left side of Resident 5's face on 5/21/2024. This failure had the potential for Resident 5 to be exposed to further abuse from Resident 9. Findings: During a review of Resident 9's admission Record (AR), the AR indicated Resident 9 was admitted to the facility on [DATE] with diagnoses that included schizophrenia (serious mental disorder in which people interpret reality abnormally) and tobacco use. During a review of Resident 9's untitled care plan (CP), dated 2/28/2024, the CP indicated for staff to intervene as needed to protect the rights and safety of others and to remove the resident from the situation and take to another location. During a review of Resident 9's Minimum Data Set (MDS, a standardized assessment and care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) for two of 12 sampled residents (Residents 1 and 3) by failing to: a. Protect Resident 1 from being slapped by Resident 2. On 4/21/2024, Resident 2 slapped Resident 1 on the back of Resident 1's head. This failure resulted in Resident 1 feeling afraid and not feel safe while under the care of the facility. b. Protect Resident 3 from being kicked by Resident 4. On 5/1/2024, Resident 4 kicked Resident 3 on Resident 3's left elbow. This failure resulted in Resident 3 to not feel safe while under the care of the facility. Findings: a. During a review of Resident 1's admission Record (AR), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including schizophrenia (a disorder that affects a person's ability to think,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a Medical Doctor's (MD) order dated 3/27/2024 at 9:59 PM for neurological checks (neuro-checks, assessing the resident's mental status by evaluating sensory [things a person sees, hears, smells, tastes, or touches] and motor functions) every four hours for 24 hours, then every shift for two days for one of four sampled residents (Resident 3) when Resident 3 sustained a hit to the head from a physical altercation with Resident 1. This failure had the potential for Resident 3 to develop complications from an injury to the head. Findings: During a review of Resident 3's admission Record (AR), the AR indicated Resident 3 was admitted to the facility on [DATE] with diagnosis that included anxiety, insomnia (difficulty in falling and or staying asleep), and stimulant (class of drugs that make people feel more awake, alert, or energetic) abuse. During a review of Resident 3's Minimum Data Set (MDS, a standardized comprehensive assessment of each…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 identify and reduce the risk of elopement (when a person wanders away, walks away, runs away, escapes, or otherwise leaves the facility unsupervised, unnoticed, and or prior to the scheduled discharge date ) in the resident's environment for one of four sampled residents (Resident 4) by failing to ensure locked Gates 1 and 2 were opened one at a time. The Director of Staff Development (DSD) unlocked and opened locked Gate 1 to the patio while entering the facility. While, at the same time, Staff Member (SM) 5 unlocked and opened locked Gate 2 facing the facility's parking lot. Consequently, Resident 4 pushed away the employees (DSD and SM 5) and ran away from the facility. This failure resulted in Resident 4 being missing from the facility and his whereabouts unknown for four days, which had the potential to result in injury and harm. Findings: During a review of Resident 4's admission Record (AR), the admission record indicated Resident 4 was admitted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to revise residents' care plans to be individualized to address residents' specific behaviors for three of eight sampled residents (Resident 2, 4, 7). 1. For Resident 2, the facility failed to revise Resident 2's care plan after having three incidents of alleged inappropriate sexual behavior on 2/14/2024 when Resident 1 reported to staff that Resident 2 pulled down his pants and asked Resident 1 for oral sex, on 2/28/2024 when Resident 2 reported to staff having multiple instances of oral sex with Resident 3, and on 3/17/2024 when Resident 4 stated Resident 2 came into Resident 4's room at night, pulled down his blanket, and asked Resident 4 for oral sex. 2. For Resident 4, the facility failed to revise Resident 4's care plan after Resident 4 hit Resident 2 on the face on 3/18/2024 at 8:45 AM. 3. For Resident 7, the facility failed to revise Resident 7's care plans after having multiple physical altercations with Resident 6 on 2/23/2024, 3/1/2024, 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 provide adequate supervision and monitoring for three of eight sampled residents (Resident 1, 2, and 4) as indicated in the facility's policies and procedures (P&P) titled, Hallway Monitor and Rounds/Headcount. 1. Resident 1 reported to the Recreational Activities Assistant (RAA) that Resident 2 pulled down Resident 2's pants and asked Resident 1 to perform oral sex on Resident 2 in Resident 2's room. 2. Resident 4 reported to staff that Resident 2 came into Resident 4's room in the middle of the night, pulled down Resident 4's blanket, tried to grab Resident 4's genitals, and asked Resident 4 for oral sex. As a result of these failures, Resident 2 experienced feelings of mental and emotional distress and felt unsafe until Resident 1 was moved to another room. Resident 4 hit Resident 2 on the back of Resident 2's head due to feeling upset about the incident with Resident 2. Cross reference F609 and F657 Findings: 1. During a review of Resident 1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to report an alleged sexual abuse incident between Resident 1 and Resident 2 immediately, but no later than two hours to the California Department of Public Health (CDPH), local law enforcement, and Ombudsman (resident advocate who investigated and resolved complaints, usually through recommendations or mediation) as indicated in the facility's policy and procedure (P&P) titled, Abuse Prevention and Prohibition Program. This deficient practice violated the Federal mandated reporting timeframe and had the potential to subject Resident 1 to possible further sexual abuse and psychological (mental and/or emotional) harm. Cross reference F689 and F657 Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 to the facility on 8/6/2023 with diagnoses including but not limited to schizoaffective disorder (mental health disorder that involves psychosis [loss of contact with reality] as well…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pureed food was not mixed together for one of one resident (Resident 4) on pureed diet in a total of 12 sampled residents. This deficient practice had the potential for Resident 4 to not be provided with palatable, attractive, and appetizing food. Findings: During an observation on 12/7/23 at 11:31 a.m., [NAME] 1 put one scoop of broccoli, one piece of chicken, one scoop of pasta into a blender and pureed the food items together. During a concurrent observation and review of the facility's Fall Menu on 12/7/23 at 11:55 a.m., the menu for lunch indicated Italian chicken, herb pasta, broccoli bake, breadstick, and chocolate pudding. Resident 4's tray had a bowl that contained pureed food, chocolate pudding, water, and juice. Resident 4 was eating independently and ate 60% of his lunch. During an interview on 12/7/23 at 11:57 a.m. with [NAME] 1, [NAME] 1 stated she mixed the food together and forgot to puree the breadstick. [NAME] 1 stated, she was supposed to puree each food separately. During a review…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety by failing to ensure: 1. Opened food items in the dry storage area and refrigerator had a written or labeled use-by-date. 2. Expired food items were removed from the dry storage area and refrigerator. 3. An insecticide spray was not inside the kitchen in an open shelf. 4. A high concentration of chemical sanitizing solution was not used for the dishwasher. These deficient practices had the potential to result in foodborne illnesses and chemical food contaminants. Findings: 1. During a concurrent kitchen observation and interview on 12/5/23 from 8:25 a.m. to 8:50 a.m. with the Dietary Services Supervisor (DSS), the following items were opened and had no open date and use-by-date: One bottle of opened black pepper had no open date and no use-by-date. The DSS checked the bottle and stated, there was no expiration date on the bottle, just the manufacturing date of 8/25/22. One bottle of garlic powder had no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 have a properly functioning call light system for 11 of 11 rooms (room [ROOM NUMBER], 24, 25, 26, 27, 28 ,29, 30, 31, 32, and 33). This deficient practice had the potential to negatively affect the residents' well-being when the residents are unable to call staff for assistance. Findings: During the resident council meeting on 12/6/23 at 1:17 p.m., 11 out of 13 residents stated their rooms did not have a working call system. Resident 41 stated, some residents had to scream or yell to call the staff for assistance. Resident 38 stated, residents could wait for the staff assigned to conduct the headcount to communicate their needs, but some residents had to scream or yell to call the staff for help. During an observation on 12/6/23 at 1:58 p.m. with Social Worker 1 (SW 1), there was a call button located close to each resident's bed in each room. Rooms 24, 25, 26, 27, 28, 29, 30, 31, 32, and room [ROOM NUMBER] did not have an audible sound…

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

Based on observation, interview, and record review, the facility failed to ensure the choice to shower was respected for one of 12 sampled residents (Resident 147). This deficient practice had the potential to violate Resident 147's right to make choices about her life in the facility including interests and preferences that were important to her and could have a negative effect on Resident 147's well-being. Findings: During a review of Resident 147's admission Record, the admission Record indicated the facility admitted the resident on 11/16/23, with diagnoses that included schizoaffective disorder, bipolar type (a mental health disorder marked by a combination of schizophrenia [affects person's ability to think, feel and behave clearly] symptoms such as hallucinations [false perception of objects or events], delusions [false belief], and mood disorder symptoms, such as depression or mania [abnormally elevated and extreme mood]) and epilepsy (disease of the brain characterized by recurrent seizures [brief episodes of involuntary movement that may involve a part of the body or 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 interview and record review, the facility failed to administer medications as scheduled and as ordered by the physician for two of 12 sampled residents (Resident 18 and 148). 1. For Resident 18, Licensed Psychiatric Technician 1 (LPT 1) failed to administer Risperdal (Risperidone, a medication used to treat symptoms of schizophrenia [a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions]) 2 milligrams (mg, unit of measurement) as scheduled during the 9 a.m. medication administration. 2. For Resident 148, LPT 1 failed to administer Metformin (a medication used to control high blood sugar levels) 850 mg with food as ordered by the physician. These deficient practices had the potential to cause uncontrolled behavioral symptoms for Resident 18 and unwanted side effects for Resident 148. Findings: 1. During a review of Resident 18's admission Record, the admission Record indicated the facility admitted Resident 18 on 12/8/22, with diagnoses that included impulse disorder (a condition in which a person has…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 range of motion exercises (ROM) for one of two sampled residents (Resident 19). Resident 19 was not receiving ROM exercises for contractures (fixed tightening of muscle, tendons, ligaments, or skin) of right and left hands since 11/6/23. This deficient practice placed Resident 19 at risk for further development of contractures of both hands. Findings: During a review of Resident 19's admission Record, the admission Record indicated the facility admitted Resident 19 on 11/6/23, with diagnoses that included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). During a review of Resident 19's Nursing admission assessment dated [DATE], the Nursing admission Assessment indicated Resident 19 was admitted with contracted upper extremities and amputated left index finger. During a review of Resident 19's Care Plan dated 11/6/23, the Care Plan indicated Resident 19 had impaired physical mobility…

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

Based on observation, interview, and record review, the facility failed to follow up and act upon a recommendation by the Registered Dietician (RD) to consider a speech therapist (ST, an individual who provides professional services in the areas of communication and swallowing) consultation for one of one resident on pureed diet in a total sample of 12 residents (Resident 4). This deficient practice had the potential to result in further weight loss for Resident 4. Findings: During a review of Resident 4's admission Record, the admission Record indicated the facility admitted the resident on 3/22/23, with diagnoses that included schizoaffective disorder (a mental health disorder where the person experiences psychosis [disconnection from reality] as well as mood symptoms). During an interview on 12/5/23 at 10:19 a.m. with Resident 4, Resident 4 stated he lost weight because he walked a lot. Resident 4 stated, he was on a pureed diet. During an observation on 12/7/23 at 11:31 a.m., inside the kitchen, [NAME] 1 put a slice of chicken, one scoop of broccoli bake, and one scoop of pasta…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 post accurate nurse staffing information on 12/5/23 and 12/6/23, that included resident census and actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift every day. This deficient practice of posting inaccurate nurse staffing information had the potential to mislead the residents and visitors and could result in inappropriate nursing care. Findings: During an observation on 12/5/23 at 9:02 a.m. and 12/6/23 at 8:15 a.m., the nurse staffing information was posted on the wall in front of the nurses' station. The nurse staffing information did not include the resident census and actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift every day. During a concurrent interview and record review on 12/6/23 at 3:05 p.m. with Licensed Vocational Nurse (LVN) 1, the facility's nurse staffing information dated 12/5/23 and 12/6/23 were reviewed. LVN 1 stated, the charge nurse was responsible for posting 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 ensure that medication was available and in stock in the facility for one of 12 sampled resident (Resident 18). Resident 18's routine medication, Risperdal (medicine that helps with symptoms of some mental health conditions) 2 mg disintegrating oral tablet, was not available during the 9 a.m. medication administration and was not in stock in the facility. This had the potential to result in an increase of behavior symptoms for Resident 18. Findings: During a review of Resident 18's admission Record, the admission Record indicated the facility admitted Resident 18 on 12/8/22, with diagnoses that included impulse disorder (a condition in which a person has trouble controlling emotions or behaviors), cerebral palsy (group of lifelong conditions that affect movement and co-ordination), and hypothyroidism (a condition in which the thyroid gland does not make enough hormones that regulate the body's metabolic rate, growth and development, to meet the body's needs). During a review of Resident 18's Minimum Data Set…

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

Based on observation, interview, and record review, the facility failed to ensure each resident was free from unnecessary drug for one of two sampled residents (Resident 27). Resident 27 was given Macrobid (antibiotic, medication used to fight infections caused by bacteria) for seven days without an adequate indication for its use. The McGeer Criteria (used to conduct infection surveillance for tracking appropriateness of antibiotic prescribing in nursing homes) was not met before the use of antibiotic drug for Resident 27. This deficient practice placed Resident 27 at risk for antibiotic drug resistance (happens when bacteria change and resist the effects of an antibiotic; resistant bacteria may continue to grow and multiply). Findings: During a review of Resident 27's admission Record, the admission Record indicated the facility admitted the resident on 3/9/23, with diagnoses that included paranoid schizophrenia (a person feels distrustful and suspicious of other people and acts accordingly). During a review of Resident 27's Physician's Orders dated 9/11/23, the Physician's Orders…

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

Based on observation, interview, and record review, the facility failed to ensure the medication administration error rate was not greater than 5%. The facility had 2 medication administration errors out of 28 medication opportunities for error observed, to yield a medication administration error rate of 7.14%. The medication errors were as follows: 1. For Resident 18, Licensed Psychiatric Technician 1 (LPT 1) failed to administer Risperdal (Risperidone, a medication used to treat symptoms of schizophrenia [a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions]) 2 milligrams (mg, unit of measurement) as scheduled during the 9 a.m. medication administration. 2. For Resident 148, LPT 1 failed to administer Metformin (a medication used to control high blood sugar levels) 850 mg with food as ordered by the physician. These deficient practices had the potential for Resident 18 and 148 to have adverse effects for not administering medications as scheduled and as ordered by the physician. Findings: 1. During 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 provide a safe and sanitary environment for residents, staff, and the public by failing to ensure: 1. Staff immediately wipe clean Resident 5's saliva on the floor due to excessive drooling (saliva flowing out of the mouth uncontrollably) to prevent risk of slip and fall of resident, staff, and the public. 2. Staff monitor Resident 5's excessive drooling and dripping of saliva on the floor to prevent incident of slip and fall in the facility. As a result, on 12/7/23 at 9:32 a.m., Health Facilities Evaluator Nurse (HFEN) 1 slipped and fell on the floor in the hallway. HFEN 1 complained of pain and difficulty walking on the left foot and sustained skin redness and discoloration on both knees and skin redness on the left foot. Findings: During a review of Resident 5's admission Record, the admission Record indicated the facility admitted Resident 5 on 12/13/22, with diagnoses that included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). 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 provide supervision while in the hallways for three of 44 residents residing in the facility. (Residents 1, 2 and 3). These deficient practices had the potential to result in resident-to-resident altercation and injury to Residents 1, 2 and 3 due to lack of supervision. Findings: During an observation and concurrent interview on 11/6/2023 at 1:37 PM, Residents 1, 2 and 3 were in the facility's hallway walking. The Director of Nursing (DON) stated there was no facility's staff in hallway to monitor and supervise the residents. The DON stated the facility was a locked facility (facility secured with doors) and the residents had mental illness (health condition involving changes in emotion, thinking or behavior). The DON stated all the residents in the facility were ambulatory (able to freely walk). The DON stated the facility did not assign a staff for hallway monitoring. The DON stated the management combined staff monitoring the hallway and staff doing headcount (to make visual contact of every patient) of…

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

Based on observation and interview the facility failed to provide sufficient nursing staff to ensure residents' safety and attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being for three of three sampled residents (Residents 1, 2 and 3). These failures had the potential to result in an adverse outcome to resident's care or services including potential for physical or psychosocial harm. Findings: During an observation and concurrent interview on 11/6/2023 at 1:37 PM, there were 3 residents (Residents 1, 2 and 3) in the facility's hallway walking and there was no facility staff monitoring the residents in the hallway. The Director of Nursing (DON) stated there was no staff in the hallway monitoring the residents. The DON stated there should be a staff monitoring the residents in the hallway for resident's safety. During an interview on 11/6/2023 at 2 PM, the facility's DON stated the facility reduced one CNA staff for each shift since 9/2023 and reduced the CNA hours from 8 hours to 7 hours and 30 minutes starting on 11/1/2023. During 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.