Rosemead Healthcare Center

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident's (Resident 41) Minimum Data Set (MDS, a federally mandated resident assessment tool) assessment was accurately coded regarding supplemental oxygen (is extra oxygen [a gas essential for life] given to a person to help them breathe when their body is not getting enough oxygen on its own) use. This failure had the potential to result in a delay of necessary care and treatments, incorrect plan of care, and interventions for Resident 41.Findings:During a review of Resident 41's admission Record (AR), the AR indicated the facility admitted Resident 41 on 12/7/2025 with diagnoses including chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing) and Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities). During a review of Resident 41's History & Physical (H&P), dated 12/8/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 41's Order…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the integrity and proper labeling of a peripheral intravenous (IV, within a vein, a small, flexible tube [catheter] inserted into a vein to deliver fluids, medications, or nutrients directly into the bloodstream) site in accordance with professional standards of practice for one of one sampled resident (Resident 99). This failure had the potential to result in infection and accidental IV dislodgement for Resident 99. Findings: During a review of Resident 99's admission Record (AR), the AR indicated the facility admitted Resident 99 on 3/23/2026 with diagnoses including urinary tract infection (UTI, an infection in the bladder/urinary tract), dementia (characterized by progressive decline in cognitive function), and muscle weakness (loss of muscle strength). During a review of Resident 99's Minimum Data Set (MDS, a resident assessment tool), dated 3/29/2026, the MDS indicated Resident 99 had moderately impaired cognition (ability to understand and process information). The MDS indicated Resident 99…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 infection control policy for one of five sampled residents (Resident 91) by failing to ensure Resident 91's urinal filled with urine was not placed on top of Resident 91's side table. This deficient practice had the potential to result in Resident 91 developing an infection.Findings: During a review of Resident 91's admission Record (AR), the AR indicated Resident 91 was admitted to the facility on [DATE] with diagnosis including encephalopathy (a brain dysfunction caused by infection and brain injury), respiratory failure (lungs can't supply oxygen to the blood) and other immunodeficiencies (immune system in the body is weak or absent reducing the body's ability to fight infectious diseases). During a review of Resident 91's History and Physical (H&P) dated 3/4/26, the H&P indicated Resident 91 had the capacity to understand and make decisions. During a review of Resident 91's Minimum Data Set (MDS, a resident 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 interview and record review, the facility failed to complete a Surveillance Data Collection Form (SDCF) dated 3/24/2026 for one of five sampled residents (Resident 96) receiving antibiotics. This deficient practice had the potential to result in increased antibiotic resistance and providing antibiotics without justification for Resident 96. Findings: During a review of Resident 96's admission Record (AR), the AR indicated Resident 96 was admitted to the facility on [DATE] with diagnoses including Extended Spectrum Beta-Lactamase (ESBL - bacteria that is not easily killed by antibiotics) resistance and urinary tract infection (UTI- infection that affects part of the urinary tract). During a review of Resident 96's Order Summary Report (OSR) dated 3/23/2026, the OSR indicated a physician's order for licensed staff to administer Meropenem (antibiotics, a substance used to kill bacteria and to treat infections) Intravenous (IV) Solution Reconstituted, one (1) gram (gr.- unit of measurement) IV two times 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 implement its policy and procedure to conduct a post-fall evaluation and prevention meeting within 72 hours of two unwitnessed falls for a resident who was rated at moderate risk for falls for one of four sampled residents (Resident 2). This deficient practice placed Resident 2 at risk for future additional falls and injury. Findings: During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included polyneuropathy (multiple peripheral nerves become damaged and include problems with sensation, coordination, or other body functions), paraplegia (loss of movement and/or sensation, to some degree, of the legs), muscle weakness (loss of muscle strength), schizophrenia (a mental illness that is characterized by disturbances in thought), anxiety disorder (excessive, persistent worry or fear), bipolar disorder, (mood swings that range from the lows of depression…

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

Based on interview and record review, the facility failed to ensure the Interdisciplinary Team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of the resident) Falls Committee met to review and document findings and interventions addressing the resident's falls on 4/19 and 4/22/2025 for one of two sampled residents (Resident 2) These failures had the potential to result in Resident 2 sustaining injury and/or harm due to falling while in the care of the facility. Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 3/27/2025 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), muscle weakness, and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 3/31/2025, the MDS indicated Resident 1 had no impairment in cognitive skills (ability to make daily…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical record for one of two sampled residents (Resident 1) when Licensed Vocational Nurse (LVN) 1 failed to document details of Resident 1's fall at the facility on 5/8/2025. This failure resulted in Resident 1's medical record containing incomplete information. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 11/14/2021 and readmitted Resident 1 on 2/24/2025 with diagnoses including hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebrovascular disease (a range of conditions that affect the blood vessels and blood flow in the brain), dementia (a group of thinking and social symptoms that interferes with daily functioning), and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). 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 develop and implement a care plan for one of three sampled residents (Resident 1) as indicated in the facility's policies and procedures titled, Care Planning, and Fall Management Program, by failing to: 1. Ensure facility staff implemented Resident 1's care plan for falls dated 10/16/2023 to keep personal items within reach and complete quarterly fall risk assessment per facility's fall protocol. 2. Ensure facility staff developed a comprehensive resident-centered care plan for Resident 1's rights, preferences, and autonomy to be in the dining room during mealtimes. These failures resulted in Resident 1's falls on 3/20/2025 and 4/9/2025. Resident 1 sustained redness to Resident 1's cheek from the fall on 3/20/2025. Resident 1 sustained skin discoloration to Resident 1's right forehead, right eye, and right hand and swelling to Resident 1's right eye and right hand from the fall on 4/9/2025. These failures had the potential to result in a decline in Resident 1's mental, physical, and emotional well-being.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a care plan (a plan that outlines resident-specific interventions used to guide a resident ' s care for a given area of concern) for one of three sample residents (Resident 1), a known fall risk, who sustained two falls from the bed on 3/20/2025 and 4/9/2025. This failure resulted in Resident 1 not receiving appropriate care treatments and services and sustaining recurrent falls, which caused Resident 1 to sustain bruising (an injury through unbroken skin resulting in discoloration) to Resident 1 ' s face from a recurring fall on 4/9/2025. Findings: During a review of Resident 1 ' s admission Records, the facility admitted Resident 1 on 11/14/2021 and readmitted to the facility on [DATE] with diagnoses which included bullous pemphigoid (an autoimmune disease that causes large fluid-filled blisters on the resident ' s skin), dementia (a progressive state of decline in mental abilities), and hemiplegia (total paralysis of the arm, leg, and trunk…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 promote the resident's right to choose where to eat during mealtimes for one of three sampled residents (Resident 1). This deficient practice had the potential to violate Resident 1's rights to self-determination and dignified existence. Cross Reference F656 Findings: During a review of Resident 1's admission Records (AR), the AR indicated the facility admitted Resident 1 on 11/14/2021, and readmitted Resident 1 on 2/24/2025, with diagnoses which included bullous pemphigoid (an autoimmune disease that causes large fluid-filled blisters on the resident's skin), dementia (a progressive state of decline in mental abilities), and hemiplegia (total paralysis of the arm, leg, and trunk of the same slight of the body) and hemiparesis (weakness on one side of the body) following cerebrovascular disease (stroke, damage to the brain from interruption of its blood supply) affecting right dominant side. During a review of Resident 1's History and Physical (H&P), dated 2/25/2025, the H&P indicated Resident 1 did not have…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the resident's dignity for two of two residents (Residents 75 and 80) by failing to: a. Ensure facility staff provided privacy while putting on the undergarment and pants onto Resident 80 that Resident 80 had removed. b. Ensure facility staff provided privacy when providing peri-care to Resident 75. These failures resulted in Residents 75 and 80's privacy not being maintained and Residents 75 and 80's dignity not being protected. Findings: a. During a review of Resident 80's admission Record (AR), the AR indicated the facility readmitted Resident 80 to the facility on [DATE], with diagnoses that included hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body), urinary tract infection (illness in any part of the urinary tract), and cerebral atherosclerosis (build-up of plaque in blood vessels of the brain). During a review of Resident 80's History & Physical (H&P), dated 11/16/24, the H&P indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of residents' needs for three of three sampled residents (Residents 20, 50, and 55) by failing to ensure the resident's call light was always within reach. These failures had the potential to result in residents to not receive care and a delay in services to meet the residents' needs and could result in a fall or injury. Findings: a. During a review of Resident 20's admission Record (AR), the AR indicated Resident 20 was admitted to the facility on [DATE] with diagnoses that included a history of falling and unspecified 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 of Resident 20's Care Plan dated 12/6/2024, the Care Plan indicated Resident 20 was as risk for falls and/or injuries related to a history of fall and fracture (break in the continuity of a bone). The Care Plan interventions indicated for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide information regarding an 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 four of six sampled residents (Residents 24, 36, 55 and 190) in accordance to the facility's policy titled Advance Directives. These failures had the potential to result in the facility staff to provide medical or surgical treatment against Residentd 24, 36, 55, and 190's will. Findings: a. During a review of Resident 55's admission Record (AR), the AR indicated Resident 55 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included unspecified dementia. During a review of Resident 55's MDS dated [DATE], the MDS indicated, Resident 55 had moderately impaired cognition…

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

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 resident (Resident 238) received care and services for the provision of a midline intravenous (IV) catheter (a long, thin, flexible tube that is inserted into a large vein in the upper arm used to safely administer medication into the bloodstream, similar to a cannula [a small tube that is inserted into a vein]) consistent with professional standards of practice, in accordance with the facility's policy and procedure (P&P) titled Midline Dressing Changes and the resident's care plan (a care plan details why a person is receiving care, assessed health or care needs, medical history, personal details, expected and aimed outcomes, and what care and support will be delivered, how, when and by whom). These failures had the potential to result in an infection to Resident 238 and worsen the residents' health condition. Findings: During a review of Resident 238's admission Record (AR), the admission record indicated Resident 238…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility's policy titled, Oxygen Administration, for three of three sampled residents (Residents 24, 43 and 292) by failing to: a. Ensure Resident 292's Nasal Cannula (NC, thin flexible tube that delivers oxygen through the nose) tubing was dated. b. Ensure Resident 43's inhalation tubing set was dated and create a care plan (CP) for oxygen use and breathing treatments for Resident 43. c. Place the NC in both nostrils for Resident 24 and post a no smoking sign outside of Resident 24's room when Resident 24 required the use of oxygen. These failures had to the potential for Residents 24, 43 and 292 to experience complications related to oxygen therapy. Findings: a. During a review of Resident 292's admission Record (AR), the AR indicated Resident 292 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included respiratory failure (occurs when the lungs cannot get enough oxygen into…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 36, 66 and 292) who received dialysis (process of removing waste products and excess fluid from the body) had a dialysis emergency kit (E-kit) at the bedside in accordance with standards of practice. These failures had the potential to delay in emergency treatment from complications of the dialysis access site for Residents 36, 66 and 292. Findings: a. During a review of Resident 292's admission Record (AR), the AR indicated Resident 292 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included end stage renal disease (ESRD, final permanent stage of chronic kidney disease where the kidney function has declined to the point kidneys can no longer function on its own) and dependence on renal dialysis. During a review of Resident 292's History and Physical (H&P, formal document of a medical provider's examination of a patient) dated 1/18/2025, 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 implement its Policy and Procedure (P&P) on the use of grab bars (bars installed on the side of the bed)/bed rails/side rails (adjustable metal or rigid plastic bars attached to the bed) for two of two sampled residents (Residents 7 and 8). These failures placed Residents 7 and 8 at risk for entrapment (an event in which resident was caught, trapped, or entangled in the tight spaces around the bed), and injury from the use of grab bars. Findings: a. During a review of Resident 7's admission Records (AR), the AR indicated Resident 7 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included osteoporosis (weak and brittle bones ), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (muscle weakness on one side of the body that can affect the arm, legs, and facial muscles). During a review of Resident 7's Minimum Data Set (MDS, a resident assessment…

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

Based on interview and record review, the facility failed to provide a 24-hour sufficient nursing staffing on seven of thirteen Saturdays and eleven of thirteen Sundays for Quarter 4 of 2024 (July 1 - September 30) consistent with Payroll Based Journal (PBJ, a system for collecting and reporting staffing information from nursing homes and other long-term care facilities) Staffing Data Report. The facility did not meet the required 3.5 nursing hours per patient day on 7/6/2024, 7/7/2024, 7/13/2024, 7/14/2024, 7/21/2024, 8/11/2024, 8/18/2024, 8/25/2024, 8/31/2024, 9/1/2024, 9/8/2024, 9/15/2024, and 9/22/2024. The facility also did not meet the required 2.4 CNA direct care hours per patient day on 7/6/2024, 7/7/2024, 7/13/2024, 7/14/2024, 7/20/2024, 7/21/2024, 8/4/2024, 8/10/2024, 8/11/2024, 8/18/2024, 8/24/2024, 8/31/2024, 9/8/2024, 9/14/2024, 9/15/2024, and 9/22/2024. These failures had the potential to affect the quality of care and negatively affect the resident's quality of life in the facility. Findings: During a review of a letter to the Administrator from California Department…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 actual nursing information for three of three recertification days inspected (2/4/2025, 2/5/2025 and 2/6/2025). These failure had the potential to misinform the residents and visitors of the actual staffing information and potentially affect the quality of nursing care provided to the residents. Findings: During an observation on 2/4/2025 at 9:09 am in Nursing Stations 1 and 2, the facility's Daily Staffing Grid (DSG) in Nursing Station 1 was dated 2/3/2025. Nursing Station 2 did not have DSG posted. During an observation on 2/5/2025 at 10:50 am in Nursing Station 2, Nursing Station 2 did not have DSG posted. During an observation on 2/6/2025 at 10:00 am in Nursing Station 2, Nursing Station 2 did not have DSG posted. During a concurrent interview and record review on 2/6/2025 at 10:35 am with the Director of Staff Development (DSD), DSGs dated 2/4/2025, 2/5/2025 and 2/6/2025 were reviewed. The DSD stated the DSG posted indicated the projected hours of staff working the 11 pm -7 am shift, 7 am - 3 pm…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and follow infection prevention procedures to prevent the transmission of infectious organisms for four of five sampled residents (Residents 66, 190, 238 and 294 ) by failing to: a. Post the correct isolation sign when an Enhanced Barrier Precaution (EBP, precautions that involve using a glove and gown during high-contact resident care activity for residents who are colonized or infected with an MDRO and those at a higher risk of developing an multidrug-resistant organisms [MDRO, bacteria that is resistant to many types of antibiotics], such as, residents with wounds or indwelling medical devices) sign was observed to be posted outside of Resident 294's door on 2/4/2025 instead of a Contact Isolation (type of isolation used with residents who have disease caused by bacteria and viruses that spread through direct and indirect contact) sign for carbapenem-resistant Enterobacterales (CRE, type of MDRO that cause infections that are…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 obtain a signed Informed Consent from the resident's responsible party (RP) prior to the administration of Ativan (medication used to treat anxiety disorders) 1 milligram (mg), for one of five sampled residents (Resident 26). This deficient practice violated Resident 26 and the RP's right and had the potential for Resident 26 to receive medication Resident 26's RP did not desire. Findings: During a review of Resident 26's admission Record (AR), the AR indicated the facility readmitted to the facility on [DATE] with diagnoses that included toxic encephalopathy (neurologic disorder), cerebral infarction (causes necrotic-death of living tissue in the brain), and chronic obstructive pulmonary disease (lung diseases that block airflow). During a review of Resident 26's History & Physical (H&P), dated 1/5/25, the H&P indicated Resident 26 did not have the capacity to make medical decisions. During a review of Resident 26'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 one of three sampled residents (Resident 85) discharge destination was coded correctly. Resident 85 was discharged to home or community. Skilled Nursing Facility (SNF - care provided by trained registered nurses in a medical setting under a doctor's supervision) but was coded in the Minimum Data Set (MDS - a federally mandated resident assessment tool) as being discharged to a short-term general hospital. This deficient practice resulted in an inaccurate reporting to the Centers of Medicare and Medicaid (CMS, a federal agency that administers the Medicare program and works with state governments to administer the Medicaid and health insurance portability standards) agency and had the potential to result in Resident 85 to not receive interventions to address specific care concerns. Findings: During a review of Resident 85's admission Record (AR), the admission record indicated Resident 85 was admitted to the facility on [DATE] with diagnoses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 189) was provided with a communication device with the language that the resident understood. This failure had the potential to affect Resident 189's communication with the staff and the potential to delay the provision of care, treatment, and services the resident needed. Findings: During a review of Resident 189's admission Record (AR), the AR indicated Resident 189 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow movements) and bipolar disorder (mental disorder with periods of depression and periods of elevated mood). The AR indicated Resident 189's primary language was Spanish and Castillan (a variety of Spanish spoken in Spain). During a review of Resident 189's Minimum Data Sheet (MDS, a resident assessment tool) dated 1/30/2025, the MDS indicated Resident 189…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care in accordance with professional standards of practice for one of one sampled resident (Resident 292) by failing to turn and reposition Resident 292 every two hours. These failures had the potential for Resident 292 to develop pressure ulcers/bedsores (PU, injuries to the skin and underlying tissue that are result of pressure on the skin for long periods of time). Findings: During a review of Resident 292's admission Record (AR), the AR indicated Resident 292 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia (inability to move one side of the body) and hemiparesis (weakness on one side of the body) affecting the right side, dependence on dialysis (procedure that filters blood to remove waste and excess fluid when the kidneys are not working), and peripheral vascular disease (PVD, occurs when the blood vessels become narrow reducing blood flow to the arms 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 provide treatment and services in accordance with professional standards to prevent the development of pressure ulcers (PU, injuries to the skin and underlying tissue that are result of pressure on the skin for long periods of time) for one of two sampled residents (Resident 27) by failing to: a. Ensure bilateral heel protectors were on Resident 27 per Medical Doctor (MD) order. b. Ensure Resident 27's low air loss mattress (LAL, medical mattress designed to reduce pressure on the skin to help prevent the development of PUs) was on the correct setting. These failures had the potential for Resident 27 to develop a PU. Findings: During a review of Resident 27's admission Record (AR), the AR indicated Resident 27 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included peripheral vascular disease (PVD, chronic condition that occurs when arteries narrow or block, reducing blood flow to the arms…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pain management for one of one resident (Resident 140) as indicated in Resident 140's care plan for pain by falling to: 1) Provide non-pharmacological interventions/measures for pain. 2) Notified Resident 140's Medical Doctor (MD) when Resident 4's pain was uncontrolled with the current pain medication/pain management. These failures resulted in Resident 140 experienced pain on the abdomen and had to wait for more than one hour to received pain medication. Findings: During a review of Resident 140's admission Record (AR), the AR indicated the facility admitted to the facility on [DATE] with diagnoses that included sepsis (a life-threatening complication of an infection), gastric ulcer with perforation (untreated ulcer in the stomach), and encounter for surgical aftercare following surgery (continued care after surgery) on the digestive system. During a record review of Resident 140's Medication Administration Record (MAR), dated 1/1/25-1/31/25,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safe and sanitary conditions were maintained in the kitchen when expired chicken nuggets were observed in the refrigerator. This failure had the potential to result in foodborne illness if served to the residents. Findings: During a concurrent initial tour observation of the kitchen and interview on 2/4/25 at 9:30 a.m. with Dietary Staff (Dietary 1), a clear plastic bag of chicken nuggets was observed in the refrigerator with an expiration date of 1/30/25. Dietary 1 stated the clear plastic bag of chicken nuggets expired on 1/30/25. During an interview on 2/4/25 at 9:40 a.m. with the Consultant Registered Dietitian (RD 1), RD 1 stated the plastic bag of chicken nuggets was labeled expired on 1/30/25. RD 1 stated the expired bag of chicken nuggets should not be in the refrigerator. RD 1 stated the importance of discarding expired food was residents could possibly get ill from consuming expired food. During an interview on 2/4/2025 at 9:52 a.m. with the Dietary Supervisor (DS), the DS stated it was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a Surveillance Data Collection form for one of 12 sampled residents (Resident 66) receiving antibiotics. This deficient practice had the potential to result in increased antibiotic resistance and providing antibiotics without justification. Findings: During a review of Resident 66's admission Record (AR), the AR indicated Resident 20 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included bacteremia (presence of bacteria in the blood). During a review of Resident 66's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 12/27/2024, the MDS indicated, Resident 66 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated, Resident 66 was dependent (helper does all the effort) on staff for oral hygiene, toileting, shower, upper/lower body dressing, putting on/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 follow its policy and procedures (P&P) titled, Communication - Call System, for eight of 35 resident rooms (Rooms 7, 20, 21, 24, 25, 26, 29, and 36) by failing to: a. Ensure call lights in the resident rooms were functioning. b. Ensure call bells were provided for the residents in the seven of the eight rooms that did not have a functioning call light. c. Ensure resident safety check rounds were conducted and documented when the residents' call lights were inoperable (not functioning). These deficient practices had the potential to result in the delay of care for the residents. Findings: During a review of the facility's Maintenance Log (ML) for the month of October 2024, the ML indicated five rooms (room [ROOM NUMBER]C, 22, 26A, 28B, and 28C) in the facility had issues with call lights not functioning. During an observation on 11/26/2024 at 11:14 am with Restorative Nursing Assistant (RNA) 1, call lights were checked in 35 resident rooms…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medications were administered timely for one of seven sampled residents (Resident 3) by failing to ensure Resident 3 received Resident 3's morning medications in a timely manner as indicated in the facility's policy and procedure (P&P), titled, Medication-Administration. This deficient practice had the potential to affect Resident 3 negatively and result in a physical decline to Resident 3. Findings: During a review of Resident 3's admission Record (AR), the AR indicated the facility admitted Resident 3 on 1/22/2020, and re-admitted the resident on 3/28/2024, with diagnoses including, type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar), muscle wasting and atrophy (the decrease in size or wasting away of a body part or tissue), dysphagia (difficulty swallowing), and dementia (a decline in mental function that affects a person's ability to think, remember, and reason). During a review of Resident 3's Minimum Data Set (MDS, a comprehensive 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 ensure smoking devices were stored in a secure area for one of seven sampled residents (Resident 1) as indicated in the facility's policy and procedure (P&P) and Resident 1's untitled care plan (CP), dated 6/20/2024, that addressed Resident 1 smoking, when on 8/27/2024, Resident 1 had an electronic smoking device resting on Resident 1's lap. This deficient practice had the potential to result in accidents and resulted in compromised safety to all residents residing at the facility. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 5/17/2024, with diagnoses including, hemiplegia (paralysis [unable to make voluntary muscle movements] that affects one side of the body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing) following cerebral infarction ( occurs when blood flow to the…

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

Based on observation, interview, and record review, the facility failed to ensure infection control practices for 1 of 7 sampled residents (Resident 2) were followed. On 8/26/2024, Resident 2 accessed the meal cart unsupervised, without performing hand hygiene (procedures that include the use of alcohol-based hand rubs [containing 60%-95% alcohol] or hand washing with soap and water) and was able to obtain Resident 2's meal tray without assistance from staff. This deficient practice had the potential to result in transmission of infectious microorganisms (an organism that is seen through a microscope) and increased the risk of infection for the residents whose food trays were in the meal cart. Findings: During a review of Resident 2's admission Record (Face Sheet), indicated the facility admitted Resident 2 to the facility on 2/27/2024, and re-admitted the resident on 4/2/2024, with diagnoses including but not limited to, lack of coordination, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions, metabolic encephalopathy (a brain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to readmit three of five sampled residents (Residents 2, 3, and 4) to the facility from the General Acute Care Hospital (GACH) after Residents 2, 3, and 4 were cleared by GACH to return to the facility. This deficient practice had the potential to violate Residents 2, 3, and 4's rights to return to the facility. Findings: a. During a review of Resident 2's admission Record (AR), the AR indicated, the facility admitted Resident 2 to the facility on 4/24/24, with diagnoses that included other acute osteomyelitis (an infection of the bone or joint) of left ankle and foot, cellulitis (a bacterial infection of the skin and the tissue beneath the skin) of left lower limb, and dysphagia (difficulty swallowing) oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat). During a review of Resident 2's Minimum Data Set (MDS, a standardized resident assessment and care screening tool), dated 5/1/24, the MDS indicated, Resident 2 had severe…

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

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), received the copy of the resident's medical records within two working days upon request as indicated in the facility's policy and procedure (P&P) titled, Resident Access to PHI. This deficient practice resulted in a delay of obtaining a copy of Resident 1's medical records for Resident 1's Requesting Party (RP). Findings: During a review of Resident 1's admission Record (AR), the AR indicated, the facility admitted Resident 1 on 5/13/24, with diagnoses that included unspecified sequelae (an aftereffect of a disease, condition, or injury) of cerebral infarction (stroke; occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), dysphagia (difficulty swallowing) oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat), and other abnormalities of gait and other mobility (inability to walk normally due to injuries or underlying conditions). During a review of Resident 1'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.

Based on observation, interview, and record review, the facility failed to implement its Mitigation Plan regarding visitation guidelines for Coronavirus (COVID-19, highly contagious disease caused by the SARS-CoV-2 virus that is spread through inhalation or contact of droplet particles into eyes, nose, or mouth) for one of four sampled residents (Resident 4) by allowing two family members (FM 1 and FM 2) to be inside Resident 4's Novel Respiratory Precaution (newly identified respiratory organism that causes acute respiratory infections which require the use of a N95 [PPE that is used to provide a tight seal on the person's face to prevent particles or liquid contamination of the face], face shield, gown and gloves prior to entering the room) room without donning (put on) on personal protective equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses). This failure had the potential to result in the spread of COVID-19 virus to residents, staff, and visitors in the facility. Findings: During a concurrent observation 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 protect its resident from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of six sampled residents (Resident 1) when Resident 2 physically assaulted (the act of causing physical harm) Resident 1 on 2/19/2024 at 9:15 pm. Resident 2 pushed the patio metal table and hit Resident 1's right lower leg. As a result, on 2/19/2024 at 9:15 pm, Resident 1 sustained a laceration (a wound when skin, tissue, and/or muscle was torn or cut open) on Resident 1's right lower leg measuring 14.3 centimeter (cm-unit of measurement) in length, by 1.9 cm in width and by 0.2 cm in depth. Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) on 2/19/2024 at 9:25 pm and required 16 surgical staples (pieces of metal used to join up pieces of tissue to close large wounds or surgical cuts) for wound closure. Resident 1 suffered a 7 out of 10 pain (on a 0 to 10 pain score, 0 = no pain at all and 10 =…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility staff failed to meet professional standard of practice of administering medications through a gastrostomy tube (G-tube, a tube inserted through the wall of the abdomen directly into the stomach for medication/food) for one of one sampled resident (Resident 74). This failure had the potential to result in G-tube occlusion and unnecessary tube replacement for Resident 74. Findings: During a review of Resident 74's admission Record, the admission record indicated Resident 74 was readmitted to the facility on [DATE], with diagnoses that included respiratory failure (a condition when the lungs cannot get enough oxygen into the blood and gastrostomy tube (G-tube, a tube inserted through the wall of the abdomen directly into the stomach for medication/food). During a review of Resident 74's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 11/15/23, the MDS indicated Resident 74 had unclear speech, rarely/never understood others,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and monitor interventions based on the resident's care plan (a care details why a person is receiving care, assessed health or care needs, medical history, personal details, expected and aimed outcomes, and what care and support will be delivered, how, when and by whom) and physician (MD) orders for four of four sampled residents (Residents 57, 82,25 and 39) by failing to: a. Follow aspiration (accidental swallowing of food or liquid into the lungs) precautions during feeding for Resident 57; b. Notify the MD of significant vital sign (measurements of the body's most basic functions) changes when Resident 82 had an oxygen (O2) saturation (amount of oxygen circulating in the blood) of 85 percent (%); c. Turn and reposition Resident 25 every two hours per Policy and Procedure (P&P); and d. Turn and reposition Resident 39 per P&P and care plan. These failures had the potential to negatively impact the residents' health condition,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 include the verifying signatures of either the Director of Nursing (DON) or a Registered Nurse (RN) along with Licensed Vocational Nurse (LVN) on the Controlled Medication Count Sheet (also known as Controlled Medication or Controlled Substance [CM/CS]- medications which have a potential for abuse) or Individual Resident Controlled Drug Record or Controlled Drug Record for 17 of 17 sampled logs reviewed. The control and accountability of CS awaiting final disposition (process of returning and/or destroying unused medications) did not follow the facility's Policy and Procedure on Documentation of Controlled Medications. This deficient practice had the potential to result in increased opportunity for controlled substance diversion (the transfer of a controlled substance or other medication from a lawful to an unlawful channel of distribution or use). Findings: During a record review on 2/1/24 at 12 PM, with the Director of Nursing (DON), 17 Controlled Medication Count Sheet, Controlled Drug Record and Individual 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 one of one sampled resident (Resident 6) met the criteria for the use of antibiotic (medication to treat infection) before it was administered. Resident 6 was administered Azithromycin (an antibiotic) Oral Tablet 250 milligrams (mg) without meeting the criteria for the use the antibiotic to ensure it has an adequate indication. This deficient practice had the potential to result in adverse consequences for Resident 6 for the use of antibiotic. Findings: During a review of Resident 6's admission record, the admission record indicated Resident 6 was admitted to the facility on [DATE], with diagnoses that included anemia, unspecified (not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), mononeuropathy (damage that happens to a single nerve in the body, causing pain, numbness, and loss of movement) unspecified and anxiety disorder (a persistent and excessive worry that interferes with daily 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 observation, interview and record review, the facility failed to ensure it was free of medication error rate of five percent (5%) or greater, as evidenced by the identification of five medication errors out of 29 opportunities for error, to yield a cumulative error rate of 17% for one of five residents during medication administration observation (Resident 74). This failure had the potential for adverse consequences for Resident 74. Cross Reference: F658 Findings: During a review of Resident 74's admission Record, the admission record indicated Resident 74 was readmitted to the facility on [DATE], with diagnoses that included respiratory failure (a condition when the lungs cannot get enough oxygen into the blood and gastrostomy tube (G-tube, a tube inserted through the wall of the abdomen directly into the stomach for medication/food). During a medication administration observation on 1/31/24 at 8:24 AM, Licensed Vocational Nurse 1 (LVN 1) was administering morning medications to Resident 74 via…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Binding Arbitration Agreement (contract that requires the parties to resolve disputes using an arbitrator instead of going to court) provided a selection of a venue convenient for the resident or their representative for three out of three sampled residents (Residents 20, 48, and 57). This failure resulted in residents signing a binding arbitration agreement that is not in compliance with applicable federal and state laws. Findings: During a review of Resident 20's admission Record, Resident 20 was admitted to the facility on [DATE] with diagnoses including but not limited to bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), Schizophrenia, and dystonia (movement disorder that causes muscles to contract involuntarily). During a review of Resident 20's History and Physical (H&P), dated 11/06/23, it indicated Resident 20 is not able to make decision for self. 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 observation, interview, and record review, the facility failed to disinfect the blood pressure cuff for one of two residents after use from Resident 74 to Resident 65. This failure had the potential to place Resident 65 and other residents at the facility at risk for an infection or disease. Findings: During a review of Resident 74's admission Record indicated Resident 74 was readmitted on [DATE], with diagnoses that included respiratory failure (a condition that makes it difficult to breathe on your own), hypertensive heart disease with heart failure (chronic elevated blood pressure causing the heart to not pump enough blood for body's needs) and a gastrostomy tube (G-tube, a tube inserted through the wall of the abdomen directly into the stomach, can be used to give nutrition and/or drugs). During a review of Resident 74's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 11/15/23, indicated Resident 74 had unclear speech, rarely/never understood others and rarely/never made…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and/or responsible party (RP) were informed of the risks and benefits of psychotropic medications (a drug that changes brain function and results in altercations in perception, mood, consciousness, or behavior) for one of four sampled residents (Resident 49). This deficient practice resulted in the violation of Resident 49's and/or RP's right to make an informed decision regarding the use of psychotropic medications. Findings: During a review of Resident 49's admission Record (AR), the AR indicated Resident 49 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included schizophrenia (mental disorder characterized by abnormal social behavior and failure to understand what is real) and bipolar disorder (mental disorder with periods of depression [persistent feelings of sadness and worthlessness and a lack of desire to engage in formerly pleasurable activities] and periods 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 to observation, interview, and record review, the facility failed to provide privacy while providing bedside care for one of one sampled resident (Resident 74). This failure resulted in the violation of Resident 74's right for personal privacy. Findings: During a review of Resident 74's admission Record, the admission record indicated Resident 74 was readmitted to the facility on [DATE], with diagnoses that included respiratory failure (a condition when the lungs cannot get enough oxygen into the blood) and gastrostomy tube (G-tube, a tube inserted through the wall of the abdomen directly into the stomach for medication/food). During a review of Resident 74's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 11/15/23, the MDS indicated Resident 74 had unclear speech, rarely/never understood others, and rarely/never made self-understood. The MDS indicated Resident 74 was totally dependent (helper does all of the effort, resident does none of the effort to complete the activity,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complete set of window blinds in Resident 65's room to maintain privacy and comfort for one of eight sampled residents (Resident 65). This failure resulted in a lack of privacy and absence of a safe, homelike environment for Resident 65. Findings: During a review of Resident 65's admission Record (undated), the admission Record indicated Resident 4 was readmitted on [DATE] with diagnoses that included a femur fracture (partial break in the upper leg bone), obesity (an excess in body fat) and hypertension (high blood pressure). During a review of Resident 65's quarterly Minimum Data Set (MDS, a standardized resident assessment and care screening tool) assessment dated [DATE], the MDS indicated Resident 65 had severely impaired cognition (thinking), had an upper and lower extremity impairment on one side and was totally dependent on staff for bed and wheelchair mobility. During an observation on 01/30/24 at 9:15 AM in Resident 65'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 interview and record review, the facility failed to notify the physician of a resident's change of condition (COC, a sudden clinical change from a resident's baseline in physical, cognitive, behavioral, or functional domains) after a significant vital sign change (measurements of the body's most basic functions) for one of three sampled residents (Resident 82) when Resident 82 had an oxygen (O2) saturation (amount of oxygen circulating in the blood) of 85 percent (%.) This failure had the potential to result in Resident 82 to develop a respiratory complication. Findings: During a review of Resident 82's admission Record, Resident 82 was admitted to facility on 03/15/23 with diagnoses including but not limited to major depressive disorder (mental health condition that causes a persistently low or depressed mood and loss of interest in activities), epilepsy (seizures [sudden, uncontrolled burst of electrical activity in the brain]), atrial fibrillation (abnormal heartbeat), heart failure (develops when…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 seven residents (Resident 70) reviewed for Limited Range of Motion [ROM, full movement potential of a joint (where two bones meet)] was assessed accurately. For Resident 70, the Range of Motion for the upper extremities was not accurately assessed to reflect resident's limitation in the range of motion on her right upper extremity (wrist and hand). This deficient practice had the potential risk for Resident 70's activities of daily living (ADL, such as bed mobility, eating, dressing, and hygiene) to decline resulting from limitation in range of motion of the resident's right hand/fingers . Findings: During a review of Resident 70's admission, the admission record indicated Resident 70 was admitted to the facility on [DATE] with diagnoses that included Degenerative Disease of the Nervous System (conditions that damage and destroy parts of the nervous system over time), Osteoarthritis (progressive loss of function 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 interview and record review, the facility failed to develop a specific and individualized person-centered care plan (details why a person is receiving care, assessed health or care needs, medical history, personal details, expected and aimed outcomes, and what care and support will be delivered, how, when and by whom) to meet the residents' needs for two of two sampled residents (Residents 43 and 56). a. A care plan was not developed for Resident 43 who was assessed as high risk for fall upon admission on [DATE]. b. A care plan was not developed for Resident 56 who was assessed as high risk for fall prior to Resident 56's incidents of fall on 7/31/23 and 11/15/23. These deficient practices had the potential for Residents 43 and 56 not to receive necessary care, treatment, and services. Findings: a. During a review of Resident 43's admission Record (AR), the AR indicated, Resident 43 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included abnormalities 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 provide an effective communication method to one of two non-English speaking sampled residents (Resident 74). This deficient practice had the potential for Resident 74 not to receive necessary care and treatment. Findings: During a review of Resident 74's admission Record, the admission record indicated Resident 74 was readmitted to the facility on [DATE], with diagnoses that included respiratory failure (a condition when the lungs cannot get enough oxygen into the blood and gastrostomy tube (G-tube, a tube inserted through the wall of the abdomen directly into the stomach for medication/food). During a review of Resident 74's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 11/15/23, the MDS indicated Resident 74 had unclear speech, rarely/never understood others, and rarely/never made self-understood. The MDS indicated Resident 74 was totally dependent (helper does all of the effort, resident does none of 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 provide one of four sampled residents (Resident 70) reviewed for nutrition, the necessary assistance in a timely manner during a lunch dining observation. This deficient practice placed Resident 70 at risk for weight loss. Findings: During a review of Resident 70's admission, the admission record indicated Resident 70 was admitted to the facility on [DATE] with diagnoses that included Degenerative Disease of the Nervous System (conditions that damage and destroy parts of the nervous system over time), Osteoarthritis (progressive loss of function affecting many tissues of the joint) unspecified site, and Diabetes Mellitus Type I (high blood sugar). During a review of Resident 70's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 11/30/23, the MDS indicated Resident 70 usually understood others and made self understood. The MDS indicated Resident 70 required set up and clean up assistance (helper sets up or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the low air loss mattress (LAL, a bed that alternates pressure to help heal and prevent pressure injuries) was set correctly for one of one sampled residents (Resident 4). This failure had the potential to prevent healing and worsen Resident 4's facility acquired pressure ulcer (an injury that breaks down the skin and underlying tissue when an area of skin is placed under pressure). Findings: During a review of Resident 4's admission Record (undated), the admission Record indicated Resident 4 was readmitted on [DATE] with diagnoses that included anemia (body has a low amount of red blood cells), schizophrenia (serious mental illness in which people interpret reality abnormally), hemiplegia (loss of ability to move one side of the body) and hemiparesis (one-sided muscle weakness caused by a disruption of the brain, spinal cord, or nerves connected to the affected muscles) following a stroke affecting the right side of the body.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 74) who was receiving tube feeding (TF, liquid form of nutrients given to people who cannot eat or drink by mouth safely) through a gastrostomy tube (G-tube, a tube inserted through the wall of the abdomen directly into the stomach, can be used to give nutrition and/or drugs), had the head of bed (HOB) elevated to at least 30 degrees during tube feeding. This failure had the potential to result in aspiration (when small particles of food or drops of liquid are breathed into the lungs) leading to aspiration pneumonia (an infection that occurs in the lungs due to aspiration), other complications and death to the resident. Findings: During a review of Resident 74's admission Record indicated Resident 74 was readmitted on [DATE], with diagnoses that included respiratory failure (a condition that makes it difficult to breathe on your own), hypertensive heart disease with heart failure (chronic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staffing information of actual hours worked by staff directly responsible for resident care per shift daily. The staffing information included the actual worked hours of the Minimum Data Set (MDS) nurse that was not directly responsible for resident care. This deficient practice of posting inaccurate staffing information could mislead the residents and visitors that may affect the quality of nursing care provided to the residents. Findings: During an observation on 1/30/24 at 9 AM and 1/31/24 at 8:32 AM, the facility's staffing information posted in Nursing Station 1 and 2 indicated the MDS nurse had worked eight hours each day on 1/30/24 and 1/31/24. During a concurrent interview and record review on 2/1/24 at 3:11 PM, the Director of Staff Development (DSD) stated she was responsible for completing the staffing information to be posted before the beginning of morning shift every day. The DSD stated staffing information needed to only include actual hours worked by the staff directly responsible…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure two of four sampled residents (Residents 12 and 64) on psychotropic drugs (any drug capable of affecting the mood, emotions, and behavior) were free from unnecessary medication, by failing to ensure: a. Staff attempt Gradual Dose Reduction (GDR-tapering down the medication dose) of Resident 12's Seroquel (antipsychotic drug) 25 milligram ([mg] unit of measurement) since ordered on 11/29/22. b. The use of PRN (as needed) orders for psychotropic drugs were limited to 14 days. Resident 64's PRN order for Trazodone HCL (antidepressant drug) 50 milligrams ([mg]unit of measurement) at bedtime was beyond 14 days from 12/20/23 through 1/30/24 (41 days) without documented rationale (a logical basis for a course of action) from the prescribing physician for the extended use of Trazadone HCL. These deficient practices placed Residents 12 and 64 at risk for adverse drug reaction (a harmful and unintended response to a medicine). Findings: a.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Binding Arbitration Agreement (a contract that requires the parties to resolve disputes using an arbitrator instead of going to court) indicated the resident or their representative had a right to rescind (withdraw) the agreement within 30 calendar days of signing it for one of three sampled residents (Resident 57). This failure had the potential to result in Resident 57 signing a binding arbitration agreement that is not in compliance with the applicable federal and state laws. Findings: During a review of Resident 57's admission Record, it indicated Resident 57 was admitted to the facility on [DATE] with diagnoses including but not limited to Parkinson's Disease (occurs when the body cannot make enough dopamine [a chemical messenger that communicates between cells and the brain] in the body causing changes in movement and mood), schizophrenia (mental disorder that causes disruptions in thought processes, perceptions, emotion responses, 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 that all essential equipment is maintained and in operating condition. This deficient practice had the potential to risk the health, safety, and welfare of the residents, staff, and visitors. Findings: During an observation on 8/8/2023 at 2:12 pm, one portable cooling unit was observed with a hose attached to a ceiling vent in front of room [ROOM NUMBER]. During further observation of the facility, six more portable cooling units were observed in the facility ' s hallways in front of Rooms 9, 16, 21, 26, 28, and 36. During a concurrent interview and observation on 8/8/2023 at 2:31 pm, the Maintenance Supervisor (MS) stated the facility ' s HVAC unit was having issues the day before. MS stated, MS and the maintenance staff installed the seven portable cooling units inside the facility while the heating and cooling company was doing the repair on the facility ' s HVAC unit. In the back of the facility two contractors were observed…

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