Santa Fe Lodge

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of one resident's (Resident 1) diagnosis of depression was accurately reflected in the Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 4/14/2026.This deficient practice resulted in inaccurate Medical Record for Resident 1 and had the potential for Resident 1 to have unmet needs.Findings:During a review of Resident 1's admission Record, (AR) the AR indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including depression (mood disorder causing persistent sadness, emptiness, or irritability, along with loss of interest in activities once enjoyed), anxiety (persistent, excessive, and uncontrollable fear or worry that interferes with daily life) and dementia (a gradual decline in mental ability usually caused by a brain disease.)During a review of Resident 1's MDS dated [DATE], the MDS indicated Resident 1 had impaired cognition (ability to understand 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.

Based on observation, interview, and record review, the facility failed to ensure a liquified diet was served as ordered by the physician for one of one sampled resident (Resident 3) who had a history of dysphagia (difficulty swallowing).The deficient practice had the potential to result in complications like aspiration pneumonia (lung infection [the invasion and growth of germs in the body] caused by inhaling foreign substances like food into the airways rather than swallowing them), choking, and 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 6/9/2016, with diagnoses that included dementia (a progressive state of decline in mental abilities) and dysphagia. During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool) dated 3/7/2026, the MDS indicated Resident 3 had severe cognitive (the ability to think and process information) deficit and was dependent with activities of daily living such as eating, oral hygiene, toileting hygiene.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 ensure three of six sampled staff (Certified Nursing Assistant [CNA] 1, CNA 2, and Licensed Vocational Nurse [LVN] 1) understood the facility's Policies and Procedures (P&P) on abuse reporting when:1. CNA 1, CNA 2, and LVN 1 did not know who the facility's Abuse Coordinator (a designated staff member responsible for managing and addressing issues related to abuse or neglect within the facility) was.2. CNA 1, CNA 2, and LVN 1 did not know that allegations of abuse must be reported to the California Department of Public Health (the Department), the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and to the local law enforcement within 2 hours.This failure had the potential for residents (in general) to be subjected to abuse while residing at the facility.During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 4/2/2026 with diagnoses which included schizophrenia (a mental illness that is characterized by…

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

Based on interview and record review, the facility failed to report an allegation of abuse for one of three sampled residents (Resident 1) to the California Department of Public Health (the Department), the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) and to the local law enforcement, within two hours, in accordance with the facility's policy and procedure (P&P), titled Abuse Prevention and Prohibition Program, revised 11/28/2022.This failure resulted in a delay in notification to the Department, the Ombudsman, and local law enforcement, and had the potential for Resident 1 to be subjected to abuse while at the facility.During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 4/2/2026 with diagnoses which included schizophrenia (a mental illness that is characterized by disturbances in thought), impulse disorder (a repeated failure to resist urges, behaviors, or temptations that cause harm to oneself or others), and hypertension (high blood pressure).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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow through (follow up) on one of four sampled resident's (Resident 1), who was at risk for falls, fall that occurred on 1/9/2026, in accordance with the facility's policy and procedure (P&P) titled, Change of Condition. The facility failed to assess Resident 1 after the fall, report the fall to Resident 1's physician (Medical Doctor [MD] 1), and complete a change in condition (COC, an alteration in a resident's physical health that differs from their previous baseline) for Resident 1.This deficient practice had the potential to result in Resident 1 not receiving the necessary care and services affecting Resident 1's physical well-being.Findings:During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including other abnormalities of gait (the pattern of walking) and mobility (ability to move freely), unspecified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 informed consents were obtained for one of one sampled resident (Resident 94) as indicated in the facility's policy and procedure (P&P), titled, Informed Consent and Alarm Monitor, by failing to: a. Ensure an informed consent was completed prior to the use of the bed/wheelchair alarms (a safety device, often a sensor pad or clip, that alerts caregivers when a patient attempts to leave their bed or chair, helping to prevent falls and injuries) b. Ensure informed consents were completed prior to the use of Lexapro (anti-depressant, medication used to treat depression [serious illness that negatively affects how one feels, thinks and acts]) and Remeron (medication used to treat depression). These failures resulted in violation of Resident 94/responsible party's right to understand Resident 94's treatment, including the risks and benefits of the medications and the purpose of the use of the alarms. Additionally, the failures had the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide and ensure Advance Directives (AD, a legal document indicating resident preference on end-of-life treatment decisions) were kept in 3 of 5 sampled resident's (Residents 14, 145, 38) medical records. This failure had the potential to cause confusion among the healthcare providers in the event Residents 14, 145 and 38 required immediate medical care and/treatment and had the potential for the residents to receive inadequate or medically unnecessary care and/or treatment or services regarding life-sustaining treatment. Findings: a. During a review of Resident 14's admission Record (AR), the AR indicated, Resident 14 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including unspecified dementia (a progressive state of decline in mental abilities), unspecified severity, without behavioral disturbance, psychotic disturbance (a mental health condition characterized by a loss of contact with reality,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 weekly weights for three of three sampled residents (Resident 34, 28, and 145) as indicated in the facility's policy and procedure (P&P) titled, Weight Change, as evidenced by: A. Resident 34's weight was not taken upon readmission to the facility on 3/14/2025 and not taken on 3/18/2025 per the physician order. B. Resident 28 weight was not taken weekly as ordered by the physician. C. Resident 145's weight was not taken on 3/18/2025 as per the physician's order. This deficient practice had the potential to result in physical declines to Residents 34, 28, and 145 due to untreated weight loss. Findings: A. During a review of Resident 34's admission Record (AR), the AR indicated Resident 34 was initially admitted to the facility on [DATE] and the resident was readmitted on [DATE] with multiple diagnosis including heart failure (the inability of the heart to pump blood effectively) and dementia (a gradual decline in mental ability usually caused by…

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

Based on observation, interview, and record review, the facility failed ensure proper food storage, in one of one kitchen walk-in refrigerator (Refrigerator 1), consistent with the facility's policy and procedure (P&P), titled, Refrigerator/Freezer Storage, by failing to: a. Ensure a transparent container with sliced cheese was labeled with an open date (date to indicate when it was opened). b. Ensure a halfway-filled pickle jar was labeled with an open date. c. Ensure two unopened plastics of whipping cream were labeled with a received date. These failures had the potential to result in food-borne illnesses (illness caused by ingesting contaminated food or beverages) to the residents consuming the facility's food. Findings: During a concurrent observation and interview on 3/17/2025 at 8:58 AM with the Certified Dietary Manager (CDM) inside Refrigerator 1, the following items were found, 1. A transparent container that had sliced cheese and the container was not dated or labeled with the date when it was opened. 2. An undated halfway-filled bottle jar with hamburger pickles. 3. 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 its binding arbitration agreements (AA, a contractual promise where parties agree to resolve disputes through arbitration instead of litigation) included a selection that allowed the residents or their responsible parties/resident representatives to communicate with federal, state, or local officials for two of two sampled residents (Residents 34 and 38). This failure had the potential to violate Resident 34 and Resident 38's rights and result in unjust arbitration. Findings: a. During a review of Resident 34's admission Record (AR), the AR indicated, Resident 34 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included schizophrenia (a mental illness that is characterized by disturbances in thought), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) and anxiety (intense, excessive, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow infection (the invasion and growth of germs in the body) prevention and control practices for 6 of 6 sampled residents (Residents 14, 16, 38, 40, 18 and 34) by failing to ensure: a. personal toiletries and resident care items were labeled and not stored inside the [NAME] and [NAME] restroom (a restroom that has two doors and is sandwiched between two bedrooms and is accessible by both bedrooms) of Residents 14, 16, 38 and 40. b. communal drinks were not accessible for Resident 18 to pour water by himself. c. the lint traps for 2 of 3 sampled dryers (Dryer 1 and Dryer 2) were kept clean and did not have a heavy thick accumulation of lint. d. Resident 34's bed sheets were clean from smeared stool. e. Proper storage/disposal of a used cup set on top of the handrail outside of room [ROOM NUMBER]. These deficient practices had the potential to result in the spread of infection and physical declines to Residents 14, 16, 38, 40, 18, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 145) was treated with dignity by failing to provide privacy and failing to cover Resident 145's right flank (the area on the side of the body between the ribs and the hip) while Resident 145 was in the shower chair. This deficient practice resulted in exposure of Resident 145's right flank to Resident 145's right thigh and had the potential to result in a psychosocial decline to Resident 145. Findings: During a review of Resident 145's admission Record (AR), the AR indicated, Resident 145 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including anxiety disorder (mental health condition characterized by persistent, excessive fear or worry that significantly interferes with daily life), unspecified and unspecified dementia (a progressive state of decline in mental abilities), unspecified severity, without behavioral disturbance, psychotic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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's (Resident 14) call light (a device used by a resident to signal the need for assistance) was within reach. This failure had the potential to result in Resident 14's needs to not be met in a timely manner and/or the potential for Resident 14 to experience harm if Resident 14 was unable to alert staff during an emergency. Findings: During a review of Resident 14's admission Record (AR), the AR indicated, Resident 14 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including unspecified dementia (a progressive state of decline in mental abilities), unspecified severity, without behavioral disturbance, psychotic disturbance (a mental health condition characterized by a loss of contact with reality, leading to distorted perceptions, thoughts, and behaviors), mood disturbance (a significant change in a person's emotional state that persists for an extended…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an assessment after a significant change in condition for one of one sampled resident (Resident 41) to include a bipolar disorder (mental health condition that causes clear shifts in a person's mood, energy, activity levels, and concentration) diagnosis as indicated in Resident 41's physician order for Depakote (medication used to treat certain psychiatric conditions such as bipolar disorder). This deficient practice had the potential to result in unmet needs for Resident 41. Findings: During a review of Resident 41's admission Record (AR), the AR indicated Resident 41 was initially admitted to the facility on [DATE] and readmitted the resident on 12/10/2024 with multiple diagnosis including dementia (a gradual decline in mental ability usually caused by a brain disease) and major depressive disorder (a mental health condition characterized by persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete an evaluation for Level II Pre-admission Screening and Resident Review (PASARR, a federal assessment requirement to help ensure individuals who have mental disorders or intellectual disabilities are placed in facilities that can provide the appropriate care) for one of one sampled resident (Residents 43). This failure had the potential to result in unmet individualized services to Resident 43. Findings: During a review of Resident 43's admission Record (AR), the AR indicated, Resident 43 was initially admitted to the facility 11/12/2024 and readmitted on [DATE] with diagnoses that included traumatic subdural hemorrhage (a collection of blood that accumulates between the outer and middle layer of the brain's protective membranes after a head injury), seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), and hypertension (HTN, high blood pressure).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 related to bipolar disorder (mental health condition that causes clear shifts in a person's mood, energy, activity levels, and concentration) for one of one sampled resident (Resident 41). This deficient practice had the potential to result in Residents 41 not to receive the necessary care and services according to Resident 41's specific needs. Findings: During a review of Resident 41's admission Record (AR), the AR indicated Resident 41 was initially admitted to the facility on [DATE] and readmitted the resident on 12/10/2024 with multiple diagnosis including dementia (a gradual decline in mental ability usually caused by a brain disease) and major depressive disorder (a mental health condition characterized by persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities, significantly impacting daily functioning). During a review of Resident 41's Minimum Data Set (MDS - a resident assessment tool)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure one of three sampled residents (Resident 1) who was at risk for elopement (when a resident leaves the facility without authorization) was monitored in the hallway and re-directed away from the exit door as indicated in the facility's policy and procedure (P&P) titled, Safety of Residents. Resident 1 eloped from the facility on 10/19/2024 without being noticed by staff and was not found until 10/21/2024. Resident 1 sustained a skin abrasion (scrape) above the left elbow. This deficient practice had the potential to result in serious bodily injury and physical decline to Resident 1 during the time Resident 1 was absent from the facility. Findings: During a review of Resident 1's admission Record, (AR), the AR indicated Resident 1 was admitted on [DATE] with diagnoses that included dementia (loss of mental skills that affect daily life and cause problems with memory, thinking and planning) and major depressive disorder (mental health…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility's temperature was in an acceptable range as indicated, in the facility's policy and procedure (P&P), titled, Homelike Environment, for six resident's rooms, one dining room, and one hallway out of 23 resident's rooms, two dining rooms, and two hallways. This deficient practice had the potential to place the residents, visitors, and staff members at risk for serious illness, harm, and/or death. Findings: During an interview on 9/10/2024 at 4:29 PM with the Director of Nursing (DON), the DON stated the facility's air conditioner for the middle part of the nursing unit was broken. The DON stated the air conditioner had malfunctioned since 9/9/2024. The DON stated they started fixing it this morning (9/10/2024) and were providing fans to the residents. During a concurrent observation and interview on 9/10/2024 at 4:40 PM with the Maintenance Director 1 (MD 1), MD 1 stated the facility's acceptable temperature range was 71…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 comprehensive person-centered care plans for two of two sampled residents (Residents 15 and 11) when: a. For Resident 15, The facility failed to develop a care plan that included interventions to address Resident 15's urinary incontinence (loss of bladder control). b. For Resident 11, the facility failed to develop a care plan that included goals and interventions to address Resident 11's rash located on Resident 11's left and right buttocks. This failure had the potential to result in unmet individualized needs for Residents 15 and 11 and the potential to affect the resident's physical and psychosocial well-being. (Cross reference F690 and F580) Findings: a. During a review of Resident 15's admission Record (AR), the AR indicated Resident 22 was admitted to the facility on [DATE] with multiple diagnoses including schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), chronic obstructive pulmonary disease…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review and revise comprehensive care plans for two of two sampled residents (Residents 41 and 18) by failing to: a. For resident 41, the facility failed to review the comprehensive care plan for falls, as indicated in the facility's policy and procedure (P&P), titled, Initial Fall Risk Assessment. b. For Resident 18, the facility failed to ensure bilateral knee extension splints (B knee splints, material used to extend or straighten the knees as much as possible) and left ankle pressure-relieving ankle foot orthosis (L PRAFO, device to maintain foot/ankle stability while in bed) care plans (CPs) for Resident 18, who had range of motion (ROM, full movement potential of a joint [where two bones meet]) and mobility limitations, were in accordance with the physician's orders. This failure had the potential to result in unmet individualized needs for Residents 41 and 18 due to outdated inadequate interventions and had the potential to result in a decline 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 interviews and record review, the facility failed to follow its policy and procedures (P&P) regarding the role of the interdisciplinary team (IDT, staff with varied clinical backgrounds-including nursing staff and resident's physician-that combine experience and knowledge when evaluating the resident's strengths, needs, and preferences to attain the best quality of care and life for the resident), for one of 13 sampled residents (Resident 1), who lacked the capacity to make healthcare decisions by failing to: Ensure the IDT consisted of Resident 1's attending physician (MD), registered nurse (RN) responsible for the resident, responsible party (RP), and other appropriate staff in accordance with the facility's P&P. This failure had the potential to cause a decline in Resident 1's physical or psychosocial well-being related to inadequate representation of the different disciplines in the care planning process. Findings: During a review of Resident 1's admission Record (AR), the facility readmitted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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's (Resident 11) physician was notified of the development of a rash on Resident 11's left and right buttocks. This deficient practice had the potential to result in a delay in treatment and/or services and could result in a physical decline to Resident 11. Findings: During a review of Resident 11's admission Record (AR), the AR indicated Resident 11 was admitted to the facility on [DATE] with diagnoses that included generalized muscle weakness and schizophrenia (a mental disorder effecting how a person thinks and feels). During a review of a History and Physical (H&P), dated 1/19/24, the H&P indicated Resident 11 did not have the capacity to understand and make decisions. During a review of a MDS, dated [DATE], indicated Resident 11 was dependent (helper does all the effort) with eating, oral hygiene, toilet hygiene, showers, upper and lower body dressing, personal hygiene, and required substantial 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 provide Skilled Nursing Facility Advance Beneficiary Notice (SNFABN, notice of liability) and Notice of Medicare Non-Coverage (NOMNC) letters/forms to one of one sampled resident (Resident 196) three days prior to Resident 196's last day covered as indicated in the facility's policy and procedure (P&P), titled, Understanding Medicare Denial Letters,. This deficient practice had the potential to result with Resident 196 to not be aware of possible charges for services rendered that were not covered after the last Medicare coverage day. Findings: During a review of Resident 192's admission Record (AR), the AR indicated Resident 192 was admitted to the facility 6/27/23 and readmitted [DATE] with diagnoses that included lack of coordination, muscle weakness, and abnormalities of gait (walk). During a review of the Minimum Data Set (MDS, an assessment and screening tool), dated 12/28/23 the MDS indicated Resident 192's cognition (ability to understand 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.

Based on interview and record review, the facility failed to ensure a comprehensive assessment of the functional limitation in range of motion (ROM, full movement potential of a joint [where two bones meet]) of one of two sampled residents (Resident 18) with mobility and ROM limitations, was complete and accurate. This failure had the potential to lead to Resident 18's worsened contractures and increased risks for pain and skin breakdown related to incorrect treatments and plan of care. Cross reference with F688 and F657 Findings: A. During a review of Resident 18's admission Record (AR), the AR indicated the facility admitted Resident 18 on 10/19/2023 with multiple diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with daily activities), syncope (fainting) and collapse, anxiety disorder (persistent and excessive worry that interferes with daily activities), and generalized muscle weakness. During a review of Resident 18's History and Physical (H&P), dated 10/21/2023, the H&P indicated Resident 18 did not have the capacity to…

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

Based on observation, interviews, and record review, the facility staff failed to administer Simbrinza 1% - 2% (brinzolamide/brimonidine tartrate, eye drops to treat glaucoma [progressive eye disease causing vision loss and blindness due to the damage to the optic nerve]), in accordance with the professional standards of practice to one of one sampled resident (Resident 7), who was selected for medication administration observation. This failure had the potential to result in worsened vision to Resident 7 due to decreased medication efficacy (ability of the medication to produce the maximal desired effect) due to the systemic absorption of the eye drops and/or subtherapeutic dose (concentration of a drug lower than what is usually prescribed to treat a disease effectively). Findings: During a review of Resident 7's admission Record (AR), the AR indicated the facility initially admitted Resident 7 on 2/4/2010 with multiple diagnoses including glaucoma, cataract (clouding of the eye lens causing cloudy, blurry, or unclear vision), astigmatism (imperfection of eye curvature causing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 9) was provided a communication tool or resources to effectively communicate Resident 9's needs when Resident 9 spoke Cantonese (a Chinese dialect). This deficient practice had the potential to result in Resident 9's needs not effectively conveyed to facility staff which could lead to a decline in Resident 9's physical and psychosocial well-being. Findings: During a review of an admission Record (AR), the AR indicated Resident 9 was re-admitted to the facility on [DATE] with diagnoses that included anemia (a deficiency when the body does not have enough iron) and dementia (a decline in mental ability severe enough to interfere with daily life). During a review of Resident 9's care plan (CP), titled Language Barrier: Vietnamese speaking, non-English speaking, initiated 6/6/16 and revised on 5/24/21, the CP's interventions indicated the facility would provide Vietnamese speaking staff to make…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the necessary care and services for one of two sampled residents (Resident 18) with limited mobility or range of motion (ROM, full movement potential of a joint [where two bones meet]) by failing to: A. Ensure an accurate assessment of Resident 18's ROM on both upper extremities (BUEs) on 10/20/2023. B. Properly assess Resident 18's tolerance to the right elbow extension splint (R elbow splint, material used to extend or straighten the elbow as much as possible) after the resident readmitted to the facilltiy on 10/19/2023. C. Ensure the order for the Restorative Nursing Aide (RNA, certified nursing aide who helps residents maintain their function and joint mobility) to apply the splints to both knees (B knees) and left ankle (L ankle), dated 12/4/2023, was in accordance with Resident 18's tolerance to splints upon discharge from rehab therapy. These failures had the potential to cause a further decline in Resident 18's mobility and ROM with worsened contractures (chronic joint stiffness) and increased…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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's interdisciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of the resident) failed to accurately assess a resident's fall risk and reassess fall prevention interventions quarterly for one of one sampled resident (Resident 41) who was at high risk of falling, as indicated in the facility's policies and procedures (P&P). These failures had the potential to result in harm and Resident 41 to sustain injury and/or harm due to falls. (Cross reference F657) Findings: During a review of Resident 41's admission Record (AR), the AR indicated Resident 41 was admitted to the facility on [DATE] with multiple diagnoses including Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), dementia (a group of thinking and social symptoms that interferes with daily functioning), and colostomy (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 provide appropriate treatment to restore continence, to the extent possible, by failing to implement a prompted toileting program (caregiver prompts the resident to use the toilet) for one of one sampled resident (Resident 15). This failure had the potential to result in incontinence and urinary tract infections (UTIs, an infection in any part of the urinary system [system of organs that makes urine]) to Resident 15. Findings: During a review of Resident 15's admission Record (AR), the AR indicated Resident 22 was admitted to the facility on [DATE] with multiple diagnoses including schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), and dysphagia (difficulty swallowing foods or liquids). During a review of Resident 15's Minimum Data Set (MDS, a standardized assessment and care screening…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pharmacy consultant recommendations were followed for one of one sampled resident (Resident 9). The facility did not act upon recommendations to include ferritin/iron panel (a lab test that determines if the body has enough iron in the cells) in Resident 9's routine labs. This deficient practice had the potential to result in a physical decline to Resident 9. Findings: During a review of an admission Record (AR), the AR indicated Resident 9 was re-admitted to the facility on [DATE] with diagnoses that included anemia (a deficiency when the body does not have enough iron) and dementia (a decline in mental ability severe enough to interfere with daily life). During a review of Resident 9's Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 2/9/24, indicated Resident 9 needed supervision for touching assistance with sit to lying (moves from lying flat to sitting in bed) and sit to standing (sting in a chair to standing).…

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

Based on interviews and record review, the facility failed to ensure the Lithium (medication used to treat mood disorders) level (blood drawn to check the Lithium level in the blood and determine if the level is within the therapeutic range [quantitative measurement of the relative safety of a drug], subtherapeutic [concentration of a drug lower than what is usually prescribed to treat a disease effectively], or indicating Lithium toxicity[an adverse drug reaction due to increased drug concentration in the blood]) for one of one sampled resident (Resident 6) was obtained as ordered by the physician. This failure had the potential to cause lithium toxicity, worsened behavioral symptoms due to not enough drug in the blood, and a decline in Resident 6's physical and psychological well-being due to a delay in services. Findings: During a review of Resident 6's admission Record (AR), the AR indicated the facility initially admitted Resident 6 on 2/5/10 with multiple diagnoses including Parkinson's disease (progressive disorder affecting the nervous system and the body parts controlled by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to date one opened bag of egg noodles and two open bags of chips in one of one food storage rooms (Food Storage room [ROOM NUMBER]), according to the facility's policy and procedure (P&P) titled, Labeling: Food. This failure had the potential to result in residents to experience food-borne illnesses (illnesses caused by contaminated food). Findings: During a concurrent observation and interview on 3/4/24 at 10 a.m. with the Certified Dietary Manager (CDM) in Food Storage room [ROOM NUMBER], three bags of opened foods were observed. There was one undated half full bag of egg noodles, one undated opened bag of tortilla chips, and one undated opened bag of potato chips all sitting on a shelf. The CDM stated the bags needed to be dated when opened to ensure kitchen staff used the bag before the food went bad. The CDM stated residents could get sick if served expired food. During a review of the facility's undated P&P titled, Labeling: Food, 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 interviews and record review, the facility failed to ensure the medical records for one of one sampled resident (Resident 6) were complete and accurate. This deficient practice had the potential to lead to inconsistent and/or inaccurate treatments provided. Findings: During a review of Resident 6's admission Record (AR), the AR indicated the facility initially admitted Resident 6 on 2/5/10 with multiple diagnoses including Parkinson's disease (progressive disorder affecting the nervous system and the body parts controlled by the nerves), and convulsions (uncontrolled shaking of the body). During a review of Resident 6's History and Physical (H&P), dated 2/20/24, the H&P indicated Resident 6 did not have the capacity to understand and make decisions. During a review of Resident 6's Minimum Data Set (MDS, a standardized resident assessment and care-planning tool), dated 2/16/24, the MDS indicated Resident 6 had severe impairment in cognition (ability to understand and process information). The MDS indicated Resident 6 required supervision or touching assistance (staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure the signed binding arbitration agreement (BAA, contract between the facility and resident requiring disputes to be resolved by an arbitrator [third party decision-maker] instead of a judge or jury in court) for two of two sampled residents (Residents 40 and 18) provided for following: A. For Resident 40, the signed BAA failed to provide for the selection of a convenient venue (location to carry out arbitration proceedings agreed upon and suitable to both parties) and a neutral arbitrator (impartial or unbiased third-party decision maker, contracted with, and agreed to by both parties to resolve their dispute). B. For Resident 18, the signed BAA failed to provide for the selection of a convenient venue and a neutral arbitrator. These failures had a potential to result in a decline in the residents' physical and/or psychosocial condition due to the possible hardships related to arbitration proceedings. Findings: A. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain and implement its Infection Control Program to prevent the transmission of disease and infection for one of two sampled resident (Resident 41) when CNA 2 failed to wear personal protective equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) while CNA 2 provided care to Resident 41 in accordance with the facility's policy and procedure (P&P). This failure had the potential to result in cross contamination (the physical movement or transfer of harmful bacteria and viruses [organisms that cause disease] from one surface to another) and the spread of infection to Resident 41. Findings: During a review of Resident 41's admission Record (AR), the AR indicated Resident 41 was admitted to the facility on [DATE] with multiple diagnoses including Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the call light (a device used by a resident to signal the need for assistance) system was within reach for one of one sampled resident (Resident 41) as indicated in the facility's policy and procedure (P&P) titled, Call Lights. This failure had the potential to result in unmet needs for Resident 41 or the potential to result in Resident 41 to experience harm if Resident 41 was unable to alert staff during an emergency. Findings: During a review of Resident 41's admission Record (AR), the AR indicated Resident 41 was admitted to the facility on [DATE] with multiple diagnoses including Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), dementia (a group of thinking and social symptoms that interferes with daily functioning), and colostomy (an operation that creates an opening for the colon, or large intestine, through 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 develop and implement the care plan (CP) for one of 10 sampled residents (Resident 1) when Resident 1 was walking around the facility, spilling liquid on the floor. This failure resulted in Certified Nurse Assistant (CNA) 1 barricading (improvised barrier erected to prevent or delay of movement of residents getting through) Residents 1 ' s doorway with two utility/linen carts (material handling cart used for bedding, linens, and other supplies) to block the entrance/exit (only one trance and exit). This deficient practice had the potential for Residents 1 to experience further incidents of involuntary seclusion that could lead to psychosocial (mental, emotional, social, and spiritual effects) harm, serious injury, serious harm, serious impairment, or death. (Cross reference F603) 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 of paranoid…

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