The Gardens Of El Monte

Based on observation, interview and record review, the facility failed to ensure safe provision of pharmaceutical services when one pill was found lying on the hallway floor. This failure had the potential to result in a resident taking the pill and leading to adverse side effects (unwanted undesirable effects that are related to a drug).Findings: During an observation on 4/7/2026 at 12:37 pm in the hallway across from Nursing Station 1, one small, round, white pill was on the hallway floor. There were two nurses in Nursing Station 1, other staff and residents were walking through the hall. During a concurrent observation and interview on 4/7/2026 at 12:41 pm with Registered Nurse Supervisor 1 (RN 1) in the hallway across from Nursing Station 1, the small, round, white pill was observed on the floor. RN 1 went to retrieve a glove to pick it up and stated, there shouldn't have been a pill on the floor. RN 1 stated, a resident could have picked it up, eaten it, and some harm could've occurred to the resident depending on what the medication was. RN 1 stated, RN 1 was unsure what 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 accurately date a resident's Care Plan (CP) for one of one sampled resident (Resident 16). This failure resulted in inaccurate documentation and had the potential to negatively impact the resident's quality of care.Findings: During a review of Resident 16's admission Record (AR), the AR indicated Resident 16 was admitted to the facility 3/5/2026 with diagnoses including metabolic encephalopathy (brain dysfunction caused by chemical or metabolic imbalance), bipolar disorder (mental health condition characterized by extreme mood swings), and depression (persistent sadness). During a review of Resident 16's History & Physical (H&P) dated 3/5/2026, the H&P indicated Resident 16 had fluctuating capacity to understand and make decisions. During a review of Resident 16's Minimum Data Set, dated [DATE], the MDS indicated Resident 16 had intact cognition (ability to think and process information) and required partial/moderate assistance to walk 10 feet (ft).…

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

Based on interview and record review, the facility failed to administer Depakote (a medication used to help control mood symptoms and behavior issues) per the physician's order for one of three sampled residents (Resident 1). This violation had the potential to compromise Resident 1's health and safety.Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 1/9/2026 and readmitted Resident 1 on 3/20/2026 with diagnoses including dementia (a progressive state of decline in mental abilities) and schizophrenia (a mental illness that was characterized by disturbances in thought). During a review of Resident 1's History and Physical (H&P) dated 1/10/2026, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 1/13/2026, the MDS indicated Resident 1 had severely impaired cognition (ability to understand). The MDS indicated Resident 1 was independent with eating, oral hygiene and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the residents receive written notice before the resident's room or roommate in the facility being changed for two of seven sampled residents (Resident 1 and Resident 6).These deficient practices violated Resident 1 and Resident 6's rights and had the potential to affect Resident 1 and Resident 6's psychosocial well-being.(cross reference F656)Findings:a. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to facility on 9/10/2025 with diagnoses including depression (a serious mood disorder causing persistent sadness, loss of interest, and impacting feeling, thinking, and acting, affecting daily life and leading to emotional/physical problems like fatigue, sleep issues, and hopelessness), anxiety disorder (a mental health condition causing excessive, persistent fear and worry disproportionate to the situation), abnormalities of gait and mobility, and schizophrenia (a mental illness that is characterized…

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 a safe and orderly transfer or discharge from the facility for three of ten sampled residents (Resident 1, Resident 3, and Resident 19) by failing to ensure:1. not discharge Resident 1 to another same level care Skilled Nursing Facility (SNF) 2 without physician's order, indicating the appropriate reason for discharge and providing Notice of Transfer/Discharge (NTD) to the resident to obtain a consent from the resident prior to discharge on [DATE].2. not discharge Resident 3 to another same level care SNF 3 without indicating the reason for discharge and providing NTD to the resident to obtain a consent prior to discharge 11/21/2025.3. not discharge Resident 19, who needs assistance for dressing and personal hygiene upon discharge, to an Independent Living Home (ILH) 1 on 8/1/2025, which does not meet the resident's needs.These deficient practices violated Residents 1, 3 and 19's rights and had the potential to result in impairing Residents 1,…

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 document the appropriate content on the Notice of Transfer/Discharge (NTD) form for three of ten sampled residents (Resident 1, Resident 3, and Resident 19) by failing to ensure:1. indicate the appropriate reason to transfer Resident 1 to another same level care Skilled Nursing Facility (SNF) 2 on 12/5/2025.2. indicate the appropriate reason to transfer Resident 3 to another same level care SNF 3 on 11/21/2025.3. indicate the location of an Independent Living Home (ILH) 1, where Resident 19 was transferred on 8/1/2025.These deficient practices result in inappropriate documentation and placing the resident at risk of misunderstanding the information in the medical records and sufficiently preparing the residents for discharge, which had the potential to impair residents' physical, mental and psychosocial well-being for Resident 1, 3, and 19.(cross reference F627)Findings:1. During a review of Resident 1's admission Record (AR), the AR indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the nurse staff developed and implemented the person-centered care plan (a treatment plan that focused on the needs and preferences of a resident or individual) for one of seven sampled residents (Resident 1) to monitor Resident 1's psychosocial well-being and satisfaction after Resident 1 was being moved to a new room.This deficient practice had the potential to place Resident 1 at risk of not receiving the individualized care services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.(cross reference F559)Findings:During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to facility on 9/10/2025 with diagnoses including depression (a serious mood disorder causing persistent sadness, loss of interest, and impacting feeling, thinking, and acting, affecting daily life and leading to emotional/physical problems like fatigue, sleep issues, and hopelessness),…

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 staff provided social services to assist one of three sampled residents (Resident 1) to get a legal personal identification (ID) card. This deficient practice violated Resident 1's right and had the potential to affect Resident 1's mental and psychosocial well-being.Findings:During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to facility on 9/10/2025 with diagnoses including depression (a serious mood disorder causing persistent sadness, loss of interest, and impacting feeling, thinking, and acting, affecting daily life and leading to emotional/physical problems like fatigue, sleep issues, and hopelessness), anxiety disorder (a mental health condition causing excessive, persistent fear and worry disproportionate to the situation), abnormalities of gait and mobility, and schizophrenia (a mental illness that is characterized by disturbances in thought).During a review of Resident 1's History and Physical (H&P), dated 9/11/2025, the H&P indicated that the resident could…

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

Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 5) was treated with respect and dignity by failing to ensure Activities Assistant (AA) 1 allowed Resident 5 to get up from the reclining wheelchair (wheelchair with backrest that moves backward so users can transition from an upright seated position to a horizontal position) on 12/1/2025 at 1:25 pm. This failure resulted in Resident 5 being confined (restricted) to Resident 5's reclining wheelchair and had the potential for Resident 5 to develop a decline in range of motion (ROM- how far and in what direction a joint or muscle can move), the ability to stand, quality of life, and lead to psychosocial (mental, emotional, social, and spiritual effects) harm.Findings: During a review of Resident 5's admission Record (AR), the AR indicated the facility admitted Resident 5 on 7/11/2025 with diagnoses that included abnormalities of gait and other mobility (inability to walk normally due to injuries or underlying conditions), other lack of coordination (uncoordinated…

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 2) was free of unnecessary restraint. This failure had the potential for Resident 2 being unable to move around freely and placed Resident 2 at risk of injuries. Findings: a. 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 metabolic encephalopathy (brain disease, damage, or malfunction caused by an illness or organs that are not working as well as they should), abnormalities of gait and mobility (changes in walking pattern caused by medical conditions), and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). During a review of Resident 2's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 8/22/25, the H&P indicated Resident 2 did not have 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 a care plan for mental health services and increased socialization to prevent isolation for one of three sampled residents (Resident 2) who was being seen by the psychiatrist (a medical doctor who diagnoses and treats mental, emotional, and behavioral disorders). This failure resulted in Resident 2 feeling sad and isolated and had the potential for Resident 2 to receive inappropriate care. 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 metabolic encephalopathy (brain disease, damage, or malfunction caused by an illness or organs that are not working as well as they should), abnormalities of gait and mobility (changes in walking pattern caused by medical conditions), and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement and revise the care plan for one of three sampled residents (Resident 1) who were assessed at high risk for falls in accordance with the facility's policy and procedure (P&P) titled, Falls by a Resident by failing to ensure: 1. Resident 1 was supervised and assisted while walking in the hallway on 9/6/25 in accordance with Resident 1's fall risk care plan. This failure resulted in Resident 1 falling on 9/6/25 and sustaining bruises, swelling, and an open wound on the forehead. 2. Resident 1's fall risk care plan was not revised with new interventions after Resident 1 fell on 9/6/25. This failure placed Resident 1 at risk for future falls and injury. Resident 1 fell on [DATE] and sustained bruises on the right side of the forehead, on the right eye, and on the right side and left side of the face. 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…

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 b. During a review of Resident 42's AR, the AR indicated Resident 42 was admitted to the facility on [DATE] with diagnoses that included pneumonia (infection that inflames the lung) and type 2 DM. During a review of Resident 42's MDS dated [DATE], the MDS indicated Resident 42 had severely impaired cognition for daily decision making. The MDS indicated Resident 42 was dependent (helper does all of the effort) to staff for toileting hygiene, shower, upper and lower body dressing, putting on/taking off footwear and personal hygiene. During a review of Resident 42's AD Acknowledgement Form dated 12/6/2024, Resident 42's AD Acknowledgment Form was not filled out completely. During an interview with the Social Worker (SW), and concurrent record review of Resident 42's AD Acknowledgement Form on 3/15/2025 at 4:25 pm, the SW stated, the AD Acknowledgement Form was not filled out completely. The SW stated, the AD Form needed to be filled out completely if Resident 42 had an existing AD or RP wanted to execute AD or not.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility licensed staff failed to perform a thorough assessment and to immediately notify the physician of a resident's sudden change of condition (COC) for one of one sampled resident (Resident 53). This failure had the potential to result in delayed treatments and services for the resident resulting in a decline of health condition. Findings: During a closed medical record review of Resident 53's admission Record (AR), the AR indicated Resident 53 was readmitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD, a group of lung diseases that cause airflow obstruction and breathing problems) and Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control). During a review of Resident 53's Minimum Data Set (MDS, a resident assessment tool) dated [DATE], the MDS indicated Resident 53 was admitted to the facility from an acute care hospital on [DATE]. During a review of the facility's Comprehensive…

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 necessary care and services for residents on oxygen therapy (treatment that provides supplemental, or extra oxygen) in accordance with professional standards of practice for four of four sampled residents (Residents 17, 30, 42 and 24) by failing to: a. Ensure Resident 17 received continuous oxygen therapy as ordered by the physician. Resident 17's nasal cannula (NC, tube which on one end splits into two prongs which are placed in the nostrils to deliver oxygen) was left hanging on top of the oxygen concentrator. Resident 17 did not have a care plan developed on the use of oxygen therapy. b. Ensure to label the NC tubing for Resident 30. c. Ensure Resident 42's oxygen tubing was not touching the floor and the nasal cannula prongs were inside the resident's nostrils. d. Obtain a physician's order before providing oxygen treatment for Resident 24. These failures placed Residents 17, 30, 42, and 24 at risk for complications related to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the physician's order for fluid restriction was implemented from 3/1/2025 to 3/15/2025 for one of two sampled residents (Resident 37) reviewed for dialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidneys are unable to do so) care. This failure had the potential for fluid imbalance for Resident 37 affecting the resident's nutrition, hydration, and general condition. Findings: During a review of Resident 37's admission Record (AR), the AR indicated Resident 37 was admitted to the facility on [DATE] with diagnoses that included Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control), hypertension (high blood pressure) and end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis). During a review of Resident 37's Minimum Data Set (MDS, a resident assessment tool) dated 12/25/2024, the MDS indicated Resident 37 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medications were administered and disposed consistent with the facility's policy and procedure (P&P) on medication administration and disposal of medications and medication-related supplies by failing to: a. Administer Losartan (medication to treat high blood pressure) as ordered during medication pass observation for one of one sampled resident (Resident 45). This failure had the potential to increase the risk of adverse drug reactions and cause harm to the resident. b. Ensure medication destruction occurs in the presence of two licensed nurses for 72 of 72 destructed medications. This failure had the potential to result in medication misappropriation. Findings: a. During a review of Resident 45's admission Record (AR), the AR indicated Resident 45 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar…

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

Based on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) on preparing and serving food in accordance with professional standards for food service safety, proper sanitation and food handling practices by failing to ensure Kitchen Aide 1 (KA 1) wore a hair net (hair cover) while preparing food in the preparation area for one of one facility kitchen. This deficient practice had the potential for food borne illnesses (infection caused by ingesting contaminated food) to residents who received food from the facility's kitchen. Findings: During an initial tour of the kitchen on 3/14/2025 at 6:07 pm, KA 1 was observed not wearing a hairnet or hair cover while pushing the food cart with meal tray at the food preparation area. KA 1 stated, KA 1 forgot to wear a hairnet while in the kitchen. KA 1 stated it was important to wear a hairnet to prevent hair from falling into the food in the food preparation area. During an interview on 3/15/2025 at 9:21 am with the Dietary Supervisor (DS), the DS stated hair covering such as hairnet was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the call light was within reach for one of one sampled resident (Resident 4) in accordance with the facility's policy and procedure titled Call Lights. This failure had the potential for Resident 4 not to receive care or receive delayed services to meet the resident's needs and could result in a fall or injury. Findings: During a review of Resident 4's admission Record (AR), the AR indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included paraplegia (impairment in motor or sensory function of the lower extremities) and dysphagia (difficulty in swallowing). During a review of Resident 4's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 1/15/2025, the MDS indicated Resident 4 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 4 was dependent (helper does all of the effort)…

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 resident's Minimum Data Sheet (MDS, a resident assessment tool) was accurately coded to reflect the resident's discharge destination for one of one sampled resident (Resident 51). This failure resulted to inaccurate reporting to the Centers for Medicare & 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 for Resident 51 not to receive interventions to address specific care concerns. Findings: During a review of Resident 51's admission Records (AR), the AR indicated Resident 51 was admitted to the facility on [DATE] with diagnoses that included cellulitis (skin infection) of right lower limb, seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) and anemia (a condition where the body does 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 ensure medications were administered before medications were documented as given in the Electronic Medication Administration Record (EMAR, a digital system used to track and document medication administration) consistent with the facility's Policy and Procedure (P&P) on medication administration for one of one sampled resident (Resident 38). This failure had the potential for missed medication or medication error for Resident 38. Findings: During a review of Resident 38's admission Record (AR), the AR indicated Resident 38 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach), dysphagia (difficulty swallowing), and acute respiratory failure (inability of the lungs to adequately exchange gases in the blood). During a review of Resident 38's Minimum Data Sheet (MDS, a resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 4) who had gastrostomy tube (GT- a tube inserted through the abdomen that delivers nutrition directly to the stomach) received necessary treatment and services as indicated in the facility's policy and procedure (P&P) titled Enteral Feedings. This deficient practice had the potential to result in weight loss for Resident 4 and altered nutritional status that could lead to complications. Findings: During a review of Resident 4's admission Record (AR), the AR indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included paraplegia (impairment in motor or sensory function of the lower extremities) and dysphagia (difficulty in swallowing) During a review of Resident 4's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 1/15/2025, the MDS indicated Resident 4 had severely impaired cognition (mental action or process of acquiring knowledge 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 b. During a review of Resident 42's AR, the AR indicated Resident 42 was admitted to the facility on [DATE] with diagnoses that included pneumonia (infection that inflames the lung) and type 2 DM. During a review of Resident 42's MDS dated [DATE], the MDS indicated Resident 42 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 42 was dependent (helper does all of the effort) to staff for toileting hygiene, shower, upper and lower body dressing, putting on/taking off footwear and personal hygiene. During a review of Resident 42's OSR dated 3/8/2025, the OSR indicated an order for licensed staff to perform Accu-Chek (blood glucose[sugar] monitoring system) one time a day for DM. During a review of Resident 42's MAR for the month of March 2025, the MAR indicated Resident 42's blood glucose level was not checked or monitored on 3/13/2025 as ordered. There was no licensed nurse's initial on the MAR to indicate 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 notify one of three sampled residents' (Resident 7) Responsible Party (RP- a person who makes decisions for a resident) that the resident had fallen (to suddenly go down onto the ground or toward the ground) while in the care of the facility. This failure had the potential to deny Resident 7's right for her representative to be informed of Resident 7's health status. Findings: During a review of Resident 7's admission Record (AR), the AR indicated the facility admitted Resident 7 on 8/1/2024, with diagnoses that included type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), urinary tract infection (UTI, an infection in any part of the urinary system, including the kidneys, bladder, or urethra), and dementia (a group of thinking and social symptoms that interferes with daily functioning). The AR indicated Resident 7's daughter (RP 1) was Resident 7's Responsible Party. During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a daily skin assessment for one of one sampled resident (Resident 8) who was at risk of developing skin breakdown and pressure injuries (localized areas of skin damage caused by prolonged or intense pressure). This failure had the potential for Resident 8 to develop skin breakdown and pressure injuries and/or to not receive treatment for skin breakdown and pressure injuries. (Cross Reference F842) Findings: During a review of Resident 8's admission Record (AR), the AR indicated the facility admitted Resident 8 on 10/31/2024, and readmitted Resident 8 on 12/6/2024, with diagnoses that included type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), metabolic encephalopathy (brain disease that alters brain function or structure), and dysphagia (difficulty swallowing foods or liquids). During a review of Resident 8's Minimum Data Set (MDS, a resident assessment tool), dated 11/4/2024, 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 maintain a complete and accurate medical record for one of three sampled residents (Resident 8) by failing to accurately document skin assessments in Resident 8's medical record. This failure resulted in Resident 8's medical record to contain inaccurate information and had the potential to affect Resident 8's care. (Cross Reference F684) Findings: During a review of Resident 8's admission Record (AR), the AR indicated the facility admitted Resident 8 on 10/31/2024, and readmitted Resident 8 on 12/6/2024, with diagnoses that included type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), metabolic encephalopathy (brain disease that alters brain function or structure), and dysphagia (difficulty swallowing foods or liquids). During a review of Resident 8's Minimum Data Set (MDS, a resident assessment tool), dated 11/5/2024, the MDS indicated Resident 8 was severely impaired (never/rarely 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.

Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Documentation Principles, to have complete documentation for one of three sampled residents (Resident 1). This deficient practice had the potential to not provide full information regarding a diagnostic service that Resident 1 received and could result in inconsistencies in providing the necessary care and treatment to Resident 1. Findings: During a review of Resident 1's admission Record (AR), the AR indicated, the facility admitted Resident 1 on 9/12/2022, with diagnosis that included parkinsonism (brain conditions that cause slowed movements, stiffness, and tremors), pneumonia (an infection and fluid in the lungs caused by bacteria, virus, or fungi), and dysphagia (difficulty swallowing) following cerebral infarction (stroke - damage to tissues in the brain due to a loss of oxygen to the area). During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/16/2024, the MDS indicated, Resident 1 was rarely/never understood…

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 notify the physician of a change in condition (COC- a change in the resident's health or functioning that requires further assessment and intervention) for one of two sampled residents as indicated in the facility's policy and procedure (P&P) titled, Significant Change in Condition, by failing to: 1. Ensure LVN 1 notified Resident 1's Primary Physician (PP/Medical Doctor [MD] 2) promptly (punctually [with little or no delay]) when LVN 1 noted Resident 1 struggled (had a hard time) to drink fluids on his (Resident 1's) own and needed encouragement with drinking fluids. 2. Ensure LVN 1 and LVN 2 communicated with MD 2 to obtain a physician's order for monitoring Resident 1's intake and output. These failures resulted in a delay in providing the necessary care and treatment for Resident 1. Cross Reference F692 Findings: During a review of Resident 1's admission Record (AR), the AR indicated, the facility initially admitted Resident 1 to the facility on 4/18/2024, and readmitted Resident 1 on 5/16/2024, with diagnoses that…

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 a safe discharge for one of two sampled residents (Resident 1). This deficient practice resulted in Resident 1 being unsafely discharged with nowhere to stay, after being discharged 497 miles away from the facility. Findings: During a review of Resident 1's Face Sheet (FS), the FS indicated Resident 1 was re-admitted on [DATE] with diagnoses that included other abnormalities of gait and mobility (unable to walk normally due to injuries, underlying conditions, or issues with the legs and feet), unspecified psychosis not due to a substance or known physiological condition (when an individual has a psychotic episode, but does not meet any other criteria for a more specific diagnosis), and Type 2 diabetes mellitus ([DM] adult-onset diabetes which is characterized by high levels of sugar in the blood). During a review of Resident 1's Quarterly Minimum Data Set ([MDS] a standardized assessment and care planning tool), dated 1/17/24, the MDS indicated…

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

Based on observation, interview, and record review, the facility failed to implement an effective pest control program by not preventing fruit flies (very small flies which eat fruit and rotting plants) from being inside the conference room and the resident's room for one of four sampled residents (Reisdent 2). This deficient practice had the potential to create unsanitary conditions for Resident 2, staff, and visitors. Findings: During an observation on 4/8/2024 at 1:05 pm, in the presence of Resident 2, one fruit fly was flying in front of Resident 2's face. Resident 2 saw the fruit fly and tried to avoid the fruit fly by moving away from it. During another observation on 4/8/2024 at 3:49 pm, in the presence of the Business Office Manager (BOM), one fruit fly was flying in the facility's conference room. During an interview on 4/8/2024 at 2:43 pm, with the Maintenance Supervisor (MS), the MS stated the facility doors have to be kept closed to prevent pests like bugs and flies from coming into the facility. During an interview on 4/8/2024 at 4:20 pm, with the Director of Nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide reasonable accommodation of need for two of three sampled residents (Resident 1 and Resident 38) by failing to: a. Ensure Resident 1's call light was within reach. b. Ensure Resident 38's clock was adjusted after Daylight Saving Time (DST, the practice of turning the clock ahead as warmer weather approaches and back as it becomes colder again). The DST was on 3/10/2024. These deficient practices had the potential for Resident 1 not to receive the necessary care and services that could result in fall/accident and Resident 38 not able to know the correct time. Findings: a. During a review of Resident 1's admission Record, the admission record indicated the facility admitted Resident 1 on 12/4/2023 with diagnoses that included need for assistance with personal care 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…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow its policy and procedure titled, Advance Directive for two of three sample residents by failing to: a. Provide information regarding 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 Resident 38. b. Ensure the AD copy was readily retrievable in Resident 18's medical records (chart). These failure had the potential to result in facility staffs provided medical care and treatment against the Resident 38 and 18's wishes. Findings: a. During a review of Resident 38's admission Record (AR) the AR indicated Resident 38 was readmitted on [DATE], with diagnoses that included dysphagia (difficult swallowing) and ascites (a condition in which fluid collects in spaces within abdomen which can affect…

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 safety and protection for Resident 24 who had injuries from unknown source for one of one sampled resident by failing to ensure: 1. Staff immediately reported Resident 24's injuries of unknown source no later than two hours to the DPH (Department of Public Health), Ombudsman, and local law enforcement. 2. Staff investigated Resident 24's injuries of unknown source in accordance with facility's policy and procedures (P&P) for resident abuse prevention in the facility. 3. Staff notified the physician and responsible party of Resident 24's injuries of unknown source. These deficient practices compromised Resident 24's safety and protection from abuse in the facility. Findings: During a review of Resident 24's admission Record (AR), the AR indicated the facility admitted Resident 24 on 12/10/23, with diagnoses that included dementia (a general term for loss of memory) and chronic kidney disease (a gradual loss of kidney function). During an observation on 3/12/24 at 8:45 a.m., Resident 24 was sitting in a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 3 of 3 sampled residents (Resident 25 and 45) receiving oxygen therapy were provided with respiratory care in accordance with the facility's policy and procedure (P&P) titled, Oxygen Administration, and Storage of Oxygen Cylinder, by failing to: a. Ensure Resident 25's nasal cannula tubing (flexible plastic tubing used to deliver oxygen to help with breathing) did not touch the floor and a cautionary sign was posted on Resident 25's door indicating oxygen in use. b. Ensure Resident 45's nasal cannula tubing was labeled and failing to ensure Resident 45's nasal cannula did not touch the floor, and a cautionary sign was posted Resident 45's door indicating oxygen in use. This deficient practice placed Resident's 25 and 45 at risk for infections and compromised the resident's safety. Findings: a.During a review of Resident 25's admission Record (AR), the AR indicated Resident 25 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.

Based on interview and record review, the facility failed to use the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week from 3/1/24 through 3/15/24 for 12 of 15 days. This deficient practice may affect the quality of nursing care provided to the residents. Findings: During a concurrent interview and record review on 3/15/24 at 11:25 a.m. with the Director of Staff Development (DSD), the nurse staffing sign-in sheet for the month of March 2024 was reviewed. The nurse staffing sign-in sheet dated 3/1/24 through 3/15/24 indicated no RN was on duty for twelve days. The DSD stated the facility had no full time RN that worked eight hours per day, seven days a week since February 2024. The DSD stated a full time RN was important to oversee residents' assessment and care in the facility every day. During a review of the facility's policy and procedures (P&P) titled, Staffing dated 3/2020, the P&P indicated the facility goal was to provide adequate staffing to provide necessary care and services to attain or maintain the highest practicable…

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 sanitizing solution used for cleaning food prepare area had the correct concentration that met industrial standard to prevent possible contamination for one of three sanitizing red buckets. The recommended concentration for cleaning solution was 200 parts per million (ppm), the sanitizing solution the facility used was 100 ppm. This failure had the potential to result in food prepare areas were not sanitized enough causing contamination and food borne illness to the residents. Findings: During a tour to the facility's kitchen on 3/12/2024 at 8:28 am with the Dietary Assistant (DA), the facility kitchen had three round red buckets with sanitizing solution and towels soaked in the solution. The DA tested each bucket's solution for quaternary (a type of chemical that is used to kill bacteria, viruses and mold) concentration with a test strip dipping in the solution and comparing color change against the color indicator on the test strip container. The color indicator had colors from light purple to dark…

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 the call light was within reach for two of two sampled residents (Resident 204,). This deficient practice had the potential to result in the residents being unable to summon health care worker for assistance for care and services as needed. Findings: During a review of the admission record (AR), the AR indicated Resident 204's was readmitted to the facility on [DATE], with diagnoses that included history of abnormalities of gait and mobility, unspecified muscle wasting and atrophy (muscle shrinking), and contracture (a deformity) of left hand. A review of the Minimum Data Set [MDS- an assessment tool] dated 12/23/23, the MDS indicated Resident 204 had severe impairment of cognitive skills for daily decision making. Resident 204 required total assistance in bed mobility, transfer, dressing, and personal hygiene. During a review of Resident 204's Care Plan titled Fall Risk, dated 12/12/2023, the Care Plan indicated Resident 204…

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 notice of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) did not have an informed decision from the resident's representative to pay for non-covered services after Resident 17 was discharged from Medicare Part A and Resident 17 continued to reside in the facility for one of two sampled residents (Resident 17). This deficient practice placed Resident 17 at risk for payment of out-of-pocket costs for non-coverage services while in the facility. Findings: During a review of Resident 17's admission Record (AR), the AR indicated the facility admitted Resident 17 on 6/4/23, with diagnoses that included dementia (a general term for loss of memory) and hypertensive heart disease (problems with the heart that can develop due to high blood pressure). During a review of Resident 17's notice of NOMNC and SNF ABN dated 8/30/23, indicated these notices were issued before the last covered day of Medicare Part A Services on 9/1/23. There was no documented evidence that Resident 17's representative was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure its alternating pressure pad (also known as APP mattress, widely used by both hospital facilities and home care users to provide complete relief from or maximum prevention and treatment of bedsores and pressure ulcers[PU, localized damage to the skin and/or underlying tissue, usually over a bony prominence, or related to a medical or other device, resulting from sustained pressure including pressure associated with shear) was in good working condition, the dial knob for weight adjustment was missing for one of one sampled residents (Resident 38). This failure had the potential to result in the reopen of Resident 38's healed/resolved pressure ulcers. Findings: During a review of Resident 38's admission Record (AR), the AR indicated Resident 38 was readmitted on [DATE], with diagnoses that included dysphagia (difficult swallowing) and ascites (a condition in which fluid collects in spaces within abdomen which can affect lungs,…

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 assess and monitor for the presence of sediments (visible particles in the urine that may contain red or white blood cells, casts, bacteria, fungi, parasites in the urine that could indicate an infection or dehydration [fluid deficit]) in the urine for one of one sampled resident (Resident 11) with an indwelling catheter (foley/urinary catheter - a tube inserted in the bladder to drain urine into a drainage bag), as indicated in the facility's policy and procedure (P&P), titled, Indwelling Catheter Use - Indications and the resident's care plan for foley catheter. This deficient practice had the potential to result in Resident 11 to receive no care or delayed care and treatment for a urinary tract infection (UTI, condition in which bacteria invade and grow in any part the urinary system). Findings: During a review of Resident 11's admission Record (AR), the AR indicated the facility admitted Resident 11 on 11/10/2023 with diagnoses that included neuromuscular dysfunction of the bladder (the nerves and muscles…

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

Based on observation, interview, and record review, the facility failed to post accurate nurse staffing information of actual hours worked by the licensed and unlicensed nursing staff, for one of one day (Recertification Survey Day 1) who were directly responsible for resident care per shift daily and the information was not posted in a prominent location readily accessible to residents and visitors for viewing. This deficient practice of posting inaccurate nurse 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 3/12/23 at 10:15 a.m., the facility's staffing information was posted inside nurse's station 1 and the information was not easily accessible for viewing by the residents and visitors. The staffing information posted indicated eight actual worked hours by one Registered Nurse (RN) during the morning shift (7AM-3PM) on 3/12/24. The staffing information was not posted in nurse's station 2. During a concurrent interview and record review on 3/12/24 at 10:20 a.m.,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to act upon the pharmacist's recommendations for medication regimen review (MRR) for one of five sampled residents (Resident 6). This failure had the potential to result in undesirable or non-therapeutic effect of the medication related to medication therapy for Resident 6. Findings: During a review of Resident 6's admission Record (AR), the AR indicated Resident 6 was admitted on [DATE], with diagnoses that included bacteremia (the presence of bacteria in the blood) and hypertension (increased blood pressure). During a review of Resident 6's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 2/21/2024, the MDS indicated Resident 6 had clear speech, able to understand others and made self-understood. The MDS indicated Resident 38 had intact cognition (able to think and process information). Resident 38 had no impairment for upper extremities (shoulder, elbow, wrist, hand) and impairment on one side of lower extremity (hip, knee,…

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

Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 24) on a psychotropic drug (any drug capable of affecting the mood, emotions, and behavior) was free from unnecessary medication by failing to ensure: 1. Resident 24's target behavior symptom for anti-anxiety medication (Lorazepam) 0.5 milligram (mg, unit of measurement) was adequately indicated and monitored. Resident 24 was non-communicative, and the resident could not express feelings of anxiety through verbalization or in writing. This deficient practice placed Resident 24 at risk for adverse drug reactions (a harmful and unintended response to a medicine). Findings: During a review of Resident 24's admission Record (AR), the AR indicated the facility admitted Resident 24 on 12/10/23, with diagnoses that included dementia (a general term for loss of memory) and chronic kidney disease (a gradual loss of kidney function). During an observation on 3/12/24 at 8:45 a.m., Resident 24 was sitting in the wheelchair while in Resident 24's room. Resident 24 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure for one of one sampled resident (Resident 254), the resident's intravenous catheter (IV, a thin plastic tube inserted into a vein using a needle allowing for the administration of medications, fluids and/or blood products) site was labeled with the date and time the IV was inserted. This failure had the potential to result in Resident 254 acquiring an infection that could worsen the resident's health condition. Findings: During a review of Resident 254's admission Record (AR), the AR indicated Resident 254 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (an alteration in consciousness caused due to brain dysfunction), cellulitis (an inflammation of the skin and deep underlying tissues), and urinary tract infection (an infection in the kidney, ureter, or bladder). During a concurrent observation and interview on 03/12/24 at 9:28 am, Resident 254 was observed awake and lying in bed with 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 observation, interview and record reviewed, the facility failed to provide the resident and or representative a copy of medical records following a written request in the acceptable time frame for one of three residents (Resident 1). This deficient practice violated Resident 1 ' s rights to allow the resident and or representative to obtain copies of his records from 6/23/2023 to 8/14/2023 (52 days). Findings: During a review of Resident 1 ' s Face Sheet, indicated Resident 1 was admitted to the facility on [DATE] and discharged from the facility on 5/7/2021. Resident 1 ' s diagnoses included hypertension (HTN, high blood pressure) and paraplegia (inability to voluntarily move the lower parts of the body). During a review of Resident 1 ' s History and Physical (H&P), dated 12/30/2020, indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 4/5/2021 indicated Resident 1 ' s…

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

Based on observation, interview, and record review, the facility failed to provide supervision for one of three sampled residents (Resident 1) who did not have the capacity to make decisions and was at risk for elopement (leaving unnoticed by staff) by failing to ensure Resident 1 did not elope from the facility on 7/18/2023, at 10:40 am. This failure resulted in Resident 1 wandered outside of the facility, took a public transportation home, and had the potential to result in Resident 1 sustaining an injury, dehydration, and abduction (take away by force). Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 7/14/2023 with diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), hypertension (increased blood pressure) and anxiety disorder (persistent and excessive worry that interferes with daily activities). A review of the facility's Elopement Risk Assessment, dated 7/14/2023, indicated Resident 1 was at risk for elopement. A review of the physician's initial…

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.