Valley View Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its Policy and Procedure (P&P) on antibiotic stewardship (a coordinated program that aims to improve the appropriate use of antibiotics to enhance patient outcomes, prevent antimicrobial, and decrease the spread of drug-resistant infections) for three of six sampled residents (Residents 78, 190, and 240). These failures had the potential to result in increased antibiotic resistance (ability of bacteria to withstand the effects of antibiotics, making standard treatments ineffective) and providing antibiotics without relevant justification. Findings: a. During a review of Resident 78's admission Record (AR), the AR indicated Resident 78 was admitted to the facility on [DATE] with diagnoses that included peritonitis (an inflammation of the thin membrane that lines the abdominal cavity and covers the abdominal organs), resistance to multiple antibiotics and long-term use to antibiotics. During a review of Resident 78's Physician's Order (PO)…

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 Orders for Life-Sustaining Treatment (POLST, a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of-life) and Advance Directive (AD, a legal document indicating resident preference on end-of-life treatment decisions) Acknowledgement Form were completed upon admission for one of one sampled resident (Resident 35) in accordance with the facility's Policy and Procedure (P&P) on AD. This failure had the potential for the facility staff to provide medical treatment and services against the will of Resident 35. Findings: During a review of Resident 35's admission Record (AR), the AR indicated Resident 35 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 control), end stage renal disease (ESRD, irreversible kidney…

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 the resident with a communication device with the language that the resident understood for one of one sampled resident (Resident 70). This failure had the potential to affect Resident 70's communication with staff and delay the provision of care, treatment, and services the resident needed. Findings: During a review of Resident 70's admission Record (AR), the AR indicated Resident 70 was admitted to the facility on [DATE] with diagnoses that included hypertension (HTN, high blood pressure), atrial fibrillation (an irregular, often rapid heart rate that causes poor blood flow) and malignant neoplasm (cancerous tumor) of the lung. During a review of Resident 70's Minimum Data Set (MDS, a resident assessment tool) dated 3/14/2025, the MDS indicated Resident 70 speaks Cantonese and needed or wanted an interpreter to communicate with a doctor or health care staff. During a concurrent observation inside Resident 70's room and interview…

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 the resident's skin condition and report the skin condition to the physician for one of one sampled resident (Resident 49). This failure resulted in the resident experiencing unrelieved itchiness in her vaginal and buttock areas. Findings: During a review of Resident 49's admission Record (AR), the AR indicated the facility admitted the resident on 6/7/23 with diagnoses that included Type 2 diabetes mellitus (elevated blood sugar level), neuralgia and neuritis (damaged, irritated and inflamed nerves), and obesity (disorder involving too much body fat). During a review of Resident 49's Minimum Data Set (MDS, a resident assessment tool) dated 3/4/25, the MDS indicated Resident 49 had moderately impaired cognition (ability to understand and process thoughts) and required substantial/maximal assistance with rolling left and right, sit to stand, and dependent for toileting hygiene. During a record review of Resident 49's recapitulated Physician's Orders (PO) for 4/1/25 - 5/2/25, the PO 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 provide care and services to meet the resident's need for one of one sampled resident (Resident 51) by failing to ensure Resident 51 who had difficulty hearing was scheduled for an audiology consult and/or hearing aids. This failure resulted in the resident's inability to hear adequately, requiring the resident to be spoken to loudly, and for the resident to lip read during conversation. Findings: During a review of Resident 51's admission Record (AR), the AR indicated the facility readmitted the resident on 3/21/25 with diagnoses that included encephalopathy (neurologic disorder), acute pulmonary edema (too much fluid in the lungs), and chronic kidney disease (kidney failure). During a review of Resident 51's MDS dated [DATE], the MDS indicated Resident 51 had severely impaired cognition (ability to understand) and required substantial/maximal assistance with sitting to stand and upper & lower body dressing, personal and toileting hygiene. During an…

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

Based on observation, interview, and record review the facility failed to ensure the resident was repositioned every two hours to prevent further skin breakdown (prolonged pressure on the skin causing tissue damage and potentially open sores) for one of one sampled resident (Resident 44). This failure placed the resident at risk of further deterioration of a sacro-coccyx (lowest sections of the spine) Stage 4 pressure ulcer (ulcers that extend deep into the tissue reaching the bones). Findings: During a review of Resident 44's admission Record (AR), the AR indicated the facility readmitted the resident on 12/6/23 with diagnoses that included encephalopathy (neurologic disorder), hepatomegaly (enlarged liver), and chronic obstructive pulmonary disease (COPD- lung diseases that block the airflow). During a review of Resident 44's Minimum Data Set (MDS, a resident assessment tool) dated 3/28/25, the MDS indicated Resident 44 had severely impaired cognition (ability to understand and process thoughts) and required substantial/maximal assistance with rolling left and right. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the resident had an environment free from accident hazards (risks) for one of four sampled residents (Resident 7) by failing to: 1. Ensure Resident 7 was provided with adequate supervision during the performance of activity of daily living (ADL, activities such as bathing, dressing, and toileting a person performs daily). 2. Ensure licensed staff developed an individualized person-centered care plan for Resident 7 who was assessed as high-risk for falls. These failures placed Resident 7 at risk of recurrent falls and injury. Findings: During a review of Resident 7's admission Record (AR), the AR indicated Resident 7 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hemiparesis (weakness on one side of the body, often affecting the arm, leg, and the face), and Alzheimer's disease (a disease characterized by 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 provide necessary care and services for a resident with Foley Catheter (FC, a medical device that helps drain urine from the bladder) in accordance with the facility's Policy and Procedure (P&P) on catheter care for one of two sampled residents (Resident 69). This failure had the potential to result in catheter-related complications for Resident 69. Findings: During a review of Resident 69's admission Record (AR), the AR indicated Resident 69 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN, high blood pressure), and anxiety (intense, excessive , and persistent worry and fear about everyday situations). During a review of Resident 69's Minimum Data Set (MDS, a resident assessment tool) dated 3/28/2025, the MDS indicated Resident 69 had severely 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to attempt to use appropriate alternative interventions before installation of bilateral (both sides) siderails (also known as bedrails, vertical bars or structures attached to the sides of a bed) for one of one sampled resident (Resident 43). This failure placed Resident 43 at risk for entrapment (when a resident can get caught by the head, neck, chest, or other body parts in the tight spaces around the bedrail) and physical injuries. Findings: During a review of Resident 43's admission Record (AR), the AR indicated Resident 43 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hemiparesis (weakness on one side of the body, often affecting the arm, leg, and the face) and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 43 Minimum Data…

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 its binding arbitration agreements included selection of a venue convenient to both the facility and resident/resident responsible party for one of three sampled residents (Residents 60). This deficient practice placed Resident 60 at risk for an unjust arbitration and delayed arbitration hearing in an event of an arbitration dispute. Findings: During a review of Resident 60's admission Record (AR), the AR indicated the facility admitted Resident 60 on 5/25/2024 with diagnoses that included diabetes mellitus type 2 (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in elevated levels of glucose/sugar in the blood and urine) and hyperlipidemia (high level of fats in the blood). During a review of Resident 60's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 2/10/2025, the MDS indicated, Resident 60 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS…

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 signage was posted and a personal protective equipment (PPE equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) cart was provided to one of six sampled residents (Resident 240) with MRSA of the wound placed on Enhanced Standard Precaution (ESP, an approach for the use of PPE to reduce transmission of multidrug-resistant organisms [MDRO] between residents in skilled nursing facilities) in accordance with the facility's policy and procedure title Enhanced Barrier Precautions. This deficient practice had the potential to transmit infectious microorganisms and increase the risk of infection for the residents and staff which could result in a widespread infection in the facility. Findings: During a review of Resident 240's admission Record (AR), the AR indicated Resident 240 was admitted to the facility on [DATE] with diagnoses that included pneumonia (an infection/inflammation in 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 report an allegation of resident-to-resident abuse for two of four sampled residents (Residents 3 and 4) to the State Licensing and Certification Agency (responsible for the licensing or certification of health care facilities), the Ombudsman and to the local law enforcement within two hours, in accordance with the facility's Policy and Procedure (P&P) on Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating. This deficient practice had the potential for delayed investigation that would compromise Residents 3 and 4's safety with potential for further abuse. Findings: During a review of Resident 3's admission Records (AR), the AR indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included acute heart failure (sudden condition when the heart can't pump enough oxygen to the body) and Diabetes Mellitus (a disease that result in too much sugar in the blood). During a review of Resident 3's Minimum Data…

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 two of three sampled milk drinks were prepared at 41 degrees Fahrenheit (F, a unit used to measure temperature) or lower as indicated in the facility's Policy and Procedure (P&P) titled, Food Receiving and Storage. This deficient practice had the potential to cause foodborne illness (illness from eating contaminated food) to already compromised residents. Findings: During an observation in the facility's kitchen on 6/13/2024 at 12:19 PM, several four-ounce glasses of milk were on trays in meal tray carts ready to be served with the residents' lunch. Two of the three glasses of milk were randomly selected and observed to have a temperature higher than 41 degrees F. During a concurrent observation and interview on 6/13/2024 at 12:23 PM, with Dietary Aide 1 (DA 1), the temperature of one cup of milk was 56 degrees F. DA 1 stated the temperature should be 56 degrees F. DA 1 stated if the milk was not in the normal temperature range, residents would get sick from drinking the milk. DA 1 stated DA 1 would…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide one to one activity to two of two sampled residents (Residents 33 and 34) for five consecutive days (May 20, 2024 to May 24, 2024) in accordance with the residents' plan of care. These deficient practices had the potential to result to boredom or loneliness which could affect the physical, emotional, and psychosocial well-being of Residents 33 and 34. Findings: a. During a review of Resident 33's admission Record (AR), the AR indicated the facility admitted the resident on 5/5/2023, with diagnoses that included hemiplegia (paralysis to one side of the body) and hemiparesis (weakness to one side of the body) following cerebral infarction (stroke) and dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning). During a review of Resident 33's untitled care plan initiated on 10/9/2023, the care plan indicated the resident needed 1:1 activity visit 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 observation, interview and record review, the facility failed to follow physician's order to administer oxygen continuously to two of two sampled residents (Residents 15 and 58). These failures had the potential to result in the resident not receiving enough oxygen leading to a decline of health condition for Residents 15 and 58. Findings: a. During a review of Resident 15's admission Record (AR), the AR indicated Resident 15 was readmitted to the facility on [DATE], with diagnoses that included dependence on supplemental oxygen, respiratory disorders (a type of disease that affects the lungs and other parts of the respiratory system) and chronic respiratory failure with hypoxia (low levels of oxygen in body tissues). During a review of Resident 15's Minimum Data Set (MDS, a resident assessment and care screening tool), dated 3/1/2024, the MDS indicated Resident 15 had clear speech, had the ability to understand and make self-understood. The MDS indicated Resident 15 had cognitive impairment (confusion…

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

Based on observation, interview, and record review, the facility failed to post accurate staffing information of actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift daily for two of two days inspected (5/21/2024 and 5/22/2024). The staffing information included the actual worked hours of the Minimum Data Set (MDS) nurse that was not directly responsible for resident care. The staffing information did not indicate the name of the facility. This failure had the potential to affect resident care from inadequate staffing. Findings: During an observation on 5/21/2024 at 9 a.m. and 5/22/2024 at 8 a.m., the facility's staffing information was posted on the consumer board. The staffing information indicated actual hours worked by the nursing staff on all shifts (7 am-3 pm, 3 pm-11 pm and 11 pm-7 am) and the MDS nurse. The facility's name was not indicated in the staffing information. During a concurrent interview and record review on 5/24/2024 at 2:05 p.m. with the Director of Staff Development (DSD), the DSD stated the staffing…

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 quaternary ammonium (chemical used as disinfectant) sanitizer solution used for cleaning the food preparation area and dishwasher chlorine had the required concentration for sanitizing for one of one facility kitchen. 1. The sanitizing solution the facility used was zero (0) parts per million (ppm, unit of measurement used to describe very small concentrations of a substance in a larger solution) and the recommended concentration for cleaning solution was 100 ppm. 2. The Low-Temperature Dishwashing Machine (wash and rinse cycles that run between 120- and 150-degrees Fahrenheit that require chemical sanitizers) chlorine level was 10 ppm and the recommended Low-Temperature Dishwashing Machine chlorine was 50-100 ppm. These failures had the potential to result in dishes and utensils not properly cleaned and food preparation areas were not sanitized that could result to food borne illnesses. Findings: During an inspection to the facility's kitchen on 5/21/2024 at 8:25 am, with the Registered Dietitian (RD),…

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 41's AR, the AR indicated the facility admitted the resident on 4/14/2020 and readmitted on [DATE] with diagnoses that included End Stage Renal Disease (ESRD - person's kidneys cease functioning on a permanent basis) and dependence on renal dialysis (treatment for kidney failure that removes toxins, waste products and excess fluids by filtering the blood). During a review of Resident 41's MDS dated [DATE], the MDS indicated the resident had intact cognition. The MDS indicated Resident 41 required maximal assistance (helper lifts or holds trunk or limbs and provides more than half the effort) for all activities of daily living except eating where the resident required set up. During a review of Resident 41's care plan for EBP initiated on 5/13/2024, the care plan indicated to utilize PPE (gown, gloves, face shield as indicated) during high-contact resident care activities (such as dressing, bathing/showering, transferring, hygiene, linen changes, brief changes, toileting assistance,…

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 notify the physician of a change in skin condition and follow its policies and procedures titled Skin Conditions for one of one sampled resident (Resident 18). This deficient practice had the potential for the facility to not implement the necessary management and worsen Resident 18's skin condition. Findings: During a review of Resident 18's admission Record (AR), the AR indicated the facility admitted the resident on 1/10/2020, with diagnoses that included hemiplegia (paralysis to one side of the body) and hemiparesis (weakness to one side of the bed) following cerebral infarction (stroke,) and aphasia (inability to express words or nonverbal equivalent of words.) During a review of Resident 18's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 5/18/2024, the MDS indicated the resident had moderately impaired cognition (ability to understand) and required maximal assistance (helper lifts or holds trunk or limbs and provides more than half the effort) with showers and toileting…

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 notification to Ombudsman (an individual who serves as an advocate for patients) of the facility-initiated discharge for one of three sampled residents (Resident 65). This failure had the potential to result in resident being inappropriately discharged . Findings: During a review of Resident 65's admission Record indicated Resident 65 was admitted on [DATE], with diagnoses that included metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood) and acute metabolic acidosis (a condition in which acids build up in the body). During a review of Resident 65's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 4/8/2024, the MDS indicated Resident 65 had moderately impaired cognition (ability to understand). The MDS indicated Resident 65 was dependent (helper does all of the effort, resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required…

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, that facility failed to turn and reposition one of one sampled resident (Resident 58) every two hours on 5/17/2024, 5/20/2024, and 5/22/2024. This failure had the potential for Resident 58 to sustain skin breakdown and possibly, develop a pressure injury (caused when an area of skin is placed under pressure and breaks down the skin and underlying tissue). Findings: During a review of Resident 58's AR, the AR indicated Resident 58 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia (unable to move or control affected muscles) and hemiparesis (one-sided weakness) after cerebral infarction (disrupted blood flow to the brain), aphasia (full or partial loss of language abilities), and atelectasis (collapse of part or all of a lung). During a review of Resident 58's untitled care plan (CP) dated 12/24/2021, the CP indicated Resident 58 was at risk for skin breakdown and for staff to assist in repositioning Resident 58 every 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 observation, interview, and record review, the facility failed to provide wound care treatment daily as ordered for one of one sampled resident (Resident 289). Wound care treatment was ordered for Resident 289 on 5/16/2024 and was started on 5/18/2024. This failure had the potential for Resident 289's left heel unstageable pressure ulcer (type of bed sore that occurs due to prolonged pressure on a specific area on the skin and is covered by eschar [dry, black, hard dead tissue]) to worsen. Findings: During a review of Resident 289's admission Record (AR), the AR indicated Resident 289 was admitted to the facility on [DATE] with diagnoses that included cellulitis (bacterial skin infection when the skin becomes swollen, warm, and painful to the touch), peripheral vascular disease (blood vessels become narrow, blocked, or spasm), and hypertension (high blood pressure). During a review of Resident 289's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 5/6/2024, the MDS…

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 appropriate care to prevent urinary tract infection ([UTI]an infection in any part of the urinary system [kidneys, bladder, ureters, and urethra]) for one of two sampled residents (Resident 1) on indwelling catheter (collects urine by attaching to a drainage bag) by failing to ensure staff monitor Resident 1's urine output and notify the physician promptly for signs and symptoms of UTI. This deficient practice placed Resident 1 at risk for infection from delayed treatment. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 7/2/2021 and readmitted on [DATE], with diagnoses that included dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) and obstructive uropathy (a blockage of the urine flow in the tube [ureter] that carries urine between the kidneys and the bladder). During a…

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

Based on observation, interview, and record review, the facility failed to reassess pain for one of one resident (Resident 40) after pain medication was administered. This deficient practice resulted in Resident 40 to continue to experience pain. Findings: During a review of Resident 40's admission Record (AR), the AR indicated the facility admitted the resident on 6/3/2021 with diagnoses that included age-related osteoporosis (a condition that weakens the bones and increases the risk for fractures) and muscle wasting and atrophy (the thinning of muscle mass due to disuse or nerve problems) During a review of Resident 40's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 3/19/2024, the MDS indicated the resident had moderately impaired cognition (ability to understand) and required maximal assistance with rolling left and right, sit to lying, lying to sitting, sit to stand and transfers. During a concurrent observation and interview on 5/22/2024 at 11:03 am, Resident 40 was sitting in a wheelchair beside her bed. Resident 40 through a phone interpreter…

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

Based on observation, interview and record review, the facility failed to attempt the use of appropriate alternatives to bed rails before its installation for one of one sampled resident (Resident 59). This deficient practice placed Resident 59 at risk for entrapment and injury from the use of bed rails. Findings: During a review of Resident 59's admission Record (AR), the AR indicated the facility admitted the resident on 12/24/2022 and readmitted Resident 59 on 2/29/2024, with diagnoses that included dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) and diabetes mellitus (a condition that happens when the blood sugar [glucose] is too high). During an observation and concurrent interview on 5/21/2024 at 9:50 a.m., Resident 59 was on left side lying position in a low bed with quarter length bed rails up on both sides. Resident 59 was alert and non-communicative. Resident 59 was able to move side to side in bed by herself without holding onto the bed rails. Certified Nursing Assistant 5 (CNA 5)…

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 five sampled residents (Resident 59) on psychotropic drugs (any drug that affects brain activities associated with mood, emotions, and behavior) was free from unnecessary medications by failing to ensure staff attempted a Gradual Dose Reduction ([GDR] the stepwise tapering of a dose to determine if symptoms, condition, or risks can be managed by a lower dose or if the dose or medication can be discontinued) of Resident 59 for the use of Quetiapine Fumarate ([antipsychotic drug] a drug use to treat symptoms of psychosis or disconnection from reality) 25 milligram ([mg] unit of measurement) since ordered on 2/29/2024. This deficient practice placed Resident 59 at risk for adverse drug reaction (a harmful and unintended response to a medicine). Findings: During a review of Resident 59's admission Record (AR), the AR indicated the facility admitted the resident on 12/24/2022 and readmitted Resident 59 on 2/29/2024, with…

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), was provided with a comfortable environment by failing to: Maintain hot water temperature of the water faucet in the restroom sink of Resident 1's room (Room A) in accordance with the facility's policies and procedures (P&P) titled, Residential Care Facilities for the Elderly and Accommodation of Needs. This deficient practice resulted in Resident 1 not having hot water to use in the restroom and had the potential for Resident 1 to feel uncomfortable during routine personal care. Findings: During a review of Resident 1's admission Record (AR), the AR indicated, the facility admitted Resident 1 to the facility on [DATE] with multiple diagnoses including traumatic hemorrhage of cerebrum (bleeding in the largest part of the brain), multiple fractures (a complete or partial break in a bone) of bilateral ribs, and pneumothorax (a collapsed lung). During a review of Resident 1's History and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a safe and orderly discharge from the facility for one of two sampled residents (Resident 2) by failing to: 1. Ensure the Social Services Director (SSD) and/or Quality Assurance Nurse (QAN) checked and confirmed a safe and appropriate discharge location for Resident 2, who had a documented history of homelessness (the state of having no home). 2. Ensure the SSD and/or QAN arranged home health agency (HHA, a public agency or private organization which is primarily engaged in providing skilled nursing services and other therapeutic services in the patient's home) and durable medical equipment (DME- equipment that can withstand repeated used for medical reasons) for a front wheel walker (FWW- device used for walking assistance that has wheel on the front legs to maneuver over difficult terrain) referrals as ordered by Resident 2's physician (MD 1) before Resident 2 was discharged from the facility. As a result of these failures, Resident 2 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a post-discharge (after discharge) plan of care in accordance with the facility's policy and procedure (P&P) titled, Discharge Summary and Plan, for one of two sampled residents (Resident 2). This deficient practice had the potential for Resident 2 not to receive the necessary information for provision of care after discharge to ensure a safe transition to Resident 2's new living environment. Cross Reference F624 Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 1/23/2023, with diagnoses of homelessness, anxiety disorder (persistent feeling of dread or panic that can interfere with daily life), and abnormalities of gait and mobility (weakness of the hip and lower extremities muscles causing unsteady balance and walking issues from an injury or underlying medical condition). During a review of Resident 2's Minimum Data Set (MDS, a standardized resident assessment and care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents ' room (Resident 1 ' s room) met the requirement of 80 square feet (sq. ft.) per resident in room [ROOM NUMBER]. room [ROOM NUMBER] was previously denied by Center for Medicare and Medicaid Services (CMS). The facility failed to comply after the request for the room waiver was denied by the CMS. This deficient practice had the potential to result in inadequate nursing care to the resident. Findings: A review of the CMS letter, dated 1/24/2018, indicated CMS denied the request for a waiver/variation of the room size requirement for Resident 1's room. The letter indicated the minimum square footage for a 4-bedroom was 320 sq. ft. This room was below the minimum requirement by 32 sq. ft. for a 4-bedroom room and could lead to possible inadequate spacing for nursing care needs to the residents in Resident 1's room. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 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.

Based on interview and record review, the facility failed to supervise medical care by a licensed physician according to the facility ' s policy and procedure (PP) titled, Physician Services, for one of six sampled residents (Resident 4) by failing to: 1. Ensure Medical Doctor (MD) 1 provided treatment to authorize Norco (Hydrocodone-acetaminophen, used to treat moderate pain) 5-325 milligram (mg, unit of measurement) to be delivered by the pharmacy per Resident 4 ' s Order Listing Report (OLR) when contacted by the facility staff. 2. Ensure the Medical Director (MDD) was reachable by phone to provide treatment for Resident 4's pain when MD 1 was not reachable by phone by facility staff. As a result of these failures, Resident 4 endured 12 hours of severe pain before being transported to General Acute Care Hospital (GACH) 1 for pain relief. Cross Reference: F697 Findings: 1. During a review of Resident 4 ' s admission Record (AR), the AR indicated Resident 4 was admitted to the 10/17/2023, with diagnoses that included unspecified low back pain (pain in lower portion of back), muscle…

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 communicate medical care problems to the medical staff in a timely, efficient, and effective manner according to the facility's policy and procedure (PP) titled, Guidelines for Notifying Physicians of Clinical Problems, by failing to for one of six sampled residents (Resident 4) by failing to: Ensure Medical Doctor (MD) 1 was notified when Resident 4 experienced lower back pain (pain in lower portion of the back) ranging from eight (8) to 10 out of 10 based on a numerical rating scale (NRS, requiring the resident to rate their pain on a defined scale, zero (0) to 10, 0 being no pain, one (1) to three (3) being mild pain, four (4) to six (6) being moderate pain, seven (7) to nine (9) being severe pain and 10 being the worst pain imaginable/very severe pain) on 10/18/2023, at 4 am. As a result of this failure, Resident 4 endured 12 hours of severe lower back pain (from 10/18/2023, at 4:25 am to 10/18/2034, at 4:09 pm) before Resident 4 was transferred to General Acute Care Hospital (GACH) 1 for pain relief and received…

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 and interview, the facility failed to treat two of three sampled residents (Resident 1 and 2) with kindness, respect, and dignity based on the facility ' s policy and procedure (PP) titled, Resident Rights, by failing to: 1. Ensure Resident 1 was given the choice to wear their own clothes instead of a hospital gown. 2. Ensure Resident 1 was given the choice to eat breakfast in the dining room instead of in bed. 3. Ensure Resident 2 was given the choice to wear their own clothes instead of a hospital gown. 4. Ensure Resident 2 was given the choice to eat breakfast in the dining room instead of in bed. These failures caused Resident 1 and Resident 2 to feel dehumanized (deprivation of human qualities). Findings: a. During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of chronic obstructive pulmonary disease (COPD- lung disease causing restricted airflow and breathing problems), muscle wasting…

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 and interview, the facility failed to provide a comfortable environment for two of three sampled residents (Residents 1 and 2) based on the facility's policy and procedure (PP) titled, Homelike Environment, by failing to provide pleasant or neutral odors. This failure caused Residents 1 and 2 to feel grossed out by the unpleasant odor and unsanitary. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of chronic obstructive pulmonary disease (COPD- lung disease causing restricted airflow and breathing problems), muscle wasting (thinning of muscle mass caused by disuse of the muscles or neurogenic conditions), and difficulty walking. During a review of Resident 2 admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses of muscle wasting and atrophy, hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle…

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 adequate supervision for one of three sampled residents (Resident 3) by failing to: 1. Ensure Resident 3's out on pass (resident temporarily away from the facility) was accurately ordered, documented, and endorsed to the oncoming shift (3 pm to 11 pm shift). 2. Notify Resident 3's Primary Physician when Resident 3 had not returned to the facility on [DATE]. 3. Report the unusual occurrence to the California Department of Public Health (CDPH) based on the facility's PP titled, Unusual Occurrence Reporting, Revised 12/2007. These failures resulted in Resident 3 leaving the facility with Responsible Party (RP) 1 on 10/19/2023 at an unknown time and did not return to the facility until 10/20/2023 at 8:10 am, unaccompanied by RP 1. Findings: a. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE], with diagnoses that included Type 2 diabetes mellitus (DM2- A condition 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 observation, interview, and record review, the facility failed to provide an effective communication method to one of two non-English speaking sampled residents (Resident 3). This failure had the potential to result in resident not receiving necessary care and services. Findings: During a review of Resident 3's admission Record indicated Resident 3 was admitted on [DATE], with diagnoses that included hemiplegia and hemiparesis affecting right dominant side (paralysis of partial or total body function on one side of the body and one-sided weakness without complete paralysis), dysphagia (difficulty swallowing) and hypertension (increased blood pressure). During a review of Resident 3 ' s Minimum Data Set (MDS, a resident assessment and care screening tool) dated 8/23/2023, indicated Resident 3 had clear speech, had the ability to understand others and make self-understood. Resident 3 required extensive assistance with one person physical assist for transfer, toilet use and personal hygiene. During a…

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

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards of food service safety, by failing to: a. Ensure the light bulb in Freezer 1 and Refrigerator 2 were in working condition. b. Ensure freezer burned (result of moisture loss from storage in the freezer which changes the quality of food) food in Freezer 1 were discarded. c. Ensure one packet of frozen chicken in Freezer 1 and one gallon of milk in Refrigerator 3 were labeled and dated. These deficient practices had the potential to result in foodborne illnesses ( illness caused by consuming contaminated food). Findings: a. During a concurrent observation of the kitchen on 2/22/22 at 8:32 am and interview with the Dietary Supervisor (DS), she verified Freezer 1 and Refrigerator 2 had missing light bulb. The DSD stated the refrigerator and freezer needed light bulbs. A review of the 2017 National Food and Drug Administration (FDA) Food Code 2017, 4-501.11 titled Good Repair and Proper Adjustment indicated equipment shall be maintained in a state of repair 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 the physician's certification for hospice benefit was current and updated for two of two sampled residents (Resident 27 and Resident 70) on hospice care ( medical service designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life). This deficient practice had the potential for the resident not to receive the needed care and services to attain physical, mental, and psychosocial well-being. Findings: a. A review the Resident 27's Record Of admission (face sheet) indicated the resident was admitted on [DATE] with diagnoses including diffuse traumatic brain injury (a sudden injury that causes damage to the brain) A review of Resident 27's Minimum Data Set (MDS), a resident assessment and care screening tool, dated 4/7/21, indicated the resident had severely impaired cognition ( ability to understand). The MDS indicated the resident required total assistance with one…

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 develop a tracking system to ensure the required training for the care and management of residents with dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) was provided to eight Certified Nursing Assistants (CNA) out of 40 CNAs currently working in the facility (CNAs 2, 3, 4, 5, 6, 7, 8 and 9). This deficient practice had the potential risk for compromising resident care and resident's physical, mental and psychosocial well being. Findings: A review of the facility's training record indicated the Director of Staff Development (DSD), conducted an in-service to CNAs on providing quality care to dementia residents on 10/28/21. During an interview and concurrent record review on 2/25/2022 at 1:58 pm, the DSD stated she provided dementia in-services a couple of times during the year. When asked if all CNAs were included in the dementia training, DSD stated she was unsure . A record review of the in-service sign in sheet with DSD against CNAs…

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

Based on interview and record review, the facility failed to complete and transmit the Discharge Assessment within 14 calendar days of the resident's discharge, for one of one sampled resident (Resident 1). This deficient practice had the potential to negatively affect the provision of necessary care and services for Resident 1. Findings: A review of Resident 1's admission Record, indicated the resident was admitted to the facility 8/20/21 and was discharged on 9/3/21. Resident 1's diagnoses included liver cancer that has spread to the lungs. A review of Resident 1's clinical record indicated the Discharge Assessment was not completed and transmitted within 14 calendar days of the resident's discharge and was 160 days overdue. During an interview with the facility's MDS Director (MDSD) on 2/24/22 at 11:00 am, she stated the Discharge Assessment for Resident 1 was missed and was not submitted timely. The MDSD stated she should have completed the Discharge Assessment when the resident was discharged and transmitted it within 14 calendar days of the resident's discharge. 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 obtain a Preadmission Screening and Resident Review (PASRR) Level II evaluation for one of one sampled resident (Resident 51). The deficient practice had the potential for Resident 51 to not receive necessary care services related to mental disorder. Findings: A review of the admission record indicated Resident 51 was admitted to the facility on [DATE] with diagnoses including schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves) and major depressive disorder (persistent feeling of sadness and loss of interest). A review of Resident 51's Minimum Data Set (MDS, a comprehensive assessment and screening tool) dated 1/20/22, indicated Resident 51 had severe impairment of cognitive ( ability to understand) skills for daily decision making. The MDS indicated Resident 51 received antidepressant medications. During an observation on 2/22/22 at 9:20 a.m. Resident 51 was lying in bed sleeping.…

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 interventions indicated in the resident's care plan after an unwitnessed fall, for one of three sampled residents (Resident 73). This deficient practice had the potential to place the resident at risk for further falls and injury. Findings: A review of Resident 73's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including muscle wasting and atrophy (decrease in size of a body part or tissue) and abnormalities with gait (a manner of walking) and mobility (ability to move) and aphasia (an inability to comprehend or formulate language) following a cerebral infarction (stroke). A review of Resident 73's Fall Risk Assessment completed on admission on [DATE], indicated the resident was high risk for falls. A review of Resident 73's Change in Condition Evaluation dated 2/15/22 indicated the resident had an unwitnessed fall on 2/15/22. Resident 73 was found on the floor on 2/15/22 at approximately 12:20…

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 services to promote healing of pressure ulcer/injury (refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) for one of five sampled residents (Resident 29) by failing to: 1. Implement the facility's turning and repositioning schedule every two hours for Resident 29. 2. Revise Resident 29's plan of care to avoid positioning the resident on the pressure ulcer/injury to prevent worsening of the pressure ulcer/injury. 3. Apply proper settings to Resident 29's pressure reducing device low air loss mattress ([LAL] a mattress that provides a flow of air to assist in managing the heat and humidity of the skin). 4. Avoid the use of plastic backed diaper that will block the airflow and may potentially trap heat and moisture against Resident 29's skin. These deficient practices had the potential for delayed healing in Resident 29's Stage 3 Pressure Ulcer…

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 20) was free from accident hazards. Resident 20 had cigarettes in her possession. This deficient practice had the potential for hazard and injury related to smoking. Findings: A review of Resident 20's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including generalized anxiety disorder (persistent and excessive worry about different things), asthma (long term lung disease), and chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe) . A review of Resident 20's Minimum Data Set (MDS) dated [DATE], indicated the resident had severely impaired cognition ( ability to understand). A review of Resident 20's Smoking Observation/assessment dated [DATE], indicated the resident may smoke with supervision and was informed that all smoking materials were kept at the nursing station. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility licensed nurses failed to accurately assess and monitor signs and symptoms of urinary tract infection (UTI - an infection in any part of the urinary system, the kidneys, bladder or urethra) for one of two sampled residents (Resident 51). This deficient practice had the potential for delayed identification and treatment and possible reoccurrence of urinary infection. Findings: A review of the admission Record indicated Resident 51 was admitted to the facility on [DATE] with diagnoses including acute kidney failure (rapid [less than two days] loss of the kidneys' ability to remove waste and help balance fluids and electrolytes in the body), history of urinary tract infection, chronic kidney disease (gradual loss of kidney function), calculus (waste materials from urine in the kidneys forms a solid, hard stone) of kidney, and obstructive and reflux uropathy (condition in which the flow of urine is blocked and causes the urine to back up and injure one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 279) received oxygen administration as ordered by the physician. This failure of not receiving proper oxygen therapy had the potential to result in complications due to excessive oxygen intake. Findings: A review of Resident 279's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses of acute respiratory failure (a condition when the lungs cannot get enough oxygen into the blood) with hypoxia (body or a region of the body is deprived of adequate oxygen supply) and chronic obstructive pulmonary disease (COPD -type of obstructive lung disease characterized by long-term poor airflow) with acute exacerbation (sudden worsening of COPD). A review of Resident 279's Physician's Order dated 2/22/22 indicated to give the resident oxygen at two liters per minute via nasal cannula (tube which on one end splits into two prongs which are placed in the nostrils 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 attending physician document in the resident's medical record that an identified drug regimen irregularity as recommended by the pharmacist has been reviewed and what, if any, action has been taken to address the irregularity, for two of five sampled residents (Residents 7 and 70). This deficient practice had the potential to result in adverse medication outcome for potential unnecessary medications to Residents 7 and 70. Findings: a. A review of Resident 7's Record Of admission (face sheet) indicated the resident was admitted on [DATE] and re-admitted on [DATE], with diagnoses including adult failure to thrive (condition characterized by poor appetite, loss of weight, increased fatigue and a progressive functional decline). A review of Resident 7's Minimum Data Set (MDS), a resident assessment and care screening tool, dated 12/2/21, indicated the resident had moderately impaired cognition ( ability to understand). The MDS indicated 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 follow its policy and procedure for the use of psychotropic medications (medicines that alter chemical levels in the brain which impact mood and behavior) for one of one sampled residents (Resident 70). For Resident 70, the duration of the PRN (as needed) use of Lorazepam (Ativan-medication to treat anxiety) was not indicated in the physician's order. This failure had the potential to result in unnecessary use of psychotropic medications. Findings: A review of Resident 70's Record Of admission (face sheet) indicated the resident was admitted on [DATE] with diagnoses including adult failure to thrive (condition characterized by poor appetite, loss of weight, increased fatigue and a progressive functional decline). A review of Resident 70's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 2/3/22 indicated the resident had moderately impaired cognitive skills ( ability to understand). The MDS indicated the resident required…

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 ensure two of 32 randomly selected resident's room (rooms [ROOM NUMBERS]) were not in disrepair and poor condition. a. The bathroom faucet in room [ROOM NUMBER] was dripping. b. The bathroom door in room [ROOM NUMBER] had a hole and the bottom of the door frame had cracks. These deficient practices had the potential for accidents and injury for the residents who use the bathroom daily. Findings: During an observation on 2/22/22 at 10:32 am, room [ROOM NUMBER]'s bathroom hand washing faucet was dripping even it if was completely closed. During an observation on 2/22/22 at 11:17 am, room [ROOM NUMBER]'s bathroom door had a hole which measured a size of a closed fist and the bottom of the door's frame had cracks. During an observation on 2/22/22, at 11:24 am, with Licensed Vocational Nurse 1 (LVN 1), he confirmed room [ROOM NUMBER]'s bathroom door had a hole measuring a size of a closed fist and the bottom of the door frame was cracked. 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.