Foundation Skilled Nursing

Based on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program to provide a safe and sanitary environment for two of four sampled residents (Residents 33 and 64) when:1.Certified Nursing Assistant (CNA) 5 did not wear appropriate personal protective equipment (PPE- specialized clothing, equipment, and supplies worn by healthcare workers protect residents and themselves from potential infectious hazards) when CNA 5 provided direct care to Resident 33 who was on enhanced barrier precaution (EBP- measures used in healthcare settings to prevent the spread of infections) for a known history of Extended Spectrum Beta-Lactamase (ESBL- are a group of bacteria that commonly cause infections both in healthcare settings and communities) producing bacterial infection/colonization on 12/3/25.2.Housekeeping Staff (HS) 1 used one pair of the same gloves when Resident 64 and Resident 64's roommate's blankets were touched and covered to respective residents on 12/2/25.These failure had the potential for CNA 5 and HS 1 to…

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

Based on observation, interview, and record review, the facility failed to maintain a resident care equipment in safe operating condition when the facility's mechanical lift (a mechanical device used by caregivers to safely lift and transfer individuals with limited mobility from one surface to another (bed, chair, toilet) using a sling, minimizing physical strain and preventing injury) was not functional to deliver residents' care and activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).This failure resulted in a delay in implementing residents' care including residents' transfers and obtaining weights as ordered and placed residents and staff at an increased risk of accidents.Findings:During an observation on 12/2/25 at 8:39 a.m. with Resident 5, in Resident 5's room, Resident 5 was lying asleep in bed. During an observation on 12/2/25 at 12:39 p.m. with Resident 5, in Resident 5's room, Resident 5 was lying asleep in bed, with food tray at bedside table.During a concurrent observation…

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 an effective pest control program when flies were flying around resident's room (room [ROOM NUMBER]) on 12/2/265 and 12/3/25 and transferring from one table to another in resident's dining room during lunch on 12/3/25.This failure had the potential for cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effects) and for residents to acquire food borne illnesses (are caused by eating or drinking something that is contaminated with germs).During an observation on 12/2/25 at 8:39 a.m. in room [ROOM NUMBER], multiple flies (three) were going around the round, landing on residents' clothing and privacy curtain.During concurrent observation and interview on 12/2/25 at 9:11 a.m. with Licensed Vocational Nurse (LVN) 3, in room [ROOM NUMBER], LVN 3 validated flies were flying around inside room [ROOM NUMBER]. LVN 3 stated she 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.

Based on observation, interview, and record review, the facility failed to provide and maintain a safe, clean, and sanitary environment for one of four sampled residents (Resident 2), when Resident 2's mattress on the floor beside his bed was dirty with brownish dirt built up on the top of the mattress and observed nursing staff walking on the floor mattress.This failure had the potential for Resident 2 acquiring an infection (the invasion and growth of germs in the body).Findings:During an observation and interview on 12/3/25 at 11:40 a.m. with LVN 1, in Resident 2's room, LVN 1 stepped on Resident 2's mattress on the floor beside Resident 2's bed. Resident 2's mattress on the floor was dirty with brownish dirt built up on the top of the mattress. LVN 1 stated, Resident 2's mattress on the floor was dirty and should be cleaned by the housekeeper and covered with a bed sheet. LVN 1 stated Resident 2 had episodes of purposedly rolling over from bed to the mattress on the floor. LVN 1 stated Resident 2's floor mattress should remain clean to prevent infection. 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 ensure one of five sampled residents (Resident 13) was free from unnecessary psychotropic (drugs that affect brain activities associated with mental processes and behavior) medications when the facility did not attempt or implement behavior monitoring for Resident 13's use of olanzapine (medication used to treat schizophrenia [a mental illness that is characterized by disturbances in thoughts]). This failure placed Resident 13 at risk for experiencing adverse effects from receiving medication without behavior monitoring. During a concurrent observation and interview on 12/2/25 at 2:40 p.m. in Resident 13's room, Resident 13 was ambulating inside the room with steady gait and appropriately dressed. Resident 13 stated he was in the acute care hospital for a week prior to admission in the facility. Resident 13 stated he was in the facility to work with therapy to get stronger and will eventually go home. Resident 13 stated he did not know…

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 their policy on discharge was followed for one of three sampled Residents (Resident 61) when Resident 61 was discharged against medical advice (AMA-patient chooses to leave before the doctor recommends discharge) when Resident 61 was discharged AMA on 9/14/25 and there was no documentation the medical doctor and administrator were notified.This failure had the potential to put Resident 61 at risk for complications like worsening of condition. Findings: During a review of Resident 61's admission Record (AR- a document containing resident profile information) dated 12/9/25, the AR indicated Resident 61 was admitted to the facility on [DATE] with diagnoses which included Spinal Stenosis (narrowing of spinal canal squeezing the nerves and causing pain, numbness, tingling, or weakness), muscle weakness and abnormalities of gait and mobility. During a concurrent interview and record review on 12/9/25 at 8:30a.m. with Minimum Data Set Nurse (MDSN) 2,…

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 Minimum Data Set Assessment (MDS-assessment of physical and psychological functions and needs) accurately reflected resident's health and functional status for one of four sampled residents (Resident 11) when Resident 11's use of Divalproex (medication used for mood stabilization) was inaccurately coded in the MDS assessment. This failure had the potential to result in Resident 11's care needs not met and the potential for adverse reaction to not be monitored.During a concurrent observation and interview on 12/2/25 at 12:15 p.m. during an initial tour in Resident 11's room, Resident 11 was lying in bed covered with blanket and lunch tray was on top of over the bed table. Resident 11 stated he already ate and refused to answer questions stated, Goodbye. During a review of Resident 11's admission Record [AR- a document with personal identification and medical information], dated 12/5/25, the AR indicated Resident 11 was admitted 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 complete a level 1 Preadmission Screening and Resident Review (PASARR), (a Federal requirement to ensure residents with mental disorder or intellectual disorder or intellectual disabilities are not inappropriately placed in a nursing home) screening notifying the state mental health authority or state intellectual disability authority promptly after a significant change for three of five sampled residents (Residents' 1, 3 and 6). This failure had the potential for Residents' 1, 3, and 6 to not receive the appropriate services related to their mental disorders.During a review of Resident 1's admission Record (AR-a document containing resident profile information), dated 12/5/25, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), psychoactive substance abuse (use of mind-altering drugs in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a comprehensive, person-centered care plan (a plan that provides direction for individualized care of the resident) was developed and implemented to meet the identified needs for one of three sampled residents (Resident 13) when:Resident 13 did not have a care plan for olanzapine (psychotropic medication used to treat schizophrenia and bipolar disorder).This failure placed Resident 13 at risk for harm by not identifying and monitoring harmful side effects of medication. During a review of Resident 13's admission Record [AR- document containing resident profile information], dated 12/5/25, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), psychoactive substance abuse (use of mind-altering drugs that cause harm, health problems, or social issues leading to dependence or addiction) and traumatic brain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to ensure nail care was provided for two of seven sampled residents (Residents 51 and 4) when:Resident 51's fingernails were long and dirty with brownish to blackish dirt built up underneath the nails.Resident 4's fingernails were long.This failure had the potential for Resident 51 and 4 in sustaining an avoidable skin related injuries (including cuts (laceration), scrapes (abrasion), scratches, etc.) and infection (the invasion and growth of germs in the body).Findings:1.During an observation on 12/2/25 at 11:59 a.m. with Resident 51, in the resident's dining room, Resident 51 was holding the bread with her left hand. Resident 51 had long and dirty fingernails on both hands with brownish to blackish dirt underneath the fingernails. During a concurrent observation and interview on 12/2/25 at 12:20 p.m. with Resident 51, in the resident's dining room, Resident 51 was cutting the bread into small pieces using her left hand and put the bread…

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 assist the resident in gaining access to vision services for one of seven sampled residents (Resident 33) when Resident 33's eye specialist referral dated 5/30/25 was not implemented.This failure resulted in Resident 33 experiencing worsening eyesight on her left eye and placed Resident 33 at an increased risk of being blind (having severe visual impairment or permanent sight loss).Findings:During a concurrent observation and interview on 12/3/25 at 8:57 a.m. with Resident 33, in Resident 33's room, Resident 33 was awake lying in bed, in upright position. Resident 33's room was dark with privacy curtain covering her entire bed and window curtains completely close. Resident 33 was alert oriented x 4 (refers to someone who is alert and oriented to person, place, time and event). Resident 33 stated she's been at the facility for over a year and had concern about her vision in her left eye. Resident 33 stated she had a left eye cataract (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 appropriate services, equipment, and assistance to maintain or improve mobility for one of seven sampled residents (Resident 4), when Resident 4's Restorative Nursing Programs (is a formal, planned and organized program of care which is intended to restore a lost ability or maintain the highest level of function of the residents) were not implemented after therapy services dated 10/23/25 and 11/12/25, and Resident 4's left hand splint (is a device designed to prevent contractures [a permanent tightening and shortening of muscles, tendons, ligaments, or skin, which restricts movement and causes stiffness or deformity in a joint, preventing normal motion] by gently stretching and maintaining the position of affected joints, such as the hand, wrist, or foot) and left leg boot (a device that provide support, stability, and protection to the lower leg, ankle, and foot) were not applied based on Resident 4's needs and assessment. This…

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, interviews, and record review, the facility failed to ensure dental services were provided for one of seven sampled residents (Resident 4) when Resident 4 was not seen and evaluated by a dentist (a doctor who specializes in teeth, gums, and mouth) as necessary to manage Resident 4's oral health.This failure had resulted in Resident 4 experiencing toothache (pain in or around the tooth) and had the potential to put Resident 4 at an increased risk of dental problems including tooth infection (happens when bacteria invade the tooth's inner pulp, causing pus buildup, severe pain (throbbing, sharp), swelling, fever, and sensitivity), tooth cavities, and gums disease. Findings:During a concurrent observation and interview on 12/2/25 at 11:14 a.m. with Resident 4, in Resident 4's room, Resident was lying in bed with a fixed pole on right side of bed. Resident 17 was awake, alert oriented x 4 (refers to someone who is alert and oriented to person, place, time and event). Resident 4 complained 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 ensure residents received adequate supervision to prevent falls for one of five sampled residents (Resident 3) when Resident 3 who was assessed as being a fall risk, had poor safety awareness and needed to be supervised while ambulating (walking) and the facility did not implement effective interventions to prevent falls, including adequate supervision, consistent with the resident ' s needs, goals and care. This failure resulted in Resident 3 ' s three unwitnessed falls within two weeks, one on 5/9/25, 5/19/25 and 5/22/25 and placed Resident 3 at risk for significant injury. Findings: During a review of Resident 3 ' s admission Record, undated, the admission record indicated, Resident 3 was admitted to the facility on [DATE] with diagnoses which included disorder of bone density (Osteoporosis-weak and brittle bones due to lack of calcium and Vitamin D), type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to treat one of two sampled residents (Resident 1) with respect and dignity when the skilled nursing facility (SNF) failed to ensure Resident 1 had adequate transportation from a doctor ' s appointment back to the SNF on 11/22/24. This failure resulted in Resident 1 staying in the doctor ' s office for several hours after the end of his appointment without an adequate meal for lunch and left him feeling hungry, forgotten, sad, and anxious. Findings: During a review of Resident 1 ' s admission Record (AR), undated, the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses of cellulitis (bacterial infection that affects the deeper layers of the skin) of right lower limb (leg), muscle weakness, and abnormalities of gait (pattern of walking) and mobility (ability to move joints). During a review of Residents 1 ' s Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan for one of three sampled residents (Resident 1) when staff did not implement Resident 1 ' s fall risk care plan to have Resident 1 thoroughly placed on the facility ' s Red Sneaker Program (RSP- the facility ' s fall prevention program which was characterized by a visual symbol of red sneakers placed by the resident ' s name placard outside the resident ' s room door, a symbol of red sneakers above the head of resident ' s bed and a red bracelet the resident wears). This failure placed Resident 1 at risk to experience another fall and had the potential to result in fall related injuries. Findings: During an interview on 11/20/24 at 9:35 a.m. with Director of Nursing (DON), DON stated, Resident 1 was admitted on [DATE] and had a fall in the facility on 11/17/24. DON stated, one of the interventions completed after Resident 1 ' s fall was the fall risk care plan was updated. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was assessed as being a fall risk, with a history of falls in the facility, and a known behavior of placing herself on the floor when tired, received adequate supervision and assistance to prevent falls when Resident 1 ambulated (walked) to an area of the facility unattended and was found on the floor by staff. This failure resulted in Resident 1's unwitnessed fall to the floor sustaining a skin tear (traumatic wound caused by direct contact of the skin to another object) to the back side of her right elbow on 9/25/24. Findings: During a review of the facility ' s document titled Fall Incident Tracking/Trend Log, dated 7/2024-9/2024, the fall log indicated Resident 1 had unwitnessed falls on 7/17/24, 8/4/24, 9/4/24 and 9/25/24. Resident 1 ' s SBAR Post Fall (SBAR-situation, background, assessment, recommendation, a communication tool used by healthcare workers when there is a change…

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 safe, comfortable, and homelike environment for three out of 12 sampled residents (Residents 22, 29, and 42) when the dining room temperature was below the temperature range of 71 to 81 degrees Fahrenheit (F). This failure placed Residents 22, 29, and 42 at risk to develop symptoms of cold exposure and cold related illnesses. Findings: During a concurrent observation and interview on 8/19/24 at 12:10 p.m. with resident 22 in the hallway, Resident 22 was observed walking toward the dining room. Resident 22 stated she needed a coat. Resident 22 stated it was always cold in the dining room. During a review of Resident 22's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 8/23/24, the AR indicated Resident 22 was admitted on [DATE] with diagnoses of…

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

Based on observation, interview, and record review, the facility failed to develop and implement comprehensive person-centered care plans (CP - a detailed approach to care customized to an individual resident's needs) for three of 24 sampled residents (Residents 8, 13, 16 ) when: 1. Resident 13's care plan was not developed to reflect interventions to address his refusal of medications. This failure had the potential for Resident 13's medical needs to not be met. 2. Resident 8's care plan was not implemented for skin assessments to monitor for skin tears, bruising or wounds. This failure placed Resident 8 at risk for skin injuries. 3. Resident 16's care plan was not implemented for placement of Resident 16's call light within reach of Resident 16. This failure had the potential for Resident 16's needs to not be met and put Resident 16 at risk for injury Findings: 1. During a review of Resident 13's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 8/21/24, the AR indicated, Resident…

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

Based on interview and record review, the facility failed to provide services which met professional standards of practice for 7 of 24 sampled residents (Residents 13, 40, 42, 100, 101, 102, and 151) when: 1. Registered Nurse (RN) 1 and Licensed Vocational Nurse (LVN) 1 failed to explain the medication names and indications to Residents 40, 100, 101, 102, and 151 during medication administration. This failure had the potential to place Residents 40, 100, 101, 102, and 151 at risk of receiving the wrong medication and experience unnecessary side effects. 2. The facility failed to notify the Attending Physician of Resident 13's ongoing refusal of Fluticasone-Salmeterol (medication to prevent inflammation and narrowing of airway) inhaler. This failure had the potential to place Resident 13 to not receive appropriate care and not to be able to attain the highest well-being. 3. The facility failed to take a current Oxygen Saturation (O2 sat - the amount of oxygen circulating in the blood) and respiration (breathing) assessments on Resident 42 prior to transporting Resident 42 to the…

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

Based on observation, interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic medications (medications which affect the mind, emotions, and behavior) for one of seven residents (Resident 39) when Resident 39 was given divalproex (an anticonvulsant medication used to treat seizures [a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations or states of awareness]) without a specific condition diagnosed and documented in Resident 39's clinical record. This failure had the potential for Resident 39 to receive unnecessary psychotropic medications and placed Resident 39 at an increased risk for developing adverse (harmful) side effects due to taking divalproex. Findings: During a concurrent observation and interview on 8/19/24 at 9:35 a.m. with Certified Nursing Assistant (CNA) 6 in Resident 39's room, Resident 39 was observed sleeping in her bed with the head of her bed elevated. Bruising was observed on Resident 39's forehead, bridge of…

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

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety when the high temperature dishwasher did not reach the required temperature during the wash cycle of 155 degrees Fahrenheit (F). This failure had the potential to place 52 out of 55 highly susceptible residents who received food from the kitchen at risk for foodborne illness (illness caused by ingestion of contaminated food or beverages) due to cross-contamination (the transfer of harmful substances or disease-causing microorganisms). Findings: During a concurrent observation and interview on 8/19/24 at 8:22 a.m. with Dietary Aide (DA) 1 in the kitchen, DA 1 was observed washing dishes in a high temperature dishwasher. The temperature reading during the wash cycle read below 150 degrees F. DA 1 stated the temperature during the washing cycle read 145 degrees F. DA 1 stated the temperature during the wash cycle should have read above 135 degrees F. During an interview on 8/19/24 at 8:34 a.m. with DA…

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

Based on observation, interview and record review, the facility failed to maintain an effective pest control program to prevent the presence of pests when flies were observed in the kitchen area on 8/20/24 and 8/21/24. This failure had the potential to lead to foodborne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) for residents who ate food from the kitchen. Findings: During an observation on 8/20/24 11:02 a.m. in the kitchen, a fly was observed flying around the food serving area. During a concurrent observation and interview on 8/21/24 at 10:25 a.m. with the Certified Dietary Manager (CDM) in the kitchen, two flies were observed flying in the kitchen by the food serving area and dishwasher area. The CDM stated there was a fly fan (Air Curtain - a mechanical device which produces a controlled plane of moving air across the opening to prevent the entrance of flying insects and other airborne contaminants) at the back entrance of the kitchen. The CDM stated the kitchen did not have a fly light trap to attract and get rid of flies. The CDM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for one of three sampled residents (Resident 1) when Resident 1 was assessed to be at high risk for falls requiring one-on-one observation for safety and Certified Nursing Assistant (CNA) 2 left the resident unattended and out of sight while she assisted another resident. This failure resulted Resident 1 falling and sustaining lacerations (skin and underlying tissues are cut or torn) and contusions (bruise caused by a direct blow to the body) to his head requiring the resident's transfer to the emergency department (ED) for treatment. Findings: During an interview on 5/30/24 at 9:03 a.m. with the Administrator (ADM), the ADM stated Resident 1 fell in the early morning hours on 5/30/24. The ADM stated Resident 1 had a change in condition prior to the fall and a CNA was assigned to provide one-on-one supervision. The ADM stated the CNA had left Resident 1 briefly to help a CNA 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.

Based on interview and record review, the facility failed to follow the policy and procedure titled In-service Training to ensure Licensed Nurses (LNs) and Certified Nursing Assistants (CNAs) received and demonstrated competency in skills and techniques necessary to care for residents with Dementia [a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning] care needs when: 1. 44 of 99 LNs and CNAs had not attended and completed the annual mandatory in-service training for Dementia Module 2 titled Accepting the Challenge. 2. 99 of 99 LNs and CNAs had not attended and completed the annual mandatory in-service training for Safety and Accident Prevention. 3. 29 of 45 CNAs had not attended and completed the annual mandatory in-service training for Elopement Prevention and Action. These failures had the potential to place residents at risk for care not provided in a safe and competent manner. Findings: During a concurrent interview and record review on 2/23/24, at 10:50 a.m., 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 interview and record review, the facility failed to report a resident abuse according to the facility ' s Policy and Procedure (P&P) titled, Abuse Investigation and Reporting, for one of four sampled residents (Resident 1), when Resident 1 was hit with a cat stuffed toy [a life size mechanical cat made of soft and hard plastic materials, four pounds in weight] by Resident 2 on 10/26/23 resulting in multiple facial bruises and swelling. This abuse incident was not reported to the California Department of Public Health (CDPH, a government agency for the State of California in charge of protecting the public's health and helping shape positive health outcomes for individuals, families and communities). This resulted in a delay into the investigation of the alleged resident to resident physical abuse, a delay in implementing effective interventions to prevent future abuse altercations and injuries and placed Resident 1 at risk for continued abuse. Findings: During a review of Resident 1's admission Record…

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

Based on interview and record review, the facility failed to ensure one of two food service staff, Evening [NAME] (EC) had appropriate competencies to safely and effectively carry out the functions of food service when EC was unable to verbalize the cool down process after cooking and/or reheating food. This failure had the potential for residents to consume food that was not safely prepared which could result in residents getting a foodborne illness and further compromise the nutritional and medical status of residents. Findings: During an interview on 7/12/22, at 1:45 p.m. with the EC, the EC was asked to state the cooling process for cooked and/or reheated foods. The EC stated, To warm it enough for the resident's preference. The EC was asked to find the reference material that could be used to verify the cooling process and required temperatures. The EC was unable to locate the reference material. The EC stated it was important to know the steps of the cool down process to prevent food-borne illness and she should have been aware of the process, and she did not. 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 ensure menus were followed when Lead [NAME] (LC) did not follow the menu during the preparation of the fresh green salad on 7/12/2022. This failure had the potential for residents to receive inadequate nutrients in their meals. Findings: During a review of the facility document, Summer Menus (Menu), dated 7/12/22, the menu indicated, . For lunch . Oregano Chicken, Polenta, Baked fresh Zucchini, Fresh [NAME] Salad, Frosted Cake. During a concurrent observation, interview, and record review with LC on 7/12/22, at 10:36 AM, LC stated she prepared the green salad for the lunch meal and after preparing the salad, it will be pureed to different textures. LC reviewed the facility document titled, Recipe: Fresh [NAME] Salad (undated). The recipe for Fresh [NAME] Salad listed the following ingredients: Romaine, spinach or mixed greens, canned garbanzo beans drained, or ay use any other can bean, or mixture, fresh cucumber diced, carrots shredded, and dressing of choice. LC finished preparing the salad and started to…

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

Based on interview and record review, the facility's Pharmacy Consultant (PC) failed to identify and report medication irregularities for four of four sampled residents (Resident 25, Resident 38, Resident 47, and Resident 150) when: 1. Resident 38 was administered Risperidone (medication used to treat certain mental disorders, such as schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves) and bipolar disorder (a mood disorder that can cause intense mood swings), Resident 47 was administered Aripiprazole (medication used to treat schizophrenia, bipolar disorder and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest)), and Resident 150 was administered Quetiapine (medication used to treat mental health disorders, including schizophrenia, bipolar disorder, and depression) and there was no monitoring to include twice a year eye exam, labs, and side effects of medications administered to residents. 2. Resident 25 was administered Lipitor (medication used to help lower bad cholesterol- a type of…

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

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food safety when: 1. A white plastic fork, spoon and eight clear plastic lids were stored on the floor under one of two pantry shelves. 2a. Two of Two pantries did not have a room thermostat or thermometer to monitor room temperature of the pantries. 2b. Two of Two pantries did not have a temperature log to document daily temperatures in the pantries. These failures placed residents at risk for food borne illness. Findings: During a concurrent interview and record review, on 7/12/22, at 8:31 a.m., with the Dietary Manager, (DM) 1, in Pantry 1, a white plastic fork, a white plastic spoon, eight clear plastic lids were stored on the floor under the pantry shelves. The DM 1 stated staff should keep the pantry clean, free of clutter and trash all the time. The DM 1 stated it was her responsibility to monitor to ensure tasks delegated to staff were completed. During a concurrent interview and record review, on 7/12/22 at 9:10 a.m. 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.

Based on observation, interview, and record review, the facility failed to ensure medical records were complete and accurately documented in accordance with accepted professional standards of practice for eight of 32 sampled residents (Residents' 3, 8, 9, 11, 12, 30, 38 and 48) when Residents' 3, 8, 9, 11, 12, 30, 38 and 48 daily activities participation was not documented in their electronic medical record (EMR). These failures placed Residents' 3, 8, 9, 11, 12, 30, 38 and 48's activities interests at risk to not be met and had the potential to negatively affect their physical, mental, and psychosocial well-being. Findings: During a concurrent observation, interview, and record review on 7/13/22, at 10:16 a.m., with the Rehabilitative Nurse Assistant (RNA) in the Television room, several residents were observed in the room actively participating with RNA and were playing games. The RNA stated he started doing activities with residents when the activity director went on leave. The RNA stated he did not remember documenting daily activities because they had a binder they need 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 develop and implement a comprehensive person centered care plan for one of six sampled residents (Resident 8) when Resident 8 did not have an individualized activities care plan to identify her activity preferences. This failure had the potential to result in Resident 8's activities needs and preferences to go unmet and placed Resident 8 at risk of inappropriate activities resulting in possible decreased psychosocial well being. Findings: During a concurrent observation, and interview on 7/11/22, at 10:30 a.m., with Resident 8 in Resident 8's room, Resident 8 sat in her bed awake and was reading a book. Resident 8 stated she was in the facility for physical therapy. Resident 8 stated she preferred to stay in her room and do her own activity. During a review of Resident 8's clinical record titled, admission Record (AR) (document containing resident personal information) dated 7/13/22, the AR indicated Resident 8 was admitted to the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 25) was free from unnecessary medication when: 1. Atorvastatin (medication used to lower cholesterol (a type of fat) in the blood) was administered for an excessive duration without adequate indication for use from 10/8/18 to daily for the diagnosis of hyperlipidemia and labs were not monitored to determine efficacy of the medication. 2. Ferrous Sulfate (form of the mineral iron that is used to treat anemia (low number of red blood cells)) was administered for an excessive duration without adequate indication for use from 6/24/14 to daily for the diagnosis of anemia and labs were not monitored to determine efficacy of the medication. These failures resulted in Resident 25 receiving multiple doses of medications that had the potential to cause symptoms of fatigue, weakness, irregular heartbeat, chest pain, joint pain, diarrhea, stomach pain, difficulty sleeping, and muscle pain and spasms. Findings: 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 observation, interview, and record review, the facility failed to ensure medications were stored and labeled in accordance with acceptable professional standards of practice when Resident 30's inhaler (a device used to give medications in the form of a spray that is breathed in through the mouth) was administered and did not have a resident identifier, an open date or expiration date on the medication. This failure had the potential for the medication to be given to the incorrect resident which could cause adverse reactions (harmful, unintended result caused by a medication) and decreased medication potency and could compromise the therapeutic effectiveness of Resident 30's inhaler. Findings: During a review of Resident 30's admission Record (AR-a one page summary of important information about a resident), dated July 2022, the AR indicated, Resident 30 was admitted to the facility on [DATE] with diagnoses which included unspecified dementia (loss of memory, language, problem-solving and other thinking…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement and maintain an effective infection control and prevention program when a dirty linen was found on the floor. This failure had the potential to result in cross contamination and infection. Findings: During an observation on 7/12/22, at 9:15 a.m., in room [ROOM NUMBER], a dirty linen was found on the floor next to bed A. room [ROOM NUMBER]'s door was open, the privacy curtain was drawn around bed A and CNA 1 and CNA 5 were observed standing on each side of 7A's bed. The Minimum Data Set Coordinator (MDSC) walked by and went inside room [ROOM NUMBER] and observed one of the staff used her foot to move the dirty linen closer and picked up the linen. During an interview on 7/12/22, at 9:25 a.m., with the MDSC, she stated she went inside room [ROOM NUMBER] to inform CNA 1 and CNA 5 to pick up the dirty linen on the floor. The MDSC stated no linens were supposed to be on the floor. The MDSC stated dirty linens were supposed to be…

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.