Grace Healthcare Center

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 two of four sampled residents (Resident 9 and Resident 36) when Resident 9 and Resident 36 did not have care plans for the use of antibiotics (medication used to treat infections caused by bacteria).These failures placed Resident 9 and Resident 36 at a potential risks for harm by not identifying and monitoring for side effects of medications. Findings: During a concurrent observation and interview on 3/17/26 at 9:48 a.m. during initial tour in Resident 9's room, Resident was lying in bed and watching a show on his electronic device. Certified Nurse Assistant (CNA) 11 was standing at bedside and trying to communicate with Resident 9 using gestures. CNA 11 stated Resident 9 did not speak and only communicated using signs, gestures and pointing at things.…

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 care plans (CP) were reviewed and revised for two of eight sampled residents (Resident 6 and Resident 11) when:1. Resident 6 had yankAuer suction catheter (YSC-a rigid, oral suction instrument used to clear blood, saliva, and secretions from a patient's mouth and throat, primarily to prevent aspiration) that he uses for his mouth and nose, and the CP was indicated for oral (relating to the mouth) suctioning use only.2. Resident 11's CP did have interventions reflective of their physician order dated 1/21/26.These failures had the potential for Resident 6 and Resident 11's needs to not be met.Findings:1. During an observation on 3/17/26 at 11:19 a.m. in Resident 6's room during the initial tour, Resident 6 was not in his room, the YSC was noted to be on Resident 6's dresserDuring a concurrent observation and interview on 3/17/26 at 12:09 p.m. with Resident 6 in his room, Resident 6 was sitting in a wheelchair. Resident 6 stated…

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 ensure1. Two of four Registered Nurses (RN 2 and RN 4) were competent in the enteral feeding (tube feeding- is a method of delivering liquid nutrients directly into the stomach or small intestine via a tube) process when providing care to Resident 40 during enteral feeding.2. The Licensed Nurse (LN)s Competency/ Skills checklist (CSC) (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics in performing that an individual need to perform work roles or occupational functions successfully) was performed upon hire for one of six staff members (RN 4).These failures had the potential for the facility to not be able to assess the skills necessary to provide nursing services such as enteral feeding and thus placed the Resident 40 at riskFindings:1. During an observation on 3/17/26 at 10:56 a.m. in Resident 40's room, Resident 40 was in bed sleeping and there was a feeding pump with feeding formula set up. The connector end of the feeding bag tubing for Resident 40 did not have 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 interview and record review, the facility did not ensure completion of a performance review/evaluation of nurse's aides were competed at least every 12 months for two of three Certified Nurse Assistant (CNA 8 and CNA 9) when the CNAs personnel files review did not have annual performance evaluations since their Date of Hire (DOH).This failure had the potential to negatively affect the competency of the CNAs and the quality of care provided to the facility residents. Findings:During a concurrent interview and record review on 3/19/2026 at 1:57 p.m., with the Director of Staff Development (DSD), CNA 8, CNA 9, and CNA 10's personnel files were reviewed. The personnel file for CNA 8 indicated CNA 8's DOH was 12/9/24, and there was no performance evaluation completed in CNA 8's file. The personnel file for CNA 9 indicated CNA 9's DOH was 6/6/23, and there was no performance evaluation completed in CNA 9's file since DOH. The DSD stated she was responsible for ensuring the performance review of the CNAs were completed. The DSD stated the sampled CNAs did not have performance…

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 appropriate monitoring and follow-up for a resident receiving valproic acid for one of four sampled residents (Resident 1) when Resident 1 had an active order for valproic acid (medication used to help control seizures and stabilize mood by affecting how the brain worked) since 12/4/26 for mood stabilization related to bipolar disorder (a condition that caused a person to have extreme mood changes, including very high moods and very low moods), and no valproic acid level had been obtained since initiation per facility procedure and and there was no documentation the physician (MD) or Responsible Party (RP) were notified.This failure resulted in the facility not ensuring appropriate medication monitoring and follow up for Resident 1 while receiving valproic acid, which had the potential to lead to undetected toxic or subtherapeutic drug levels, placing Resident 1 at risk for adverse effects, including liver dysfunction (when the liver…

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 drugs and biologicals (a class of drugs that are produced using a live system, such as a microorganism, plant cell, or animal cell) were locked and labeled in accordance with current accepted professional standards of practice and facility procedures for two of thirteen sampled residents (Resident 42 and Resident 36) when:1.Resident 42 had one metered dose inhaler (MDI-pressurized canister that delivers precise, pre-measured puff of medication directly into the lungs) with no label of name, direction, open date and used by date, three over the counter (OTC-nonprescription drugs bought off-the-shelf for self-treating minor ailments like pain, allergies, or colds) ointments (thick oil-based, and greasy medications applied directly to the skin) kept in the top drawer of his bedside table and two bottles of OTC eye drops (treat temporary symptoms like dryness, itching, and mild redness) on top of his bedside table.These failures 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 store, prepare, distribute and serve food in accordance with professional standards for food service safety when:1. One of two Dietary Aids (DA 1) working in the kitchen did not have a hair net on.2. One wet quarter pan was stacked on top of another quarter pan.3. Ground beef was thawing in the refrigerator with no pull/thaw date on it (the date marked on a food item when it is removed from the freezer to thaw), and no use by date. These failures had the potential to cause cross contamination (the process by which germs are unintentionally transferred from one substance or object to another, with harmful effect) and the growth of microorganisms (a microscopic organism, especially a bacterium, virus, or fungus) that harbor foodborne pathogens (a bacterium, virus, or other microorganism that can cause disease) of residents' food which could lead to food-borne illness (stomach illness acquired from ingesting contaminated food) for the 56 residents admitted to the facility who receive meals from the kitchen.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 maintain medical records which were complete and accurately documented in accordance with accepted professional standards and practices for one of four sampled residents (Resident 9) when Resident 9's weekly wound assessment and change of condition were not completed.These failures resulted in inaccurate medical records being kept for Resident 9 and had the potential to not meet and provided treatment needed which could have resulted to serious health problems.Findings:During a concurrent observation and interview on 3/17/26 at 9:48 a.m. during initial tour in Resident 9's room, Resident was lying in bed and watching a show on his electronic device. Certified Nurse Assistant (CNA) 11 was standing at bedside and trying to communicate with Resident 9 using gestures. CNA 11 stated Resident 9 did not speak and only communicated using signs, gestures and pointing at items and things. During a review of Resident 9's admission Record (AR- 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 designate a full time (working more than 40 hours per week) Registered Nurse as the Director of Nursing (DON) for 58 of 58 residents when the current DON license expired on [DATE]. This failure had the potential to result in a lack of oversight and guidance for the provision of care, which could result in decreased resident safety, optimal well-being, and quality of care. Findings: During a concurrent interview and record review on [DATE], at 10:32 a.m., with Assistant Director of Nursing (ADON), the Director of Nursing (DON) California Board of Registered License, dated [DATE] was reviewed. The ADON stated the DON had notified him of her license being inactive and expired. The ADON validated the DON's Registered Nurse (RN) license from the Board of Registered Nurses (BRN) had been inactive as of [DATE]. The ADON stated he did not notify any leadership of the DON's inactive license and the DON was still working as the DON during the month of [DATE]…

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 right to be free from misappropriation of resident property for eight of eleven residents (Resident 55, 57, 59, 67, 69, 71, 73, 75) when: 1. For Resident 67, a licensed nurse removed 41 alprazolam (a highly addictive medication used for generalized anxiety disorders, panic disorders and insomnia [inability to sleep]) tablets from the medication cart and did not administer the medication to the Resident or waste (discard) the medication in accordance with facility policy and procedure and nursing standards of practice for medication administration. 2. For Resident 59, a licensed nurse removed 25 alprazolam tablets from the medication cart and did not administer the medication to the Resident or waste the medication in accordance with facility policy and procedure and nursing standards of practice for medication administration. 3. For Resident 69, a licensed nurse removed 21 tramadol (a highly addictive medication used for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure: 1. An adequate system for maintaining controlled drugs (substances that have an accepted medical use and have a potential for abuse and may also lead to physical or psychological dependence) records when facility was unable to provide record account for Resident 63's hydrocodone/acetaminophen (pain medication) 5-325 mg (milligram- unit of measurement), maintenance of records for stored controlled drugs awaiting destruction, maintenance of records for controlled drugs used from the facility's e-kit (emergency kit containing medications for facility use when patient specific medication not available from 7/2024 to 10/2024, and used e-kit was not replenished in accordance with facility policy and procedure. 2. Destruction of controlled drugs not accordance with facility policy and procedure. 3. An adequate system for the Director of Nursing (DON) to reconcile controlled drugs periodically in the facility. These failures resulted 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 interview and record review, the facility failed to ensure three of seven sampled residents (Residents 55, 57, 59) were administered medications appropriately when: 1. Resident 55's oxycodone (controlled pain medication that has a potential for abuse and may also lead to physical or psychological dependence) order was changed from as needed (given to resident only if needed on scheduled time) to routine (given to resident around continuously on scheduled time) without clinical justification, with no side effect monitoring. 2. Resident 57's hydrocodone-acetaminophen (controlled pain medication that has a potential for abuse and may also lead to physical or psychological dependence) 5-325 mg (milligram- unit of measurement) order was changed with the addition of an additional hydrocodone-acetaminophen 5-325 mg order without clinical justification, with no side effecting monitoring. 3. Resident 59's tramadol (controlled pain medication that has a potential for abuse and may also lead to physical or…

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

Based on interview and record review, the facility administration failed to ensure one of one sampled employee, Licensed Vocational Nurse (LVN) 1, did not work in the facility while he was suspended from employment and under investigation for drug diversion (theft of resident medications), when he returned to work in the facility with approximately 30 residents during one 12-hour shift. This failure had the potential for further drug diversion, evidence tampering, falsification of records, or other investigation interference. Findings: During a review of the Centers for Disease Control (CDC) website titled, Clinician Brief: Drug Diversion, dated 3/18/24, the CDC website indicated, Drug diversion happens when healthcare providers obtain or use prescription medicines illegally. Drug diversion puts patients at risk. Some healthcare providers steal prescription medicines or controlled substances, such as opioids [highly addictive, narcotic medications that can produce a powerful feeling of well-being, or a 'high', in the brain], for their own use. Addiction to opioids is a major driver…

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 two Licensed Nurses (Registered Nurse, or RN 3, and Licensed Nurse, or LN, 22) properly disinfected a glucometer (a handheld device used to measure how much sugar is in a drop of blood) after obtaining a blood sample from residents. This failure had the potential to spread bloodborne diseases via the glucometer to as many as nine other residents also receiving these blood tests. Findings: During a review of the website page for the Centers for Disease Control (CDC), titled, Considerations for Blood Glucose Monitoring and Insulin Administration, the website page indicated, Blood glucose meters [also known as glucometers] are portable devices that measure blood glucose levels and aid in diabetes [a chronic and serious disorder where glucose, a type of sugar, is poorly regulated in the blood] . management. Healthcare providers use these types of devices in a variety of clinical settings. Blood glucose meters can easily become contaminated during use. When used in healthcare or other group settings,…

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 three of three nursing staff (Licensed Vocational Nurse 1, Licensed Nurse 22, and Registered Nurse 3) received essential competencies were conducted on new staff hired by the facility. This failure had the potential for incompetent or untrained nursing staff to deliver care to residents. Findings: During a concurrent record review and interview, on 10/11/24, at 9:25 a.m., with the Director of Staff Development (DSD), Licensed Nurse (LN) 22's personnel file and training records was reviewed. The DSD stated he was responsible for overseeing and directing the orientation of new nursing staff. The DSD stated new nurses are to have two classroom days of orientation before they work the floor providing care to residents. The DSD stated LN 22 only had one day of classroom orientation before she was instructed by the Director of Nursing (DON) to go work on the floor on her second day. The DSD stated the DON made this decision as a shortcut and to start LN 22 working directly with residents as soon as possible. The DSD…

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 observation, the facility failed to have an effective QAPI (Quality Assurance and Performance Improvement) program when four of four sampled staff (Licensed Nurse 22, Certified Nursing Assistant 1 and 2, and Registered Nurse Supervisor) were not aware of the facility's QAPI plan, and failed to have a tool for measuring Performance Improvement. This failure led to nursing staff being unable to verbalize an understanding of the facility's active performance improvement goals aimed at successfully implementing a program to improve resident safety. Findings: During an interview on 10/10/24, at 3:45 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 was not aware of the facility's QAPI program. CNA 1 stated, No, not heard of that. During an interview on 10/10/24 at 3:50 p.m., with CNA 2, CNA 2 was not aware of the facility's QAPI program. During an interview on 10/10/24 at 3:52 p.m., with Licensed Nurse (LN) 22, LN 22 was not aware of the facility's QAPI program. During an interview on 10/10/24, at 3:55 p.m., with the Registered Nurse Supervisor (LNS), the LNS…

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 check the references for two of five sampled employees (Licensed Vocational Nurse 1 and Licensed Nurse 22) prior to being employed at the facility. This failure had the potential for the facility to employ unqualified and/or abusive staff to provide direct care to residents. Findings: During an interview on 10/18/24, at 10:45 a.m., with the Owner/Administrator (OA), the OA stated it was his expectation that previous employment and personal references checks be done for all candidates considered for employment. During a concurrent record review and interview, on 10/11/24, at 9:25 a.m., with the Director of Staff Development (DSD), Licensed Vocational Nurse (LVN) 1's personnel file was reviewed. There was no indication LVN 1 had any reference checks performed. The DSD stated, We need at least two references. I have no idea where [LVN 1's] references are. During a concurrent record review and interview, on 10/11/24, at 11:55 a.m., with the DSD, LN 22's personnel file was reviewed. The file indicated LN 22 had just graduated…

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 implement an effective training program for infection control and prevention for two of three Licensed Nurses (Licensed Vocational Nurse 22, and Registered Nurse, or RN 3), when LN 22 and RN 3 did not have documented training on hand hygiene and personal protective equipment (PPE, items such as gloves, gowns, and masks). This failure placed residents at a risk for potential spread of infection from the Licensed Nurses' lack of training on infection control. Findings: During a concurrent interview and record review on 10/11/2024 at 9:30 AM with Director of Staff and Development (DSD), Licensed Vocational Nurse (LN )22's employee record was reviewed. The employee record indicated, LN 22 did not have signatures indicating training on hand hygiene and personal protective equipment. DSD stated, It is blank, it was not done. During a concurrent interview and record review on 10/11/2024 at 11:55 AM with DSD, RN 3's employee record was reviewed. The employee record indicated, Registered Nurse (RN) 3 did not have signatures…

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

Based on observation, interviews and record review, the facility failed to ensure dietary cook (DC) 1 was competent to carry out the functions of food and nutrition services safely and effectively when: 1. DC 1 served to much food for a large portion size diet for Residents' 15, 48 and 50. 2. DC 1 did not fortify food for the fortified diets for Residents' 15, 18 and 50. 3. DC 1 did not follow pureed food recipe for Residents' 11, 18, 44, 53 and 214. 4. DC 1 did not checked the temperature for pureed foods prior to serving. 5. Kitchen did not have enough chile relleno casserole to serve to Residents' 17, 22 and 31. These failures resulted in Residents' 15, 18, 50, 11, 44, 53, 214, 17, 22 and 31's diet orders and the facility menu to not be followed. Findings: 1. During observation on 9/10/24 at 12:32 p.m. during tray line in the kitchen, Dietary [NAME] (DC) 1 observed plating food for large portion diet. DC 1 placed one and one half serving of main dish (chile relleno casserole) in the plates of large portion diet. During a concurrent interview and record review on 9/10/24 at 3:15…

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.

FACILITY Based on observation, interview and record review, the facility failed to ensure food served met the daily nutritional needs for seven of 54 sampled residents (Residents' 15, 48, 50, 18, 17, 22, 31) when: 1. Residents on large portion diets (Residents 15, 48 and 50) were served more than the required portion size of the chile relleno casserole based on the facility's menu. This failure had the potential to result in Residents 15, 48 and 50 to receive more than the recommended daily caloric intake based on the Medical Doctor's order and Registered Dietitian's (RD) assessment of residents' nutritional dietary needs and the potential for unintended weight gain. 2. Residents' 15, 18 and 50 did not received fortified (foods with nutrients added to help boost nutritional value and benefit health) diet as ordered by physician. This failure had the potential to result in Residents' 15,18 and 50 to not receive the additional calories recommended based on resident nutritional dietary needs. 3. Residents' 17, 22 and 31 received alternate food on 9/10/24 due to not enough chile relleno…

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 establish and maintain an effective infection control and prevention program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable (contagious) diseases and infections for 62 of 62 residents when: 1.Resident 4's wheelchair was found to have brown dried matter on the seat and staff did not clean and maintain the wheelchair in accordance with facility policies and procedures. 2.Resident 33's two used urinal bottles (a container used to collect urine) were found on top of his nightstand. Staff did not follow established facility policies for the discarding of urine and the cleaning of urinal bottles. 3.Dirty water was found pooled in the laundry room where clothing and linens were being washed for the entire facility of 62 residents. These failures had the potential to increase the risk of spreading pathogens (microscopic organisms that cause disease) to all…

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 safe, functional, and comfortable environment for residents, staff and the public when: 1. Eight of eight resident rooms were observed with non functioning privacy curtains. These failures had the potential of violating residents rights to their privacy. 2. Water leaked from one of three washing machines amd water pooled underneath and around the floor where the machines were located. This failure had the potential to place residents and staff in an unsafe and unsanitary environment which had the potential to lead to electrocutions, slips, and other avoidable accidents. Findings: 1. During an observation on 9/12/24 at 9:30 a.m. in room [ROOM NUMBER], door was slightly open, observed a certified nursing assistant providing care to Resident 15, no privacy curtain to the foot of the bed exposing Resident 15 to visitors, staff and other residents walking by the room. During an interview on 9/12/24 at 9:43 a.m. with Certified Nursing Assistant (CNA)…

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 two of 10 sampled residents (Residents' 53 and 51) when: 1. Resident 53 did not have a care plan for apixaban (anticoagulant - prevent blood clots from forming). This failure put Resident 53 at risk for harm by not identifying and monitoring for harmful side effects. 2. Resident 51 did not have a care plan for Enhanced Barrier Precaution (EBP-set of infection control practices that uses gowns and gloves during high contact care of residents in nursing homes) status. This failure placed Resident 51 at a potential risk for her needs to go unmet while under enhanced barrier precaution. Findings: 1. During a review of Resident 53's admission Record (AR), (a document containing pertinent resident profile information) dated 9/15/24, the AR indicated, Resident 53…

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 meet professional standards of practice for two of 11 sampled residents (Resident 27 and Resident 44) when 1. A medicine cup with seven tablets was left on top of Resident 27's breakfast tray. This failure had the potential for Resident 27 to not received the prescribed medications and for other residents to have access to the medications which could lead to serious health condition. 2. Resident 44 physicians order for padded siderails were not followed. This failure had the potential to cause injury to Resident 44 if he hit the side rails. Findings: 1. During a concurrent observation and interview on 9/9/24 at 8:20 a.m. in Resident 27's room, Resident 27 was sitting up in his wheelchair at bedside eating breakfast. Resident 27 was dressed appropriately. On the breakfast tray was a medication cup with seven tablets in it. Resident 27 stated the licensed nurse left the medication cup with the medications for him to take. Resident 27 stated…

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 safely when: one of two medication carts were properly stored when : 1. medication were not labeled in accordance with accepted professional principles for 11 out of 11 residents (Resident 2, Resident 6, Resident 14, Resident 31, Resident 32, Resident 36, Resident 44, Resident 51, Resident 54, Resident 56, Resident 57 ) when medications that are administered via an inhaler (a medical device used for delivering medicines into the lungs through the work of a person's breathing ) to treat difficulty breathing were not labeled with use by dates or the medication expiration dates. This failure had the potential for residents to being given expired medications which could lead to difficulty breathing due to reduced efficacy of the medications. 2. One of two medications carts was left in the hall outside of resident room [ROOM NUMBER], with keys on top of the medication cart. This failure had the potential for…

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

Based on observation, interview, and record review, the facility failed to ensure safe, sanitary food preparation and storage practices were followed in for 54 out of 62 resident when the two-compartment prep sink in the kitchen did not have an air gap. This failure had the potential to cause food-borne illness (illnes caused by consuming contaminated foods or beverages) to the facility's fragile residents. Findings: 1. During a concurrent observation and interview on 9/9/24 at 7:20 a.m. with Dietary Service Supervisor (DSS) in the kitchen in front of the two-compartment sink, DSS stated the two-compartment sink did not have an air gap (an air gap refers to fixture that provides back-flow prevention). DSS stated the dietary staff used the two compartments sink as a prep sink (sink used to washed produce). During an interview on 9/10/24 at 3:08 p.m. with the Maintenance Supervisor (MS), he stated he was aware the two-compartment sink did not have an air gap. During an interview on 9/10/24 at 3:35 p.m. with DSS, the DSS stated she was aware there was no air gap under the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents were treated with dignity and respect for one of four sampled residents (Resident 15) when Certified Nurse Assistant (CNA) 9 did not provide privacy while providing personal hygiene care to Resident 15. This failure resulted in Resident 15 not being provided with respect and dignity while receiving care. Findings: During an observation on 9/12/24 at 9:30 a.m. in the hallway outside Resident 15's room, the door was open and Resident 15 was lying in bed, his buttocks were uncovered, exposed and visible from the hallway to visitors, staff and other residents. Certified Nursing Assistant (CNA) 9 was standing on the side of the bed providing personal hygiene care to Resident 15, the privacy curtain was not drawn past the foot of Resident 15's bed. During a review of Resident 15's admission Record, dated 9/11/24, the admission Record indicated, Resident 15 was admitted to the facility on [DATE] with diagnoses which included…

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 seven residents (Resident 19) was free from abuse and neglect when Resident 19 did not receive the supplies he requested to conduct suprapubic catheter (a hollow flexible tube surgically inserted below the belly button used to drain urine from the bladder) care. This failure resulted in Resident 19 soiling himself with urine. Findings: During a review of Resident 19's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 9/12/24, the AR indicated, Resident 19 was admitted on [DATE] to the facility. Resident 19 had the following diagnoses: quadriplegia (partial or total loss of use of all four limbs and torso), neuromuscular dysfunction of bladder (a condition which affects bladder control due to damage to the nervous system), and depression (mood disorder which causes extreme sadness). During a review of Resident 19's Minimum Data Set (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 interview and record review, the facility failed to notify the Long Term Care Ombudsman office (LTC-Ombudsman, a resident advocacy agency) of transfer to the hospital for one of four sampled residents (Resident 26) when the facility failed to send a copy of Resident 26's transfer notification to the local LTC-Ombudsman office. This failure resulted in the LTC-Ombudsman not aware of Resident 26's emergency transfer to an acute care facility for treatment on 5/24/24. Findings: During a review of Resident 26's admission Record (AR, documents containing resident demographic information and medical diagnosis), dated 9/12/24, the AR indicated Resident 26 was admitted to the facility on [DATE] with diagnoses which included hydronephrosis (a condition that occurs when urine builds up in the kidney, causing it to swell and stretch), infection (invasion and growth of germs in the body) due to nephrostomy (a surgical procedure that creates an opening in the kidney to drain urine or for other purposes) , and…

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

Based on interview and record review, the facility failed to meet the required timelines for encoding, completion and transmission of Minimum Data Set assessments (MDS-evaluation of cognition, care needs and functional abilities) for one of four sampled residents (Resident 58) when Minimum Data Set Nurse (MDSN) did not complete or transmit discharge MDS assessment for Resident 58. This deficient practice resulted in the potential harm of Resident 58's needs upon discharge going unmet. Findings: During a concurrent interview and record review on 9/12/24 at 9:07 a.m. with the Minimum Data Set Nurse (MDSN), the MDSN reviewed the MDS assessment and submission for Resident 58. The MDSN stated the last assessment for Resident 58 was dated 4/11/24 and it was a quarterly assessment. The MDSN stated Resident 58 was discharged to home on 5/1/24. The MDSN did not find a completed and transmitted MDS discharge assessment tracking for Resident 58 when Resident 58 was discharged to home on 5/1/24. The MDSN stated there should have been a discharge assessment opened and submitted when Resident 58…

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 re-evaluate and document current condition for Level I 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) for one of four sampled residents (Resident 15). This failure had the potential for Resident 15 to not receive the appropriate services related to his mental disorder, intellectual disabilities or other related cognitive impairment. Findings: During an observation on 9/9/24 at 8:15 a.m. in Resident 15's room, Resident 15 was sitting up in bed eating breakfast from breakfast tray placed on top of over the bed table placed across the bed. Resident 15 was appropriately dressed and did not answer any questions asked. During a review of Resident 15's admission Record, dated 9/11/24, the admission Record indicated, Resident 15 was admitted to the facility on [DATE] 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 assess one of seven residents (Resident 59) for risk of entrapment (caught, trapped, or entangled in the space in or about the bed and side rail) from bed rails (adjustable metal or rigid plastic bars that attach to the bed), obtain informed consent (form signed by resident or family explaining the risks of side rail use), obtain physician order with indication for use, and create care plans prior to the use of bed rails when Resident 59 had his right bed rail raised up. These failures had the potential to place Resident 59 at risk for decreased freedom of movement, entrapment and/or injury. Findings: During a review of Resident 59's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment, dated 8/14/24, indicated Resident 59's Brief Interview for Mental Status (BIMS - screening tool used to assess resident cognitive level) score was 11 out of 15 indicating Resident 59 had moderate cognitive impairment (0-7 indicated severe…

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

Based on observation, interview and record review, the facility failed to provide acetylsalicylic acid 325 mg (ASA-a medication that reduces pain, fever, inflammation, and blood clots [mg-milligrams a unit of measurement]) for one of one sampled resident (Resident 1) who has an order for acetylsalicylic acid 325 mg when the facility ran out of the medication. This failure cause Resident 1 to miss a scheduled dose of medication ordered to prevent blood clots (gel like clump of blood that can form inside the veins and restrict blood flow) . Findings: During a concurrent observation and interview on 9/11/24 at 8:17 a.m. with (Licensed Vocational Nurse) LVN 2, in front of Resident 1's room, Resident 1's acetylsalicylic acid 325 mg was missing. LVN 2 stated the medication was not available. During an interview on 9/11/24 at 8:36 a.m. with the (Director of Nursing) DON the DON stated, the (Associate Director of Nursing) ADON was sent to get the medication from a local pharmacy. During an interview on 9/11/24 at 4:27 p.m. with the Skilled Nursing Pharmacy Consultant (SN PC) the SN PC…

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 maintain a low air loss mattress (LAL- a special mattress designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) cover sheet in intact for one of three sampled residents (Resident 39) when the LAL mattress cover was torn where Resident 39 rested his head. This failure had the potential to cause the LAL mattress to not function properly and lead the resident to develop skin breakdown. Findings: During a review of Resident 39's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 9/13/24, the AR indicated Resident 39 was admitted to the facility on [DATE]. Resident 39 was admitted with the following diagnoses: diabetes mellitus (a condition that happens because of a problem in the way the body uses sugar as a fuel), quadriplegia (a condition which causes partial or total loss of function in all four…

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 report physical abuse in accordance with the facility's policy and procedure titled Abuse Prevention Program, for one of four sampled residents (Resident 1), when a Licensed Vocational Nurse (LVN) 1 reported a physical abuse allegation to the Administrator (ADM) on 5/14/24, and the facility did not notify the appropriate agencies of Resident 1 ' s allegations of abuse within the required timeframe. This failure resulted in a delay of reporting Resident 1 ' s allegation of physical abuse investigation and had the potential to place Resident 1 and other resident ' s health and safety at risk of harm or injury. Findings: During an interview on 5/16/24 at 5:31 p.m. with LVN 1, LVN 1 stated during medication pass she overheard Resident 1 on the phone staff were hitting her. LVN 1 stated she reported the abuse allegation to the ADM on 5/14/24. During a review of Resident 1's Progress Notes (PN), dated 5/14/24, the PN indicated, .Resident 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 release medical records requested in writing by on behalf of Resident 1 within the required 48 hours advance notice indicated in facility ' s policy and procedure (P&P) titled, Release of Information dated November 2009. This failure resulted in Resident 1's family, denial of timely documents. Findings: During an interview on 1/4/24 at 2:10 p.m. with Medical Records Director (MR), MR stated, she received a request for information with the signed release form on the 12/15/23. She stated she notified her supervisor the Administrator (ADM). MR stated she assumed after she informed the Administrator (ADM) that he was taking care of the request. During a concurrent interview and record review on 1/4/24 at 2:39 p.m. with MR, the facility ' s P&P titled, Release of Information, dated November 2009, indicated . may obtain photocopies of his or her records by providing the facility with at least a forty-eight (48) hour (excluding weekends and holidays) advance notice of such request . MR stated facility did not follow P&P. MR…

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 and comfortable environment, for eight of eight sampled residents (Residents 1, 2, 3, 4, 5, 6, 7, and 8), when on 6/30/23, the Heating, Ventilation, and Air Conditioning system unit (HVAC), which regulate and move heated and cooled air throughout a home or a building had malfunctioned and caused the ambient (immediate surroundings) room temperatures in room [ROOM NUMBER] to exceed the safe and comfortable level of 71 to 81 degrees Fahrenheit (F- a scale for measuring temperature). This failure placed Residents 1, 2, 3, 4, 5, 6, 7, and 8 at risk to experience heat related illnesses such as heat exhaustion (manifested by weakness, headache, vomiting, cramps, loss of consciousness) or heat-stroke (a serious heat-related illness manifested by high body temperature of 104 degrees F or higher, rapid breathing, increased heart rate); and reduced ability to participate in normal activities of daily living. Findings: 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 provide oral hygiene for two of 12 sampled residents (Residents 1 and 3) when: 1. Resident 1 ' s lips were dry, chapped, and crusty. 2. Resident 3 had a cracked area on the right corner of his mouth that was covered with dried blood. This failure resulted in Residents 1 and 3 to have poor oral hygiene and undignified appearance and placed them at risk to have bad breath and mouth lesion which could lead to bacterial, viral, or fungal mouth infections. Findings: 1. During a concurrent observation and interview on 7/3/23 at 2:27 p.m. with the Assistant Director of Nursing (ADON), inside Resident 1 ' s bedroom, Resident 1 was observed in bed awake and listening to music. Resident 1 was observed to have contractures (fixed tightening of muscle, tendons that prevents normal movement of the associated body part) to both arms and legs Resident 1 ' s lips was observed to be dry, cracked and the corner of his mouth had white-color substances. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS- a resident assessment tool used to identify resident care needs) assessment accurately reflected resident's current status for six of six sampled residents (Resident 9, 10, 23, 37, 46 and 47) when MDS assessments failed to accurately code restraints according to the Resident Assessment Instrument (RAI- guidelines on gathering definitive information on a resident's strengths and needs) guidelines. These failures had the potential for Residents 9, 10, 23, 37, 46 and 47 not being provided with the necessary care and services to meet their healthcare needs. Findings: 1. During an observation on 6/12/23, at 9:05 a.m., Resident 9 was observed laying in bed, had tube feeding running (tube that supplies nutrients to individuals that can not get enough by eating), left sided weakness and was continuously hitting the raised side rails with his right arm and hand. Resident 9 did not answer any questions. 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 safe, sanitary food preparation and storage practices were followed in the kitchen when: 1. The ice machine was dirty. 2. The two compartment prep sink did not have an air gap. 3. The dish wash machine had higher parts per million (ppm - a unit of measurement) concentration of chlorine than required by manufacturer guidelines. 4. The sprinkler pipes and hood filter above the stove were covered with grease and dust. 5. Torn gasket found on refrigerator number (#) 1's door. 6. Broken tiles found under dish wash machine and around the ice machine air gap. 7. The wooden shelves used to store clean serving plates was rough and had peeling and chipped paint. 8. Dust found on the following areas: a. Ceiling fan, b. Insect light, c. Ceiling above exit door of the kitchen , d. Inside ventilators of refrigerator which the facility referred as 3 door refrigerator, e. Stainless kitchenware storage shelves, f. Inside ventilator of refrigearator # 2, g. Dry storage room shelves. 9. The microwave was dirty. 10. 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 observations, interviews, and record review, the facility failed to implement and maintain an infection prevention and control program when the Infection Preventionist (IP) was assigned the Director of Staff Development (DSD-creates and implements employee training programs, orient new hires, supervise certified nursing assistant staff and serve with the interdisciplinary team) duties which prevented the IP from implementing and maintaining a system to prevent, identify, investigate, and control infections consistent with national standards and the facility's policy and procedures. These failures placed 62 of 62 residents at risk for the transmission of communicable diseases (illnesses that spread from one person to another) and infections. Findings: During an interview on 6/15/23, at 10:28 a.m. with the IP, the IP stated she had moved to the IP position on 5/22/23. The IP stated the DSD went on a leave of absence at the same time. The IP stated she had been instructed to focus on the DSD duties. The IP stated she did not know what systems were in place before she 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 ensure the Comprehensive Minimum Data Set (MDS-an evaluation of care needs, memory and physical functions) were completed and submitted within the required 14 day time frame for four of 14 sampled residents (Resident 3, 15, 21 and 36). This deficient practice had the potential to negatively affect the delivery of care and services needed by the residents. Findings: During an interview on 6/15/23 at 2:22 p.m., with Minimum Data Set Nurse (MDSN), the MDS stated, facility is not following Resident Assessment Instrument (RAI- guidelines on gathering definitive information on a resident's strengths and needs) guidelines. MDSN stated, MDS assessments are late and not submitted on time according to the Resident Assessment Instrument (RAI- guidelines on gathering definitive information on a resident's strengths and needs) guidelines. MDSN stated, the Director of Nurses (DON) assists with MDS submission to Centers for Medicare and Medicaid Services (CMS-…

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 Quarterly Minimum Data Set (MDS) assessment (an evaluation of care needs, memory and physical functions) were completed and submitted within the 14 days required from the start date of the assessment for nine of 14 sampled residents (Resident 2, 7, 20, 22, 31, 34, 35, 49 and 50). This failure had the potential to delay updating care plans related to providing residents with the appropriate care and services needed. Findings: During an interview on 6/15/23 at 2:22 p.m., with Minimum Data Set Nurse (MDSN), The MDSN stated, facility is not following the Resident Assessment Instrument (RAI- guidelines on gathering definitive information on a resident's strengths and needs) guidelines. MDSN stated, MDS assessments are late and not submitted on time according to the Resident Assessment Instrument (RAI- guidelines on gathering definitive information on a resident's strengths and needs) guidelines. MDSN stated, the Director of Nurses (DON) assists with MDS submission to Centers for Medicare and Medicaid Services…

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 meet the required timelines for encoding (input of information for data transfer), completion, and transmission of Minimum Data Set (MDS) assessments (evaluation of cognition, care needs and functional abilities) for 14 of 14 sampled residents (Resident 2, 3, 7,15, 20, 21, 22, 25, 31, 34, 35, 36,49 and 50). This failure resulted in not using the most up to date MDS assessment information in the residents' clinical record and not communicating to CMS the required quality data. Findings: During an interview on 6/15/23 at 2:22 p.m., with Minimum Data Set Nurse (MDSN), The MDSN stated, facility is not following the Resident Assessment Instrument (RAI- guidelines on gathering definitive information on a resident's strengths and needs) guidelines. MDSN stated, MDS assessments are late and not submitted on time according to the Resident Assessment Instrument guidelines. MDSN stated, the Director of Nurses (DON) assists with MDS submission to Centers for Medicare and Medicaid Services (CMS-organization responsible for creating…

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 services provided met professional standards of quality for five of six sampled residents (Residents 9, 23, 24, 25 and 42) when: 1. The nurses did not monitor and assess Residents 24, 25 and 42 for adverse reactions after receiving COVID-19 (infectious disease caused by the SARS-CoV-2 virus) vaccinations (creates immunity from a disease) on 4/28/23. This failure placed Residents 24, 25 and 42's health and safety at risk for delayed recognition of adverse reactions to the vaccine. 2. Nursing staff did not ensure Resident 9's physician order to check phenytonin (medication used to decrease seizure activity) level quarterly was completed and the last phenytoin level was completed on 1/23/23. This failure placed Resident 9's health and safety at risk for serious medical condition. 3. Resident 23's did not receive mediations as prescribed by the physician on 5/3/23. This failure placed Resident 23's health and safety at risk for serious…

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 30) received treatment and care in accordance with professional standards of practice when Resident 30's nephrostomy (surgical opening between kidney and the skin with a tube inserted for urine drainage) and suprapubic catheter (placement of a drainage tube between the urinary bladder and skin just above the pelvis) site treatments were not performed according to the physician orders. This failure placed Resident 30 at risk for urinary tract infection (UTI- infection in any part of the urinary system-kidneys, ureters or bladder), sepsis (the body's life-threatening response to an infection), and hospitalization. Findings: During a review of Resident 30's admission Record, dated 6/14/23, the admission record indicated, Resident 30 was admitted to the facility on [DATE] with diagnoses which included paraplegia (paralysis of the legs and lower body), encounter for fitting and adjustment 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 assess six of 17 sampled residents (Residents 9, 10, 23, 37, 46, 47) for the risk of entrapment (resident caught, trapped, or entangled in the space in or about the bed and side rail) from bed (side) rails (adjustable metal or rigid plastic bars that attach to the bed), prior to installation. The facility failed to ensure safety for Resident 37 when staff did not obtain an informed consent (form signed by resident or family explaining the risks) and physician orders prior to use. These failures had the potential to place Residents' 9, 10, 23, 37, 46, and 47 at risk for decreased freedom of movement, entrapment and/or injury. Findings: 1. During an observation on 6/12/23, at 9:05 a.m., Resident 9 was observed laying in bed, had tube feeding running (tube that supplies nutrients to individuals that can not get enough by eating), left sided weakness and was constantly hitting the raised side rails with his right arm and hand. Resident 9 did…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the facility medication error rate did not exceed five percent or greater when: 1. Licensed Vocational Nurse (LVN) 4 administered Resident 1 [brand name] insulin (medication used to treat diabetes mellitus) after its expiration date. This failure had the potential for Resident 1 to not received the full therapeutic effect of the medication which could lead to elevated or low blood sugar and serious medical condition. 2. LVN 1 administered phenytoin (medication used to treat seizure) suspension to Resident 9 and did not used the recommended tool to measure accurate dose. This failure had the potential for Resident 9 to not received the therapeutic effect of the medication which could lead to more seizure activities and serious medical condition. 3. LVN 4 administered amlodipine (medication used to treat high blood pressure) medication to Resident 44 without checking the blood pressure. This failure resulted in Resident 44 not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the faciltiy failed to ensure three of 10 sampled residents (Residents 1, 9 and 44) were free from significant medication errors when: 1. Licensed Vocational Nurse (LVN) 4, administered expired [brand name] insulin (medication used to treat diabetes mellitus) to Resident 1. This failure had the potential for Resident 1 to not receive the full therapeutic effect of the medication which could lead to lower or higher blood sugar results which could lead to more serious medical complications. 2. LVN 1 administered phenytoin (medication used to treat seizure) suspension to Resident 9 and did not use the recommended tool to measure the accurate dose. This failure had the potential for Resident 9 to not receive the full therapeutic effect of the medication which could lead to seizure activity and more serious medical complications. 3. LVN 4 administered amlodipine (medication used to treat high blood pressure) medication to Resident 44 without checking the blood…

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 drugs and biologicals were labeled in accordance with currently accepted professional principles when: 1. Two tuberculin (combination of proteins that are used in the diagnosis of tuberculosis [potentially serious infectious bacterial disease that mainly affects the lungs]) vials (small container for liquids) were opened with no indication of used-by date or open date. This failure had the potential to produce inaccurate purified protein derivatives (PPD) test (skin test is a test that determines if you have tuberculosis) results and or cause harm to vulnerable population if administered beyond the manufacturer's used by date. 2. Resident 6's levetiracetam (medication used to prevent and treat seizure) medication label was soiled, damaged and illegible and was stored in the medication cart, available for use. This failure had the potential for the medication to be given to the wrong resident and cause adverse reactions. 3. Resident…

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

Based on observation, interview, and record review the facility failed to ensure that staff safely and effectively carried out the functions of food and nutrition services when: 1. Maintenance Director did not follow manufacturer guideline to clean the ice machine. (Cross reference 812) 2. Two Dietary Aides (DA 1 and DA 2) and Dietary Manager (DSS) were unable to accurately test the concentration of chorine as per manufacturer guideline in the dish wash machine. (Cross reference 812) 3. One Dietary Aide (DA 3) and one evening (PM) [NAME] were unable to accurately test the sanitizing solution used to sanitize food preparation surfaces in the kitchen. 4. DSS did not follow physician order for honey thick beverages for two residents (Resident 2 and 205) during lunch on 6/13/23. (Cross reference 805) 5. PM [NAME] did not record the cool down process (a process used in food production to prevent foodborne illness. Bacteria grow best in food in the temperature range 135°F to 41°F, also referred to as the temperature danger zone. Food must be cooled quickly to minimize bacterial growth. If…

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 appropriate food textures was provided when two of two residents (Residents 2 and 205) did not receive honey thickened liquids as ordered on 6/12/23 and 6/13/23. These failures had the potential to place the residents at risk of aspiration (when food is breathed into the lungs) and choking. (Cross reference 802) Findings: 1. During a concurrent observation, interview, and meal tray ticket review on 6/12/23 at 12:18 p.m. with Restorative Nursing Assistant (RNA) 1 in dining room. Resident 205 was observed with a mug of hot chocolate that was not honey thick (liquid that has a similar conistency to honey or milkshake) consistency. Review of meal tray ticket indicated, Honey thick liquid. RNA 1 stated, she made the hot chocolate in dining room for Resident 205 before meal tray come out. RNA 1 stated, she was unaware that Resident 205 was a on honey thick liquid. RNA 1 stated, Resident 205 could have potential risk of aspiration and choking with the hot chocolate she served. During a review of Resident…

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

Based on observation, interview, and record review, the facility failed to ensure resident's beverage preference was honored for one of 57 sampled residents (Resident 2) when apple juice was placed on Resident 2's lunch tray on 6/13/23. This failure had the potential to result in decreased liquid intake, and could result in unplanned dehydration, further compromising Resident 2's nutritional and medical status. Findings: During a concurrent observation, interview, and meal ticket review on 6/13/23 at 12:10 p.m. at dining room with Infection Preventionist (IP) and Activities Director (ACT), Resident 2 meal tray ticket was reviewed. Resident 2 meal tray ticket indicated, 4-ounce (oz unit of measurement) lemonade. Resident 2 was observed receive a 4 oz apple juice. Resident 2 did not consume the provided 4-ounce apple juice. IP confirmed Resident 2 did not receive lemonade as indicated on the meal tray ticket and he did not consume the served apple juice. ACT stated, Resident 2 communicated via hand gesture. ACT stated, when Resident 2 liked something, he would show his thumb up. ACT…

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 and effective systematic approach was implemented to monitor and maintain optimal nutritional status for one of two sampled residents (Resident 17) when: 1. The facility failed to ensure the weight goal range for Resident 17 was established with the involvement of the resident's legal representative (RP). 2. The facility failed to follow standards of practice for Resident 17 and find a substitution or alternate nutritional intervention for [brand name] (a frozen dessert used for adding calories and protein) which the facility no longer provided. These failures had the potential for Resident 17 to experience continued weight loss. Findings: During a review of Resident 17's admission Face Sheet, dated on 6/13/23, the admission Face Sheet indicated, Resident 17 was admitted to the facility on [DATE]. Resident 17's diagnoses included Protein -Calories Malnutrition ( is a type of undernutrition when resident is not…

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

Based on interview and record review, the facility failed to meet the minimum requirement of a registered nurse (RN) on duty when an RN was not scheduled for eight consecutive hours per day, seven days a week for 17 (3/4/23, 3/5/23, 3/9/23, 3/11/23, 3/12/23, 3/18/23, 3/19/23, 3/21/23, 3/22/23, 3/25/23, 3/26/23, 4/4/23, 4/6/23, 5/7/23, 5/16/23, 5/23/23 and 5/30/23) of 103 days sampled. This failure had the potential to result in residents not receiving appropriate services with RN oversight. Findings: During a review of the facility census, dated 6/11/23, the facility census indicated a resident census of 62 residents. During a concurrent interview and record review on 6/14/23 at 10: 37 a.m. with the Director of Nursing (DON), the facility's licensed nursing (LN) staffing schedule, dated 3/1/23 to 6/11/23 was reviewed. The licensed nursing staffing schedule indicated for the dates of 3/4/23, 3/5/23, 3/9/23, 3/11/23, 3/12/23, 3/18/23, 3/19/23, 3/21/23, 3/22/23, 3/25/23, 3/26/23, 4/4/23, 4/6/23, 5/7/23, 5/16/23, 5/23/23 and 5/30/23 there were no RN's scheduled to work eight consecutive…

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 dispose of garbage and refuse properly when two of the three dumpsters did not have the lids of the dumpsters closed properly. This failure had the potential to attract pests and rodents. Findings: During an observation on 6/12/23 at 2:00 p.m. outside of the facility, two out of three dumpsters were overflowing with grabage and the lids were not properly closed. During a concurrent observation and interview on 6/12/23 at 2:21 p.m. with Dietary Manager (DSS), DSS confirmed two of the dumpsters were overflowing with the lids not properly closed. The DSS stated, the lids of dumpsters should be close at all the times otherwise it would attract flies. During an observation on 6/13/23 at 1:37 p.m. outside facility, one of the dumpsters lid was observed wide open. During a concurrent observation and interview on 6/13/23 at 1:40 p.m. with Administrator (ADM), ADM confirmed one of the dumpster lid was wide open. During an interview on 6/14/23 at 4:00 p.m. with the Registered Dietitian (RD). RD stated, dumpsters should…

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 facility document review, the facility failed to ensure an effective pest control program was in place for the kitchen when house flies were observed flying and landing in the facility. This failure had the potential to lead to food borne illnesses (illness caused by food contaminated with bacteria, viruses, parasites or toxins) in the facility residents who eat food prepared in the kitchen. Findings: During a concurrent observation and interview on 6/13/23 at 8:23 a.m. with Certified Nursing Assistant (CNA) 2 at the bedside table of Resident 32. A house fly was observed landing on Resident 32's finished breakfast meal tray. CNA 1 confirmed the house fly was landing on Resident 32's finished breakfast meal tray. During an observation on 6/13/23 at 8:30 a.m. in the Administrator office, a house fly was observed flying around in the Administrator office. During an interview on 6/13/23 at 8:54 a.m. with the Dietary Manager (DSS). DSS stated, there was lot of flies in the building especially during summer. During a concurrent observation and…

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