Healthcare Centre Of Fresno

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to document changes in resident health status according to professional standards of practice and the facility's policy and procedure titled Licensed Nurse Weekly Progress Notes, for one of three sampled residents (Resident 1) when the facility nursing staff did not accurately assess, document and monitor Resident 1's skin changes that included multiple bruising to bilateral (both) upper thighs, knees, buttocks and right ankle. This failure placed Resident 1 at risk for further injury, potential for falls, increased pain and further skin breakdown. Findings:During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for Parkinsons Disease (disorder that causes nerve…

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 and follow the policy and procedure titled, Referrals to Outside Services, Resident Rights and NP04 Comprehensive Person-Centered Care Planning for two of five sampled residents (Residents 2 and Resident 3) when: 1. Licensed Nurse (LN) did not develop a care plan when Resident 2 refused all showers from 1/26/26-2/19/26.This failure had the potential to result in Resident 2 developing wounds and infections.2. Social Service department did not provide Resident 3 with transportation to his urology [a specialized branch of medicine that focus on diseases of the male and female urinary tract (the body's drainage system for removing waste and extra fluid, acting as a filter to produce, transport, store, and release urine)] appointment to assess removing his urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) for discharge and Resident 3 missed his appointment.This failure…

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 necessary services for activities of daily living to maintain personal and oral hygiene for three of four sampled residents (Resident 1, Resident 2, Resident 3), when the facility staff did not provide oral care or grooming to Resident 1, Resident 2 and Resident 3 daily. These failures resulted in Resident 1, Resident 2 and Resident 3 to feel unclean and placed residents at risk for loss of dignity and potential tooth decay, oral, respiratory and skin infections.Findings:During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for hemiplegia (weakness or complete loss of movement in the arm, leg, and sometimes face on that side) affecting…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow the policy and procedures Medication Storage, Disposal of Medications and Medication Related Supplies and have a secure medication destruction bin (MDB- a bin for unused medications that are set to be destroyed) for two of two medication rooms (Medication room [ROOM NUMBER] and Medication room [ROOM NUMBER]), when the medication destruction bins' lids were not sealed. This failure had the potential for drug diversion (when healthcare providers obtain or use prescription medicines illegally) and overall unsafe medication practices. Findings: During a concurrent observation and interview on 1/8/25 at 10:58 a.m., with the Nurse Supervisor (NS) 2 in the second-floor medication room, the medication room had a MDB with a lid that was loose and crooked. The MDB lid was not sealed. The NS 2 stated the lid was not secure to the bin and staff could have taken medications out of it. The NS 2 stated narcotics (highly addictive drug 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 store drugs in a safe manner for two of two medication rooms (Medication room [ROOM NUMBER] and Medication room [ROOM NUMBER]), when seven pills (Five in Medication room [ROOM NUMBER] and two in Medication room [ROOM NUMBER]) were found on the floor without packaging or labels. This failure had the potential for drug diversion (when healthcare providers obtain or use prescription medicines illegally) and overall unsafe medication practices. Findings: During a concurrent observation and interview on 1/8/25 at 10:58 a.m., with the Nurse Supervisor (NS) 2 in the second-floor medication room, the medication room had five different (shapes and colors) unidentifiable pills on the floor. The NS 2 stated there should not have been pills on the floor. The NS 2 stated the pills were unidentifiable (impossible to recognize) and could be any medication the facility provided, even a narcotic (highly addictive drug used for treating pain). The NS 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 the meal served on 1/7/25 reflected the menu items for 49 of 54 residents on the first floor (Resident 122, 73, 66, 34, 109, 88, 110, 69, 7, 84, 79, 3, 31, 96, 70, 61, 130, 131, 126, 37, 59, 105, 72, 111, 113, 108, 114, 64, 103, 65, 6, 8, 24, 39, 13, 60, 92, 23, 133, 20, 14, 15, 112, 86, 119, 48, 78, 101, 42) when residents received an alternate food for lunch on 1/7/25 due to the kitchen ran out of spinach bake. The facility failed to ensure the food served to the majority of residents on the first floor reflected the menu items served to other residents. The facility did not ensure sufficient food was cooked to serve the main menu items to all residents. This failure resulted in Residents 122, 73, 66, 34, 109, 88, 110, 69, 7, 84, 79, 3, 31, 96, 70, 61, 130, 131, 126, 37, 59, 105, 72, 111, 113, 108, 114, 64, 103, 65, 6, 8, 24, 39, 13, 60, 92, 23, 133, 20, 14, 15, 112, 86, 119, 48, 78, 101, 42 not receiving the same food distributed…

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 observations, interview and record review, the facility failed to provide meals at regular times comparable to normal mealtimes in the community or in accordance with resident requests, preferences for 141 of 141 sampled residents, when the lunch meal on 1/7/25 was served 30 to 45 minutes after the scheduled mealtime and the dinner meal on 1/10/25 was served 50 minutes after the scheduled mealtime. These failures had the potential to trigger resident feelings of anger and frustration which could diminish a resident's ability to eat resulting in a resident not meeting hydration and nutritional needs which could lead to unexpected weight loss or delay the timely recovery of clinical illness or injury. Findings: During an interview on 1/6/25 at 10:17 a.m. with Resident 3 on the 1st Floor, Resident 3 stated the meals were served late and wished meals would be served on time. Resident 3 stated lunch is typically served around 2:00 p.m., dinner served late around 7:30 p.m. During a record review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (CP-a detailed approach to care customized to an individual resident's needs) for two of 12 sampled residents (Residents 94 and 63) when: 1. Licensed nurses (LNs) did not implement CP for Resident 94's foley catheter (a thin, flexible tube that is inserted into your bladder to drain urine) to monitor signs and symptoms of infectious disease process. This failure had the potential for Resident 94 to develop an infection and placed an increased risk on Resident 94's health and safety. 2. Resident 63 did not have a comprehensive care plan for his diagnosis of Post Traumatic Stress Disorder (PTSD- a disorder in which a person has difficulty recovering after witnessing or experiencing a terrifying event). This failure had the potential to result in Resident 63 to not received the care needed for his PTSD which could result in serious mental health. Findings: 1. 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 follow the policy and procedure (P&P) to ensure the Care Plans (CP) were reviewed and revised for five of 23 sampled residents (Resident 45, 67, 74, 76, and 392) when: 1. The CP for Resident 45 was not reviewed and revised after Resident 45 had a fall and was sent to the acute care hospital. This failure placed Resident 45 at an increased risk for additional falls. 2. Resident 67's care plan was not updated and revised when his pressure ulcer (a wound which develops as a result of prolonged pressure to one area) progressed to a stage III (a deep skin wound where the full thickness of the skin is damaged, exposing the fatty layer underneath, but not reaching the muscle or bone) wound. This failure had the potential to result in Resident 67 to not receive the wound care needed. 3. Resident 74's care plan was not updated and revised for significant weight loss of above five percent in 30 days. This failure had the potential for Resident 74's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure professional standards of quality were met in accordance with the comprehensive care plan and facility policies and procedures for four of nine sampled residents (Residents 74, 67, 55 and 392) when: 1. Resident 67's change of condition and Nutritional Assessment for a facility acquired pressure ulcer (a wound which develops as a result of prolonged pressure to one area), Stage 2 pressure ulcer to right thigh and Stage 3 pressure ulcer to left buttock were not assessed. This failure had the potential for Resident 67's wounds to worsen which could result in more serious health condition. 2. Resident 74's change of condition for significant weight loss above five percent in one month was not developed and Interdisciplinary team (IDT-group of people with different areas of expertise working together to achieve a common goal) note was not completed. This failure had the potential to put Resident 74 at risk for further weight loss. 3.…

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 observations, interviews and record reviews, the facility failed to ensure food was palatable and served at an appetizing temperature when 5 of 32 sampled residents (Resident 3, 67, 74, 96 and 112) complained of the food being served cold, undercooked and without flavor. This failure had the potential for Residents 3, 67, 74, 96 and 112 not eating their meal and placed their nutritional status at risk which could potentially lead to weight loss. Findings: During a concurrent observation and interview on 1/6/25 at 8:47 a.m. with Resident 74, in Resident 74's room, Resident 74 was sitting on her walker seat in her room, alert and oriented and understood the questions clearly. Resident was clean and well groomed. Resident 74 stated she had been at the facility since June of last year. Resident 74 stated she could not tolerate the food at the facility. Resident 74 stated the food was undercooked and cold. Resident 74 stated her stomach was weak and anything could come up just looking at the food. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide a safe, functional, and comfortable environment for residents, staff and the public when: 1. Five of 23 residents' rooms on the first floor were observed with non functioning vertical blinds (window coverings made of long, vertical slats that are attached to a headrail and can be opened and closed by sliding along a track). These failures had the potential of violating residents rights to their privacy. 2. A hole measuring approximately 2.5 X 2.5 inches on the wall with exposed wiring. This failure had the potential to place residents and other staff in an unsafe environment which had the potential to lead to electrocutions and pest infestation. 3. room [ROOM NUMBER]'s ceiling light fixture did not have light bulb and Resident 55's overhead light had missing light bulb not providing adequate lighting to meet the needs of Resident 55. This failure resulted in Resident 55's room having decreased visibility resulting in eye straining, and had the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents were treated with dignity and respect for two of three sampled residents (Residents 69 and 191) when Residents 69 and Resident 191's urinary catheter (flexible tube inserted into bladder to drain urine) bag were uncovered and visible to other residents and visitors to see and not in accordance with facility's policy and procedure. This failure resulted in the violation of Residents 69 and 191's right to privacy and dignity. Findings: During a concurrent observation and interview on 1/6/25 at 7:50 a.m. in Resident 69's room, Resident 69 was lying in bed and observed with contractures (stiffening/shortening at any joint, that reduces the joint's range of motion) of right arms and left legs. Resident 69 had a urinary bag connected to urostomy (surgical opening in the abdomen to allow urine to drain from the body) and placed on top of Resident 69's bed. Resident 69's urinary catheter bag was uncovered and placed on top of 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 provide the right to self-administer medication for one of seven sampled residents (Resident 92), when Resident 92 had not been assessed for her ability to keep her albuterol (a medication which makes it easier to breathe) inhaler at bedside and self-administer it as needed. This failure violated Resident 92's right to self-administer her own medication and had the potential to cause her to experience breathing difficulties as a result of not having her inhaler nearby. Findings: During a review of resident 92's admission Record (AR- a document which provides resident contact details, a brief medical history level of functioning, preferences, and wishes), dated 1/9/25, the AR indicated, Resident 92 was her own responsible party (person designated to make decisions regarding treatment) and was admitted with asthma (lung disease which makes breathing difficult as a result of swelling in the airway), and shortness of breath (the feeling of not being able to breathe normally or deeply enough). 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 complete a Significant Change of Condition Assessment (an assessment which captures a major decline or improvement in a resident's condition) in the Minimum Data Set (MDS-a federally mandated resident assessment tool) assessment for one of five sampled residents (Resident 67) when Resident 67 developed a facility acquired Stage 3 pressure ulcer (a wound which develops as a result of prolonged pressure to one area) to left buttock and did not have a significant change of condition assessment in accordance with facility's policy and procedure. This failure placed Resident 67 at risk for further decline in health including worsening of her wounds. Findings: During a concurrent observation and interview on 1/6/25 at 10:45 a.m. with Resident 67, in Resident 67's room. Resident 67 was observed lying in bed watching television, clean and well groomed. Resident 67 was alert and oriented and understood questions clearly. Resident 67 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Level l Preadmission Screening and Resident Review (PASRR- The State is required to ensure that every person entering a Medicaid certified Nursing Facility [NF] receives a admission level screening and if necessary a level ll evaluation to ensure that their NF residence is appropriate and to identify what specialized services they may need) was completed accurately for one of six sampled residents (Resident 17) when Resident 17 was re-admitted to the facility on [DATE] and an updated PASRR was not completed. This failure had the potential for Resident 17 not to receive the necessary and appropriate psychiatric treatment and evaluation in the facility. Findings: During a review of Resident 17's admission Record [AR], dated 1/9/25, the AR indicated, Resident 17 was readmitted to the facility on [DATE] with diagnoses which included Depressive disorder (mental health condition that involves a persistent low mood and loss of interest 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 complete personal hygiene and follow the policy and procedure (P&P) Grooming Care of the Fingernails and Toenails for one of one sampled residents (Resident 94), when staff did not cut Resident 94's fingernails on his contractured (a permanent tightening of the muscles, tendons, skin, or nearby tissues that limits the range of movement of a joint or body part) right and left hands. This failure resulted in Resident 94 to have long fingernails that were growing into his hand with the potential to cause pain and infection. Findings: During a review of Resident 94's admission Record (AR) the AR indicated, Resident 94 was admitted to the facility on [DATE] with a diagnosis which included paraplegia (the inability to voluntarily move the lower parts of the body), contracture of the left and right hand (a permanent tightening of the muscles, tendons, skin, or nearby tissues that limits the range of movement of a joint or body part) and muscle…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide foot care and follow the policy and procedure (P&P) Grooming Care of the Fingernails and Toenails for one of seven sampled residents (Resident 40), when staff did not cut Resident 40's toenails. This failure resulted in Resident 40 having thick and long toenails and placed resident 40 at risk for an infection and pain when ambulating. Findings: During a review of Resident 40's admission Record (AR), dated 1/10/25, the AR indicated, Resident 40 was admitted to the facility on [DATE] with a diagnosis which included muscle weakness (loss of muscle strength) and unspecified dementia (the loss of brain functioning, such as, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). During a review of Resident 40's Minimum Data Set (MDS -a federally mandated resident assessment tool) assessment dated [DATE], Resident 40's MDS assessment indicated, Resident 40's Brief Interview…

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

Based on observation, interview, and record review, the facility failed to ensure one of seven sampled residents (Resident 92) was provided food that accommodated her allergies and preferences, when Resident 92 had a listed dislike and allergy for lactose (sugar present in milk) products and was served milk on 1/7/25. This failure had the potential to cause Resident 92 to experience distress and an allergic reaction if she drank the milk. Findings: During a review of resident 92's admission Record (AR- a document which provides resident contact details, a brief medical history level of functioning, preferences, and wishes), dated 1/9/25, the AR indicated, Resident 92 had an allergy to lactose and was admitted with gastroesophageal reflux disease (GERD- a condition where stomach contents flow back up into the throat), asthma (lung disease which makes breathing difficult as a result of swelling in the airway), and shortness of breath (the feeling of not being able to breathe normally or deeply enough). During a review of Resident 92's Minimum Data Set (MDS- resident assessment tool…

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

Based on observation, interview, and record review, the facility failed to provide a mechanical soft diet (a diet that involves only foods that are physically soft with the goal of reducing or eliminating the need to chew the food) according to the physician order for one of 32 sampled residents (Resident 83) when, Resident 83 did not receive mechanical soft diet per physician's order and was served whole kernel corn with her meal. This failure placed resident 83 at risk for choking and aspiration (when food, liquid, or other material enters a person's airway and eventually the lungs by accident). Findings: During a concurrent observation and interview on 1/6/25 at 8:24 a.m. with Resident 83 in Resident 83's room, Resident 83 was observed lying in bed wearing a gown. Resident 83 stated she had been at the facility for three years. Resident 83 stated the food served was always cold and tasted bad. Resident 83 stated she had no teeth, and the facility gave her food she could not chew. Resident 83 stated she was on a mechanical soft diet, but the facility did not always chop her food.…

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 accurate and complete medical records in accordance with facility's policy and procedure (P&P) and professional standards of practices for one of five sampled residents (Resident 137) when the Physician Orders for Life-Sustaining Treatment (POLST- a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) was not accurate and complete. Sections C for POLST form which included -artificially administered nutrition, physician signature, physician license, physician phone number, and date was incomplete. This failure had the potential for Resident 137's decisions regarding treatment options and end-of-life wishes to not be honored. Findings: During a review of Resident 137's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide a sanitary environment to prevent the development and transmission of communicable diseases and infections for one of two sampled residents (Resident 55) when Resident 55's oxygen nasal cannula (O2 NC- tube that directs oxygen into the nose) tubing and nebulizer mask (a mask used to inhale liquid medication in the form of a mist to treat lung conditions) were laying on the residents nightstand not in a protective bag. This failure had the potential to result in Resident 55's O2 NC tubing and nebulizer mask getting bacteria and potentially resulting in a respiratory infection (an illness that inflames the respiratory system, which includes the throat, nose, airways, and lungs). Findings: During a review of Residents 55's admission Records (AR), the AR indicated, Resident 55 was admitted to the facility on [DATE] with an admission diagnosis which included Chronic Obstructive Pulmonary Disease (COPD a condition of the airways and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide services which met professional standards of quality for one of nine sampled residents (Resident 1) when, Licensed Vocational Nurses (LVN)s did not administer oxygen (O2- a colorless, odorless and tasteless gas essential for life) per physician's order for Resident 1 and physician ordered parameters for O2 administration were not followed. LVNs did not document the administration of O2 treatment for Resident 1 in Treatment Administration Record (TAR). This failure had the potential for Resident 1 to receive inadequate amount of O2 which could affect her health and well-being. Finding: During a review of Resident 1's admission Record (AR) (a document containing demographic information), undated, the AR indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses that included Type 2 Diabetes Mellitus (body has trouble controlling blood sugar) Adult Failure to Thrive, Shortness of Breath, Hypoxemia (absence of enough oxygen 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 residents were free form involuntary seclusion not required to treat the resident's medical symptoms for two of three sampled residents (Resident 1 and Resident 2), when Licensed Vocational Nurse (LVN) 1 closed the door to Resident 1 and Resident 2's room while the needs of both residents (Resident 1 and Resident 2) were not met. This failure resulted in isolation for Resident 1 and Resident 2 and their basic care needs were unmet. Resident 1 expressed feeling sad, unheard and angry when she did not receive the assistance to leave her room to a quiet area of choice and was instead left in her room with Resident 2, while Resident 2 was yelling with closed door. Findings: During a concurrent observation and interview on 7/31/24 at 9:16 a.m. with Resident 1, in Resident 1's room. Resident 1 was observed crying while recalling events that transpired on 7/13/24. Resident 1 stated on the night of 7/13/24, Resident 2 was experiencing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation interview and record review the facility failed to provide a safe environment for 28 of 134 residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, Resident 11, Resident 12, Resident 13, Resident 14, Resident 15, Resident 16, Resident 17, Resident 18, Resident 19, Resident 20, Resident 21, Resident 22, Resident 23, Resident 24, Resident 25, Resident 26, Resident 27 and Resident 28) when 15 resident rooms were observed to have loose window screws that were used to secure the windows in place from opening more than three inches (unit of measure) on the second and third floors of the facility. This failure placed residents in an unsafe environment which could potentially lead to an avoidable resident injury. Findings: During an interview on 7/12/24 at 8:45 a .m., with the administrator (ADM). The ADM stated that Resident 1 had opened the window in her room located on the second floor and jumped off to the ground on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to maintain an effective pest control program to keep the facility free of pests for 181 out of 181 residents, when on 7/9/2024 the dish washing station was observed with roaches crawling in the sink with dirty dishes, numerous roaches crawling up the walls and dishwasher. The floor to the dish washing room had roaches crawling into the dish racks located near the sink on the floor where dirty dishes were placed to go into the dishwasher. The clean dish area had roaches crawling around the counter and wall. The dishwasher itself had roaches swimming in the water inside. The walls of the dishwashing area had roaches nesting in the corners. This failure resulted in an unsanitary work environment where food was prepared and had the potential to cause harm to 181(the census during the survey) residents due to cross contamination and transmission of infections from cockroaches' infestation that could place residents at risk for food borne…

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 needed care according to professional standards of practice for one of three sampled Residents (Resident 1) when Resident 1 did not receive pain medication according to physician ' s order for three days. This failure had the potential to result in inadequate pain management for Resident 1. Findings: During a concurrent observation and interview on 6/11/24 at 9:31 a.m. with Resident 1 in Resident 1's room, Resident 1 was observed lying in bed guarding her abdomen with hands and complaining of abdominal pain. Resident 1 stated she did not want to talk at the moment regarding alleged incident and continued to complain of abdominal pain. During a review of Resident 1's admission Record (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), indicated, Resident 1 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.

Based on interview and record review, the facility failed to provide care in accordance with professional standards of practice when one of nine sampled residents (Resident 1) had dry, cracked peeling skin to his left foot and there was no documented weekly skin assessment that included documentation of Resident 1's feet appearance by the licensed nurses since 9/9/23. This failure had the potential for Resident 1's left foot treatment status and progress to worsen. Findings: During a review of Resident 1's admission Records, dated 2/20/17, the admission Records indicated, Resident 1 was admitted to the facility with a diagnosis of Type 2 Diabetes Mellitus (a condition that affects the way the body processes blood sugar), adult failure to thrive, and chronic venous hypertension with ulcer to left lower extremity (increase in blood pressure causes ulcers). During a review of Resident 1's Order Summary, dated 9/1/23, the Order Summary indicated, .Left Lower Extremity Edema [fluid trapped in the body's tissues] with Drainage: cleanse entire lower leg with normal saline, pat dry 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 observations, interviews, record review, and facility document review, the facility failed to serve palatable food for 2 of 2 sampled test trays. This deficient practice had the potential to affect 122 of 122 residents who received meals from the kitchen. Findings included: A review of the facility's planned menu for the week of 10/02/2023 through 10/08/2023, revealed the following meals were planned: - 10/03/2023 Lunch: chicken with rosemary sauce, boiled red potatoes, seasoned peas, cornbread, and ice cream. - 10/04/2023 Lunch: beef cubes with mushrooms, egg noodles, seasoned spinach, tossed green salad, and spiced applesauce cake. During an interview on 10/02/2023 at 9:25 AM, Resident #73 stated the food was terrible and the alternative menu consisted of three other items residents could choose from, but those were also bad. A review of Resident #73's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/04/2023, revealed Resident #73 had a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact.…

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, record review, and facility policy reviews, the facility failed to ensure 1 (Resident #31) of 2 sampled residents reviewed for assistance with activities of daily living (ADLs) were treated with dignity during mealtimes. Specifically, facility staff placed a meal tray in front of Resident #31, left the room, and continued to deliver trays to other residents before returning to feed Resident #31. In addition, Resident #31's roommates were served and consumed their meals before Resident #31 received their meal tray. Findings included: A review of the facility's policy titled, Dining Program, revised 01/01/2012, revealed Purpose To ensure that the Facility serves meals in a timely manner, provides residents with adequate supervision and/or assistance during meal times, and maintains adequate nutrition and hydration of residents. A review of the facility's policy titled, Resident Rights, revised 01/01/2012, revealed, Employees are to treat all residents with kindness, respect and dignity and honor the exercise of residents' rights. A review of an…

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

Based on observations, record review, interviews, and facility policy review, the facility failed to ensure 1 (Resident # 31) of 2 sampled residents reviewed for assistance with activities of daily living (ADLs) had a care plan that addressed the level of assistance the resident required for ADLs. Findings included: A review of a facility policy titled, Comprehensive Person-Centered Care Planning, revised in November 2018, revealed, Purpose To ensure that a comprehensive person centered care plan is developed for each resident. Policy It is the policy of this Facility to provide person-centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being. The policy further specified, IV. Comprehensive Care Plan a. Within 7 days from the completion of the comprehensive MDS [Minimum Data Set] assessment, the comprehensive care plan will be developed. All goals objectives, interventions,…

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, record review, interviews, and facility policy review, the facility failed to ensure 1 (Resident #62) of 4 sampled residents reviewed for smoking did not use an electronic cigarette device (e-cigarette; vape product) in their room. In addition, staff failed to ensure Resident #62's Smoking and Safety assessment reflected the resident's use of vape products, despite staff's knowledge the resident vaped. Findings included: A review of a facility policy titled, Smoking by Residents, revised in January 2017, revealed, Purpose To provide a safe environment for residents, staff, and visitors. Policy It is the policy of this facility to accommodate residents who desire to smoke by taking reasonable precautions, providing a safe environment for them, and protecting the non-smoking residents. Smoking whether it is traditional tobacco or herbs (does not include marijuana or its derivatives) smoked in cigarettes, pipes, cigars or electronic cigarettes are governed by this policy. Procedure Definitions: A. Smoking is the inhalation of the smoke of burning tobacco or other…

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, record review, and facility policy review, the facility failed to ensure nursing staff followed a physician's order for water flushes for 1 (Resident #102) of 1 resident in the facility with a gastrostomy tube (a surgically placed device used to administer supplemental feeding, hydration, or medication directly to the stomach). Specifically, Resident #102 was ordered to receive a 200 milliliters (mL) water flush every four hours (q4h), but during 2 of 4 observations, the resident only received 150 mL q4h. Findings included: A review of the facility policy titled, Tube Feeding/ TPN [total parental nutrition], revised on 06/01/2014, revealed, Purpose: To ensure that the Facility meets the nutritional guidelines and resident's nutritional requirements per physician orders. A review of Resident #102's admission Record revealed the facility admitted the resident on 10/25/2022. Per the admission Record, Resident #102 had a medical history that included diagnoses of dysphagia (difficulty swallowing foods or liquids) following cerebral infarction (stroke),…

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, record review, and facility document and policy review, the facility failed to serve meals according to the planned menu. Specifically, planned menu items were not provided to all residents who received food from the kitchen for 2 of the 6 meals observed during the recertification survey. Findings included: A review of the facility policy titled, Menus, revised on 04/01/2014, revealed, The Dietary Manager will develop menus in collaboration with the Dietitian. Menus are to be designed in consideration of resident preferences, Dietary Department resources, and seasonal availability of foods. Daily menus will include planning for three meals and an evening snack. Selective menu plans are based on weekly cycles. Menus should be adjusted seasonally and allow for specialty food items, typically served during holidays. The policy further indicated, Food served should adhere to the written menu. A review of the facility's planned menu for the week of 10/02/2023 through 10/08/2023, revealed the following meals were planned: - 10/02/2023 Lunch: homestyle…

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.