Pacific Gardens Nursing And Rehabilitation Center

Based on observation, interview, and record review, the facility failed to ensure activities of daily living (ADL's- routine activities such as grooming, bathing, dressing and toileting a person performs daily to care for themselves) was not provided for one of three sampled residents (Resident 178), when Resident 178's fingernails on both hands were long, jagged (sharp, uneven edges), and dirty with brownish to blackish dirt built up underneath her nails.This failure had the potential for Resident 178 to obtain skin-related injuries including cuts, scratches, and infections.During a concurrent observation and interview on 4/22/26 at 1:03 p.m. with Resident 178 in Resident 178's room, Resident 178 was observed having a Peripherally Inserted Central Catheter (PICC -a long, thin tube that's inserted through a vein in the arm) line placed to her right upper arm. Resident 178 stated her antibiotic was given through the PICC line. Resident 178 stated she was admitted to the facility since April 19, 2026. Resident 178 stated her nails were long, dirty, and felt like a mess. Resident 178…

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 acceptable parameters of nutritional status were maintained for one resident (Resident 12) when when weekly weights were not implemented to track and monitor the effectiveness of interventions that were put into place such as snacks, nutritional shakes and daily intake.This failure resulted in a weight loss of 4.49 % (percent) in a month from 11/19/25 to 12/17/25, 13.48 % in three months from 11/19/25 to 2/18/26, and 9.14% in three months from 12/17/25 to 3/18/26 for Resident 12. Findings: During an observation on 4/21/26 at 8:19 a.m. with Resident 12, in Resident 12's room, Resident 12 was sitting up in bed with breakfast tray on bedside table, cover off plate with a hard-boiled egg.During an observation on 4/23/26 at 10:08 a.m. with Resident 12, in Resident 12's room, Resident 12 was lying asleep in bed, with bilateral mats (a cushioned floor pad designed to help prevent injury should a person fall) on the floor.During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of seven sampled Residents (Resident 12) was assessed 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 in various sizes that attach to the bed, and can be placed in a guard (raised) or lowered) prior to installation and had a consent form (form signed by resident or family explaining the risks of side rail use), physician order, indication for use, and care plans prior to the use of side rails when, Resident 12 had bed rails on the right and left side of her bed in the guard position (a position that is intended to prevent an individual from inadvertently rolling out of bed).These failures had the potential to cause entrapment, serious harm, injury, or death to Resident 12.Findings:During an observation on 4/21/2026 at 7:02 a.m. in Resident 12's room, Resident 12 was observed asleep in bed, wearing a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents were free of significant medication errors, when one resident (Resident 34) was administered expired latanoprost ophthalmic solution (a medication for glaucoma-eye diseases that damage the optic nerve, often due to high fluid pressure inside the eye, leading to irreversible vision loss or blindness) for over one month.This failure put Resident 34 at risk for infection due to bacteria or fungi growth from the expired medication and at risk of uncontrolled glaucoma, leading to permanent vision loss over time.Findings:During a concurrent observation, interview and record review on [DATE] at 1:14 p.m. in nursing station 4b with Charge Nurse (CRN) 1, latanoprost 2.5 ml (milliliters- metric unit used to measure the volume of a liquid) ophthalmic solution partially used and almost empty bottle with open date [DATE] and beyond use date [DATE] was in the medication cart available for use for Resident 34. CRN 1 stated discontinued…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure residents' food was prepared and processed appropriately to meet residents' needs for two of three sampled residents (Resident 86 and Resident 73) when large pieces of broccoli were not in proper form of minced and moist on their lunch meal tray on 4/23/26.This failure to properly process the minced and moist food can result in choking (when the airway is obstructed by food, drink, or foreign objects) for Residents 86 and 73 on a minced and moist diet at the facility. During a review of the lunch menu for 4/23/26 indicated, for the MM5 (minced and moist level 5 diet) the following: Japanese Vegetable Blend. soft mashed broccoli, sweet and sour pork SBMM (soft and bite and minced and moist), rice, puree bread.During an observation of the lunch meal service on 4/23/26 at 12:39 p.m. in the kitchen, Resident 86's lunch plate contained minced sweet and sour pork, rice, puree bread and large pieces of broccoli. The Registered Dietitian…

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 resident's food preference was provided for one of 20 sampled residents (Resident 26) when Resident 26's lunch tray did not include double protein (one of the many substances found in food such as meat, cheese, fish, or eggs, that is necessary for the body to grow and be strong) on 4/21/26.This failure had the potential for Resident 26 not to receive her food preference which can result in undernutrition that could compromise her medical and nutritional status.During a review of the lunch menu for 4/21/26 indicated, for the house (regular diet) the following: .Baked Honey Glazed Ham 4.4 oz (ounces- a standard unit of weight), Baked Sweet Potato1 each, French Style [NAME] Beans 1/2 (half) cup.During a review of Resident 26's lunch meal ticket during the lunch meal service, Resident 26's lunch meal ticket showed two servings of protein under the standing order. During a concurrent observation of the lunch meal service and interview on…

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 food was stored, prepared and served in accordance with professional standards for food safety when:1. Gloves were not changed by Dietary [NAME] (DC) 2 after handling non-food items (a box made of cardboard) while making sandwiches for the residents' lunch meal on 4/22/26.This failure had placed residents at an increased risk of acquiring food-borne illnesses (an illness that comes from eating contaminated food [refers to food or beverages containing harmful microorganisms (bacteria, viruses, parasites), toxins, or foreign physical/chemical substances that make them unsafe for human consumption]).2. Incorrect thermometer usage in residents' freezer. Residents' freezer contained an oven thermometer (used to measure high heat to ensure accurate baking and identify hot spots).This failure had the potential for not obtaining and maintaining accurate temperatures for cold foods which could lead to the growth of microorganisms (bacteria) and placed residents at an increased risk of acquiring 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 establish and maintain an effective infection prevention and control program to help prevent the development and transmission of infections for two of seven sampled residents (Resident 18, and Resident 43) when:1. Resident 18 was placed on Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce transmission of resistant organisms [bacteria that have become resistant to certain antibiotics] that requires gown and glove use during high contact resident care activities) and Certified Nursing Assistant (CNA) 2 and CNA 3 did not put on the appropriate personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) prior to providing high contact care to Resident 18.2. Resident 43's nasal cannula (NC-a flexible tube with two prongs that fit inside the nostrils), and oxygen tubing (flexible tube connected to an oxygen source)…

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 professional standards of quality and the standard of practice according to the facility's policy and procedure (P&P) titled, Charting and Documentation for five of five sampled residents (Resident 1, 2, 3, 4, and 5), when:Licensed Vocational Nurse (LVN) 1 did not document the wound (any physical injury that disrupts the anatomical structure and functional integrity of skin, mucous membranes, or other body tissues) care for Resident 1 on 12/27/25 during the day shift.LVN 2 did not document the wound care for Resident 2 on 12/4/25 during the night shift.LVN 2 did not document the wound care for Resident 3, 4, and 5 on 1/21/26 during the night shift.This failure had the potential to result in infection and delayed wound healing for Resident 1, 2, 3, 4, and 5.Findings:During a record review of Resident 1's admission Record (AR), dated 4/1/26, the AR indicated Resident 1 had a history of Metabolic Encephalopathy (a brain dysfunction caused by systemic illness, organ failure, or toxicities, rather than structural damage),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow the policy and procedure (P&P) titled, Admission, Transfer, Discharge and Bed-Holds, for one of three sampled residents (Resident 1) when Resident 1 (a veteran - someone who has served in a nation's armed forces) was denied admission for rehabilitation services based on payment source. This failure had the potential to delay recovery for Resident 1 following an Esophagogastroduodenoscopy (EGD - a medical procedure used to examine the lining of the esophagus, stomach, and the first part of the small intestine), Robotic Ivor [NAME] Esophagectomy (a minimally invasive surgical procedure with the use of a surgical robot to remove a portion of the esophagus to treat cancer) and Exploratory Laparotomy (a surgical procedure involving a large incision in the abdomen to visually examine the abdominal organs to identify the cause of unexplained symptoms or injuries).During an interview on 8/26/25 at 11:01 a.m. with [Hospital A] Social Worker (SW), the SW…

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 inform and provide written information on how to formulate an advance directive (a legal document that outlines a person's wishes regarding their medical care in the event they become unable to make decisions for themselves due to illness or injury) for four of 163 residents (Resident 12, Resident 30, Resident 57 and Resident 306) when the facility did not document information on how to obtain an advance directive in residents charts. This failure violated the rights of Resident 12, Resident 30, Resident 57 and Resident 306, which could have potentially prevented these residents' wishes from being followed if they were unable to make decisions. Findings: During an interview on 2/3/25 at 8:55 a.m. with Resident 30 in Resident 30's room, Resident 30 stated she did not have an advanced directive and the facility did not speak to her about formulating one. During a review of Resident30's admission Record (AR-a document with personal identifiable and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a safe, clean, comfortable, and homelike environment for: 1. Two of 156 residents (Resident 34 and Resident 57) when Resident 34 and Resident 57 were cold at night and staff did not ensure the temperature range was between 71-81-degree Fahrenheit (a measurement of temperature on a standard in which 32 degrees is the temperature at which water freezes and 212 degrees that at which it boils) This failure resulted in an uncomfortable homelike environment for Resident 34 and Resident 57, which had the potential risk for causing hypothermia (a medical emergency that occurs when your body loses heat faster than it can produce heat) in an already vulnerable population due to their decreased ability to regulate heat. 2. When Resident 42's wall was observed with one large hole and one small hole with exposed insulation and wiring on the wall behind the bed. This failure had the potential to result in exposure to environmental hazards…

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 properly store, and label drugs and supplies in accordance with acceptable standards of practice when: 1. Two inhalers did not have an open date and expiration date for two of 16 sampled residents (Resident 507 and Resident 36). 2. Two of four sampled refrigerators' temperatures were not within parameters that stored three residents (Resident 558, Resident 138, and Resident 506) medications. These failures had the potential to place Residents at risk of receiving spoiled, expired, and ineffective medications and placed Residents at risk for experiencing adverse reactions (define) from spoiled, expired and ineffective medications. Findings: 1. During a concurrent observation and interview on 02/04/25 at 3:01 p.m. with Licensed Vocational Nurse (LVN) 3 in Station 1 medication cart, an inhaler (a small, handheld device that delivers medications directly into the lungs) of fluticasone (define), umeclidinium (define), and vilanterol…

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 cook staff failed to accurately measure milk and margarine when preparing the pureed rice recipe for 12 of 12 sampled Residents (Resident 64, 505, 78, 95, 9, 96, 111, 123, 65, 93, 74, 85) with a pureed diet order. This failure had the potential to result in 12 Residents (Resident 64, 505, 78, 95, 9, 96, 111, 123, 65, 93, 74, 85) to receive reduced or excess amount of nutrients in their food potentially leading to unexpected weight loss or weight gain. Findings: During a concurrent observation and interview on 2/4/25 at 10:28 a.m. with the [NAME] (COOK) 1 in the kitchen, COOK 1 measured 1.5 cup of milk using the 1/2 cup metal measuring cup three times, and the milk did not level to the top edge of the measuring cup for each measurement. COOK 1 placed a round plastic measuring cup that was larger than the width of the square block of margarine, pushed the measuring cup completely through the block of margarine leaving open areas between the block and measuring cup wall, and the margarine was not pushed down to ensure 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 maintain safe and sanitary food preparation and storage practices when: 1. A box of potatoes was not labeled with a received date or use-by date. 2. A dietary aide failed to wash their hands after scratching their ear and continued to place clean cups in a clean crate. 3. Thawing frozen beef kabobs were not labeled with the prepared by or use-by date, was found in the walk-in refrigerator. 4. Dust was identified on the ceiling above the fan in the food storage room. These failures had the potential to cause food borne illness to a highly susceptible population of 163 residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview on 2/3/25 at 8:02 a.m. with the Dietary Manager (DM) in the kitchen, raw potatoes were stored in an uncovered box without a label identifying the received date or use-by date. The DM stated the box of potatoes were not dated. The DM stated all food should be dated so kitchen staff knew how long food had been on the shelf. The DM stated old…

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 6. During a concurrent observation and interview on 2/3/25 at 8:51 a.m. with Resident 505 in the resident's room, Resident 505 was sitting upright in bed wearing glasses, a dark blue sling cradled her right arm, and an oxygen nasal cannula and oxygen tubing were lying on the floor. Resident 505 was alert and oriented, able to state her name, date, location and was able to understand and answer questions. Resident 505 stated she did not use oxygen continuously and was not aware the tubing was on the ground. During a record review of Resident 505's admission Record (AR), dated 2/6/25, the AR indicated, Resident 505 was admitted to the facility on [DATE] with diagnoses: fall with a left broken thigh bone surgically repaired with an artificial hip joint, uneven broken right collarbone, and difficulty breathing. During a review of Resident 505's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 2/4/25, the MDS section C indicated, Resident 505 had a Brief Interview for Mental Status (BIMS-an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure corridors were equipped with firmly secured handrails on each side of the corridor. This failure put residents at increased risk for falls when utilizing the handrail for assistance with walking. Findings: During an observation on 2/03/25 at 8:43 a.m. in the Station 2 Hallway, across from room [ROOM NUMBER], the handrail across the hall was observed to be broken and loose. The handrail next to room [ROOM NUMBER] on the west side of the doorway was observed to be missing a curved piece of wood exposing the metal bracket and screws. During an interview on 2/05/25 at 10:34 a.m. with the Maintenance Supervisor (MS), the MS stated the facility used the TELS System to notify his department of any issues that needed repair. The MS stated any staff could access the system for repairs. The MS stated he was notified of broken handrails, and they were repaired right away. The MS stated the curved ends of the handrails were obsolete and the facility could 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 facility failed to ensure dignity was provided for two of 11 sampled residents (Resident 3, and 305) when: 1. Resident 3's foley catheter (a soft, flexible tube inserted into the bladder to help drain urine into a bag) drainage bag was without a dignity bag (a bag used to the cover and hold the catheter drainage and collection bag so it is not visible), leaving the urine visible to anyone who walked into Resident 3's room This failure resulted in Resident 3 not being provided his right to have a dignified existence while in the facility. 2. Resident 305's foley catheter drainage bag was without a dignity bag. This failure violated Resident 305's privacy and had the potential to affect the self-esteem, self-worth, and quality of life of Resident 305. Findings: 1. During an observation on 2/3/25 at 9:57 a.m. in Resident 3's room, Residents 3 foley catheter bag was uncovered leaving the urine visible to anyone who entered the room. During a concurrent…

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 residents and residents' responsible party (RP- a person designated to make decisions for a resident) written information regarding the bed hold policy for two of six sampled (Resident 3 and Resident 455) when: 1. No written notices about the facility's bed hold policy was provided to Resident 3 or their RP when he was transferred to the hospital on 2/2/25. This failure violated Resident 3 and his RP's right to be notified in writing of the facility's bed hold policy. 2. Resident 455 was not provided a bed hold policy prior to being transferred out of the facility due to being a non-Medi-Cal member. This failure had the potential to result in loss of bed availability, confusion, disputes, and quality of care concerns for Resident 455. Findings: 1. During a concurrent interview and record review on 2/6/25 at 10:53a.m. with Licensed Vocational Nurse (LVN) 3, Resident 3's Notice of Transfer (NT),dated 2/6/25 was reviewed. The NT indicated Resident 3 was transferred to the hospital on 2/2/25. LVN 3 stated nursing staff…

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 7 of 36 sampled residents (Residents 20, 26, 34, 37, 54, 86, and 409) when: 1. Resident 37 did not have a CP developed for an indwelling foley catheter (a thin, flexible tube that is inserted into your bladder to drain urine). This failure of developing a CP for Resident 37's foley catheter had the potential to place Resident 37's safety at risk and her specific needs not being met. 2. Resident 26's CP interventions were not implemented to meet his visual needs. This failure resulted in Resident 26 not wearing his glasses for five days which had the potential to lead to injury or decreased participation in activities of daily living (ADLs). 3. Resident 409's CP was not developed to address the use of an anticoagulant (blood thinner). This failure had the potential for Resident 409 to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to revise a comprehensive person-centered care plan for one of three sampled residents (Resident 120), when Resident 120's care plan had active treatment interventions (actions to address resident identified needs) for a stage two pressure ulcer (partial-thickness loss of skin, presenting as a shallow open sore or wound) that had already healed. This failure had the potential for Resident 120's care to not be centered and could cause unclear communication amongst the healthcare team. Findings: During the review of Resident 120's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes) dated 12/8/23, the AR indicated Resident 120 was admitted on [DATE] with the diagnoses of: hypertension (HTN-high blood pressure), obesity (excessive fat accumulation that presents a health risk), and gait abnormalities ( unusual or irregular walking pattern). 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 meet professional standards of practice for two of nine sampled residents (Resident 112 and Resident 306) when: 1. Resident 112 was receiving 2.5 liters per minute (LPM- a unit that expresses flow rate define) of oxygen when the continuous oxygen ordered was for 2 LPM. 2. Resident 306's oxygen flow rate was set at 3 L/min and not 2 L/min as indicated on the physician order (a set of instructions written by a doctor for clinicians to follow when caring for a resident). These failures had the potential to result in serious health conditions for the resident including oxygen toxicity that could cause damage to lung tissue and respiratory issues. 3. Resident 306's oxygen tubing was not labeled with the date the tubing should be changed. This failure put Resident 306 at risk of infection. Findings: 1. During a review of Resident 112's admission Record (AR), dated 2/5/25, the AR indicated Resident 112 had a diagnosis of Chronic Obstructive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of five sampled Residents (Resident 28), received toenail care consistent with professional standards of practice when Resident 28's toenails were long and jagged. This failure resulted in Resident 28's toenails to become long, jagged, and caused discomfort which had the potential to lead to ingrown toenails, infection, and injury. Findings: During a review of Resident 28's admission Record (AR- document containing resident personal information), dated 11/25/24, the AR indicated, Resident 28 was admitted to the facility on [DATE], with diagnoses which included, displaced intertrochanteric fracture of right femur (a break in the bone just below the hip joint) subsequent encounter for closed fracture (a type of bone break where the broken bone does not penetrate the skin) with routine healing, muscle weakness generalized, need for assistance with personal care, and other reduced mobility. During a review of Resident 28's Minimum…

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 six sampled residents (Resident 37), was free from accidents when: 1. Resident 37's foley catheter (helps drain urine from your bladder) tubing was wrapped around her prosthetic (artificial leg that replaces the part of the leg below the knee joint) right lower leg while sitting in her wheelchair. This failure had the likelihood to cause a fall or injury to Resident 37 via the catheter tripping her during a transfer (movement from wheelchair to bed and vice versa) or being pulled from her bladder as a result of being caught on her prosthesis (artificial leg). Findings: 1. During a review of Resident 37's Face Sheet (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 2/5/25, the Face Sheet indicated, Resident 37 was admitted to the facility on [DATE] with 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 observations, interview, and record review the facility failed to post the total number of licensed and unlicensed staff and actual hours worked when the posting did not represent the actual hours worked by direct care staff daily. This failure resulted in all residents and their family members to not have access to view the actual direct care staff hours and total number of direct care staff providing care daily and possibly not meeting the needs of the residents. Findings: During an observation on 2/6/25 at 2:35 p.m. in the hallway, the Census and Direct Care Services Hours Per Patient Day (DHPPD) form (a document used in healthcare facilities, to track the total number of direct care hours provided to patients each day) did not contain the total number and the actual hours worked by Registered Nurses (RN), Licensed Vocational Nurses (LVN) and Certified Nursing Assistants (CNA). During an interview on 2/6/25 3:46 p.m. with the Assistant Staff Development Coordinator (ASDC), the ASDC stated she was responsible for filling out the DHPPD form. The ASDC stated, I cannot tell…

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 drug regimen which was free from unnecessary drugs for one of six sampled residents (Resident 3) when Resident 3 was administered mirtazapine (a medication used to treat depression [a condition characterized by extreme sadness]) from 11/2/24 to 2/6/24 without any documented attempts at a gradual dose reduction (GDR- a system used to slowly stop the use of medication over time). This failure had the potential of causing Resident 3 to receive unwanted side effects such as dry mouth, dizziness, constipation, drowsiness, and headaches as a result of being given the mirtazapine unnecessarily. Findings: During a review of Resident 3's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 2/6/25, the AR indicated, Resident 3 was admitted to the facility with diagnoses of depression and anxiety (a mental health disorder characterized by…

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 six sampled residents (Resident 556), were free of any significant medication errors when Resident 556's potassium chloride (a type of salt that gives the body potassium that gives the body minerals needed for the muscle and heart) 20MEQ (milliequivalent- a unit of measure) was not given according to manufacturer's instructions. This failure had the potential to cause poor absorption of the medication (meaning the body could not use it properly) and stomach upset for Resident 556. Findings: During an observation on 02/04/25 at 9:25 a.m. in Resident 556's room, Resident 556 was awake and lying down in bed watching tv. During a concurrent observation and interview on 02/04/25 at 9:56 a.m. with RN 1, Resident 556's potassium medication blister pack (a card that packages doses of medication within small, clear, or light-resistant amber-colored plastic bubbles [or blisters]) indicated, .Potassium CHL (chloride) 20MEQ TABLET .GIVE…

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 accurate and complete medical records in accordance with professional standards of practice were maintained for one of five sampled residents Resident 306, 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 complete. This failure had the potential for Resident 306's decisions regarding treatment options and end of life wishes to not be honored. Findings: During a concurrent observation and interview on [DATE] at 10:18 a.m. with Resident 306 in Resident 306's room, Resident 306 was observed dressed, lying in bed with oxygen infusing via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) at 3L/min (Liters per minute - a unit of measurement). Resident 306 stated she had been at the facility for five or six days due…

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 meet professional standards of practice for one of three sampled residents (Resident 1) when License Vocational Nurse (LVN 1) did not perform necessary assessment of her assigned residents and continued to document on Resident 1's clinical record Resident 1's vital signs, pain assessment, feeding tube assessment, enteral feeding intake, and provided non-pharmacological pain interventions care she did not provide from 12/25/21 to 12/30/21 during the time Resident 1 was admitted in general acute care hospital (GACH) from 12/25/21 to 12/30/21. These failure resulted in an inaccurate Resident 1's clinical record which did not reflect Resident 1's current medical status and the lack of resident assessment could negatively impact the care of other residents residing in the facility. Findings: During a review of Resident 1's admission Record (a document containing demographic information), dated, [DATE] the admission Record indicated,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure license nurse perform residents assessment and document accurately according to the care provided when License Vocational Nurse (LVN 1) did not perform necessary assessment of her assigned residents and continued to document on Resident 1's clinical record Resident 1's vital signs, pain assessment, feeding tube assessment, enteral feeding intake, and provided non-pharmacological pain interventions care she did not provide from 12/25/21 to 12/30/21 during the time Resident 1 was admitted in general acute care hospital (GACH) from 12/25/21 to 12/30/21. These failure resulted in an inaccurate Resident 1's clinical record which did not reflect Resident 1's current medical status and the lack of resident assessment could negatively impact the care of other residents residing in the facility. Findings: During a review of Resident 1's admission Record (a document containing demographic information), dated, [DATE] the admission Record indicated,…

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

Based on observation, interview, and record review, the facility failed to ensure sanitary conditions was maintain in the kitchen when: 1. [NAME] to golden-colored buildup behind the stove and floor behind the stove had accumulation of debris. 2. The floor in the corner next to water inlet, behind the ice machine, between the pantry and kitchen had soiled napkins, straw, beverage cup, wrapper, and food debris. 3. The pantry floor had dark granular substance and a dark glob (a round clump of soft substance or thick liquid). 4. The floor underneath the pantry wire storage rack had scattered debris such as utensils, jelly cups, brown paper bag, napkins, hairnet, and saltine crackers in plastic wrap. 5. In the pantry a one-foot length of vinyl base board molding peeled off and was on the floor. 6. The pantry storage counter holding a five-gallon water jugs had black substance buildup. 7. Two dead cockroach observed under the food preparation table, one dead cockroach beneath the three compartment sink area, and one dead cockroach caught in a web near the ceiling by the dishwasher. These…

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 as evidenced by presence of multiple dead cockroaches in the kitchen ' s floor beneath the food preparation area, the three-compartment sink, and on the floor behind the two-hallway ice machine. These failures had the potential to cause foodborne illnesses (illness caused by food contaminated with bacteria, viruses, and parasites) in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: During an interview on 10/4/24 at 8:05 a.m., with the Ombudsman, the Ombudsman stated on 7/2024 during her visit at the facility she saw a live cockroach in a resident room. The Ombudsman stated she took a photograph of the cockroach and showed it to the Administrator. During an interview on 10/4/24 at 9:43 a.m., with the Housekeeping Staff (HS) 1, HS 1 stated she was aware of the cockroaches in the facility. During an interview on 10/4/24 at 10 a.m., with HS 2, HS 2 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.

2. A review of Resident #208's admission Record indicated the facility admitted the resident on 11/19/2023, with diagnoses that included acute respiratory failure with hypoxia and obstructive sleep apnea. Review of Resident #208's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/21/2023, revealed Resident #208 resident received oxygen. Review of Resident #208's care plan, initiated 11/21/2023 revealed the resident had oxygen therapy related to acute respiratory failure. Interventions indicated the resident received continuous oxygen at a rate of two liters per minute. Review of Resident #208's Order Summary Report, with active orders as of 11/29/2023, revealed an order dated 11/21/2023, for continuous oxygen at two liters per minute by way of nasal canula for acute respiratory failure with hypoxia. On 11/29/2023 at 8:30 AM, the surveyor observed Resident #208 receiving oxygen by way of a nasal canula with the oxygen concentrator set at three liters per minute. During a concurrent observation and interview on 11/29/2023 at 9:19 AM, Registered Nurse (RN)…

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 policy review, the facility failed to assess a resident prior to self-administration of medication for 1 (Resident #114) of 28 sampled residents. Findings included: Review of a facility undated policy titled, Self-Administration of Medication, revealed, 2. If the resident expresses a desire to self-administer their medications, or a physician orders self-administration, the facility will not allow the resident to self- administer meds [medications] until the following procedures are done: a. A Licensed Nurse will complete the Self-Administration Assessment Review which includes the resident's physical and cognitive ability to safely administer and store their medication(s). Review of Resident #114's admission Record, revealed the facility admitted the resident on 09/11/2023 with diagnoses that included wedge compression fracture of thoracic 11 and thoracic 12 vertebra, spondylosis of the lumbar region, intervertebral disc degeneration of the lumbar region, and abnormalities of gait and mobility. Review of Resident #114's…

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

Based on observations, interviews, record review, and facility policy review, the facility failed to provide a comfortable environment and a building in good repair for 2 (Resident #97 and Resident #114) of 3 sampled residents reviewed for the environment. Findings included: A review of a facility policy titled, Safe, Clean, Comfortable, and Homelike Environment, implemented in June 2023, revealed, Policy: In accordance with residents' rights, the facility will strive to provide a safe, clean, comfortable, and homelike, allowing the resident to use his or her personal belonging to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. 1. A review of Resident #97's admission Record revealed the facility admitted Resident #97 on 04/02/2022 with diagnoses that included acute kidney failure, muscle weakness, and hypertension. A review of Resident #97's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of…

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

Based on the interviews, record review, and policy review, the facility failed to ensure 1 (Resident #72) of 4 sampled residents reviewed for nutrition was provided assistance with their meals. Findings included: Review of a facility's policy titled, Weight Management, dated August 2014, revealed Residents identified to be at risk of weight variance, will have routine assessment and care plan interventions implemented in accordance with Advance Directives. The objective of this process if to assess, and manage weight variances. The policy specified, 14. Evaluate meal and intake patterns for irregularities; Consider smaller, more frequent meals, or adding calorie dense foods to meals with higher consumption. * Provide oversight of meal intake and offer appropriate substitutes as indicated. Post available substitutes in designated area for staff awareness. * Evaluate level of assistance /supervision needs. Determine if restorative dining, social dining or additional dining assistance during meals is indicated. Review of Resident #72's admission Record revealed the facility admitted…

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.