The Pavilion At Sunny Hills

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement the facility's infection prevention and control program in accordance with the facility's P&P for three of 34 final sampled residents (Residents 117,154, and 231). * The facility failed to ensure PT Assistant 1 had donned on the proper PPE (gown) during transfer from bed to wheelchair for Resident 117 on enhanced barrier precautions. * The facility failed to ensure LVN 8 observed proper hand hygiene during Resident 231's wound care treatment. * The facility failed to ensure facility staff did not keep/store personal belongings in the clean laundry room and no Sani-cloth disinfectant wipe containers being kept with the clean linen. * The facility failed to ensure Resident 154's urinary catheter drainage bag was not touching the floor. These failures placed the residents at risk for increased risk of infection and transmissions of diseases. Findings: Review of the facility'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, facility document review, and facility P&P review, the facility failed to maintain the essential equipment in a safe operating conditions for one of 34 final sampled residents (Resident 231) and three nonsampled resident (Resident 52, 171, and 235). * The facility failed to ensure Resident 52 and 231's the oxygen concentrator filter was free of thick, dust like particles. This failure had the potential to negatively affect the residents' respiratory health. * LVNs 4 and 11 used the non-facility issued automatic BP machines to take Resident 171 and 235's BP reading. This failure had the potential for the residents to have inaccurate BP measurements. Findings: Review of the facility's P&P titled Storage Maintenance and Handling of Oxygen revised January 2026 showed ensure any cleaning repair, or filling of oxygen equipment is performed by qualified trained staff. 1. On 6/29/26 at 1133 hours, during the initial tour of the facility, Resident 52's oxygen concentrator was at bedside.…

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, medical record review, and facility P&P review, the facility failed to ensure one of 34 final sampled resident (Resident 5) and one nonsampled resident (Resident 108) was assessed for safe self-administration of medications. * The facility failed to ensure Resident 5 was safe to administer the saline nasal spray (medication to relieve nasal congestion) medication found at bedside. * The facility failed to ensure Resident 108 was safe to administer the Salonpas Lidocaine Plus (a topical anesthetic to temporarily numb localized muscle, joint and nerve pain) roll on medication and maximum strength Neuropathy (manage tingling, burning and sharp nerve discomfort in your hands, feet and legs) cream found at bedside. These failures had the potential for Residents 5 and 108 to administer the medication inaccurately and negatively impact the health and safety of the residents.Findings: Review of the facility's P&P titled Self-Administration of Medication revised 1/2026 showed 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, medical record review, and facility P&P review, the facility failed to ensure the physician was informed of a change of condition for one or five final sampled residents (Resident 13 ) reviewed for nutrition. * The facility failed to notify Resident 13's physician and the resident's responsible party of the 9 lbs. (12.2%) weight loss from 2/3/26 to 3/4/26. This failure had the potential for Resident 13 to not receive the necessary care and treatment to manage the resident's weight loss and the resident's responsible party to not be aware of the resident's current condition.Findings: Review of the facility's P&P titled Notification of Changes revised 1/2026 showed the facility shall immediately or as soon as practicable, inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident representative(s) when there is:a. An accident involving the resident which results in injury and has the potential for requiring physician…

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, medical record review, and facility P&P review, the facility failed to ensure the comprehensive care plan was developed to reflect the individual care needs for two of 34 final sampled residents (Residents 106 and 144). * The facility failed to ensure care plan was developed for Resident 106's use of the CPAP machine. * The facility failed to ensure a care plan was developed to address Resident 144's difficulty in hearing. These failures posed the risk of not providing the residents with the appropriate, consistent, and individualized care. Findings: Review of the facility P&P titled Develop-implement Comprehensive Care Plans revised 1/2026 showed the facility develops a person-centered comprehensive care plan that is culturally competent and trauma-informed, developed and implemented to meet each resident's preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs. Each resident will have a person-centered comprehensive care plan…

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, medical record review, and facility P&P review, the facility failed to ensure the comprehensive person-centered care plan was revised to reflect the residents' current care needs and interventions for two of 34 final sampled residents (Residents 3 and 154). * The facility failed to ensure Resident 3's care plan interventions for the use of the pain medications was revised to include the nonpharmacological interventions as per physician's order. * The facility failed to ensure Resident 154's care plan for the risk for fall was revised to include the use of the pad alarm in bed as per the physician's order. These failures posed the risk for the residents to not receive individualized and person centered care in accordance with their assessed needs. Findings: Review of the facility's P&P titled Develop-Implement Comprehensive Care Plans revised 1/2026 showed the care plans must be person-centered and reflect the resident's goals for admission and desired outcomes, interventions that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure one of 34 final sampled resident (Resident 144) was provided with proper care to maintain resident's ability to hear. * The facility failed to ensure Resident 144's had no difficulty in communication when the hearing aide got lost in the facility. This failure had caused the resident difficulty in communication and potentially cause not to meet her needs and psychosocial harm. Findings: 1. On 6/29/26 at 0825 hours, during the initial tour, Resident 144 was observed in bed. Resident was observed unable to hear. Resident was spoken to by talking close to the resident's ear. Resident stated she had lost her hearing aid in the facility. Medical record review for Resident 144 was initiated on 6/29/26. Resident 144 was admitted to the facility on [DATE]. Review of Resident 144's MDS assessment dated [DATE], showed the resident's hearing was adequate with the use of the hearing aid. Resident's BIMS score was 14, which indicates 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, medical record review, and facility P&P review, the facility failed to ensure the necessary care was provided to prevent the development of pressure injuries for one of two final sampled residents (Resident 231) reviewed for pressure ulcer/ injury. * The facility failed to ensure the LVN (LVN 8) assessed Resident 231's pain prior providing the wound care treatment. This failure had the potential for not providing the necessary care and services and effectively managing the resident's needs.Findings: 1. Review of the facility's P&P titled Treatment Services to Prevent/ Heal Pressure Ulcers dated January 2025 showed the assessment and treatment of a resident's pain are integral components of pressure ulcer or pressure injury prevention and management. Pain that interferes with movement and/or affects mood may contribute to immobility and contribute to the potential for developing or for delayed healing or non-healing of an already existing pressure ulcer or pressure injury. Medical…

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, medical record review, facility document review, and P&P review, the facility failed to ensure one of five final sampled residents (Resident 13), reviewed for nutrition, received the appropriate services needed to maintain acceptable parameters of nutritional status. * The facility failed to ensure an effective monitoring of acceptable parameters of nutritional status were implemented through systematic approach when Resident 13 experienced severe weight loss. The severe weight loss of nine lbs. in one month was not assessed and monitored timely as per the facility's P&P. In addition, the facility failed to ensure the physician was notified of Resident 13's severe weight loss and poor PO (per orem or by mouth) intake and failed to ensure Resident 13 received the hashbrowns for her morning breakfast meal. These failures had the potential for adverse nutritional outcomes and to negatively affect Resident 13's well-being.Findings: A professional reference review of the National…

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 medical record review, the facility failed to provide the necessary care and services to maintain the IV accesses for two of two final sampled resident (Residents 37 and 224) reviewed for IV therapy consistent with professional standards of practice. * The facility failed to ensure Resident 37's PICC line was monitored accurately when the facility failed to measure IV line on insertion site and arm circumference as ordered.* The facility failed to ensure Resident 224's peripheral IV was correctly labeled and dated.These failures posed the risk for Resident 37 and 224 to develop complications related to the IV therapy. Findings: 1. On 6/29/26 at 1035 hours, during the initial tour, Resident 37 was observed with PICC line catheter inserted on her left upper arm with a dressing dated 6/25/26. Medical record review for Resident 37 was initiated on 6/29/26. Resident 37 was admitted to the facility on [DATE]. Review of Resident 37's PICC insertion record showed the PICC line was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review and facility P&P review, the facility failed to provide the necessary pain management care and services for three of five residents (Residents 3, 6, and 69) reviewed for unnecessary medications. * The facility failed to ensure the nonpharmacological interventions were provided and documented prior to administering the pain medications to Residents 3, 6 and 69. These failures posed the risk for the residents to receive unnecessary pain medications and negatively affect the residents' well-being.Findings: Review of the facility's P&P titled Pain Assessment and Management revised 1/2025 under the Strategies for Pain Management section showed developing and implementing both non-pharmacological and pharmacological interventions/approaches to pain management, depending on factors such as whether the pain is episodic, continuous, or both. Under the Use of Opioids for Pain Management section, showed the physician considers alternative pain management approaches…

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, medical record review, and facility P&P review, the facility failed to ensure safe and effective pharmaceutical services was observed for one of 34 final sampled residents (Resident 148) and two nonsampled residents (Residents 120 and 171).* The facility failed to ensure LVN 10 flushed Resident 148's GT (gastrostomy tube) with 30 ml of water after the final medication administration as per the physician's order and the facility policy. This failure had the potential to affect the resident's well-being by not being given the prescribed GT flushes during medication administration.* The facility failed to ensure Resident 120's pregabalin (controlled substances medication) was wasted/disposed of by two licensed nurses in accordance with the facility policy. In addition, LVN 9 failed to ensure pregabalin was recorded and accounted for in Resident 120's Drug Control Receipt Record/Disposition Form. These failures posed a risk for drug diversion of the controlled medications* 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, medical record review, and facility P&P review, the facility failed to ensure two of 34 final sampled residents (Residents 3 and 228) was free from the unnecessary medications. * The facility failed to ensure the monitoring for the signs and symptoms of bleeding was completed related to use of apixaban medication (anticoagulant, use to prevent blood clots) to Resident 3. * The facility failed to follow the physician's order to hold the carvedilol and nifedipine (medications to treat high blood pressure) medication when Residents 228's systolic blood pressure was below 110 mmHg. These failures had the potential for the residents to receive unnecessary medications and develop significant side effects. Findings: Review of the facility's P&P titled Administering Medication revised 3/2023, showed to provide employee with guidelines for the safe and timely administration of medications per physician order. Medications must be administered in accordance with the orders. The following information…

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, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 12% when the prescribed medications were not administered to two residents (Residents 148 and 171) during two of five medication administration observation. * The facility to administer the riluzole (medication used to change the activity of certain natural substances in the body that affect nerves and muscles) and cyclosporine (an immunosuppressant medication) medications to Resident 148. * The facility failed to administer the ferrous sulfate (iron supplement) medication to Resident 171. These failures had the potential risk for the residents to experience adverse clinical outcomes, complications, and disease progression.Findings: Review of the facility's P&P titled Administering Medications revised 3/2023 showed for the Guidelines: Medications must be administered in accordance with the orders. 1. Medical record review…

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, facility document review, and facility P&P review, the facility failed to ensure the menu was followed for 16 residents who received a pureed diet of 168 residents who receive food from the kitchen.* The facility failed to ensure the pureed tamale pie recipe was followed.This failure had the potential to not meet the residents' nutritional needs and negatively impact the residents' nutritional health.Findings:Review of the facility's document titled Diet Roster Rollup dated 6/29/26, showed 168 of 172 residents in the facility received food prepared in the kitchen, and 16 of 168 residents who received a pureed diet. Review of the facility's P&P titled Menus revised 1/2025, showed menus meet basic nutritional needs by providing meals based on individual nutritional assessment, the individualized plan of care, and established national guidelines and are periodically updated to mitigate the risk of menu fatigue. Review of the facility's document titled Tamale Pie undated, showed for the dysphagia/pureed diet: for every five portions needed, add five…

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 the facility's assessment (document describing resident population and needs to determine staff and other resources necessary to competently care for residents) review did not address or include a contingency plan for the facility staffing needs. These failures placed the residents at risk for unmet care needs if their assessed population's needs and resources were not comprehensively identified and addressed.Findings: Review of Facility Assessment (FA) dated 9/17/25, failed to include a contingency plan for staffing needs. On 7/1/26 at 1607 hours, an interview was conducted with the Administrator. The Administrator stated the contingency plan was part of the emergency plan. The Administrator was informed and acknowledged the above findings.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medical records for five of 34 final sampled residents (Resident 37, 226, 227, 228, and 230) were complete and accurately documented. * Resident 37's IV MAR for was incomplete and/or inaccurate. * The facility failed to ensure copy of the Advance Directive for Resident 226 was correct. In addition, the copy of the DPOA for property management was found on the medical record. * The facility failed to ensure Resident 227 and 228's blood pressure access site was accurately documented in the medical record. * Resident 230's advance directive and POLST (Physician Orders for Life-Sustaining Treatment) form did not match. These failures have the potential for the residents' care needs not being met as their medical information was inaccurate and incomplete. Findings: 1. On [DATE] at 1035 hours, during the initial tour, Resident 37 was observed with PICC (Peripherally Inserted Central Catheter, is a long,…

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, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services for one of two final sampled residents (Resident 10) reviewed for hospice services. * The facility failed to ensure the hospice visitation monthly calendar for June 2026 was completed to show the scheduled visits by the hospice skilled nurse. In addition, the facility failed to ensure the hospice visit notes were available in the resident's medical record for June 2026. These failures posed the risk for delay in communication and/or uncoordinated medical care between the facility and hospice provider which may affect Resident 10's care.Findings: Review of the facility's P&P titled Hospice Services revised 1/2026 showed the facility ensures the hospice services meet professional standards and principles that apply to individuals providing services in the facility, and to the timeliness of the services, the care meets the assessed needs of each resident, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, closed medical record review, and facility P&P review, the facility failed to ensure the quality care and services were provided for one of eight sampled residents (Resident 5) reviewed for accidents. * The facility failed to ensure two staff performed Resident 5's transfer to her bed while using a mechanical lift. * The facility failed to notify Resident 5's physician when the resident reported hitting her neck and/or head during a mechanical lift transfer experiencing pain. In addition, the facility failed to document and monitor the resident for potential injury. These failures had the potential for Resident 5 not to receive the necessary care and services to maintain the highest physical well-being.Findings: Review of the facility's SOC 341 dated 5/11/26, showed during a post-discharge telephone call with Resident 5, the resident alleged she felt mistreated while at the facility and referenced an incident during a mechanical lift transfer. The facility reported that the incident had been…

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 follow infection control standards for one of eight sampled residents (Resident 7). * The facility failed to ensure Resident 7's floor mat was stored properly. The floor mat was temporarily propped up against the side of the resident's bed, with the surface of the mat touching the bed linen. This failure placed the risk for contamination of Resident 7's bedding and the potential spread of microorganisms, increasing the risk of infection.Findings: Medical record review for Resident 7 was initiated on 5/26/27. Resident 7 was admitted to the facility on [DATE]. On 5/26/26 at 1030 hours, an observation and concurrent interview was conducted with CNAs 2 and 3. CNAs 2 and 3 were observed using a mechanical lift to transfer Resident 7 from his bed to a wheelchair. Resident 7 was observed lying in his bed. A floormat was observed propped up lengthwise against the left side of Resident 7's bed and the upper grab bar, with the upper portion of the floormat…

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, closed medical record review, and facility P&P review, the facility failed to ensure the comprehensive plan of care were revised to reflect the specific care needs for one of seven sampled residents (Resident 1). * The facility failed to revise Resident 1's care plan problem for a heart monitoring device. * The facility failed to revise Resident 1's care plan problem for urinary retention. * The facility failed to revise Resident 1's care plan problem for rectal bleeding. These failures placed the resident at risk to not receive the necessary care to safely maintain the resident's physical well-being.Findings: Review of the facility's P&P titled Comprehensive Care Plans-Timing revised 1/2025 showed each resident has a person-centered, comprehensive care plan, developed, reviewed, and revised by the facility interdisciplinary team including the resident and resident representative, if applicable. Intent: To ensure the timeliness of each resident's person-centered, comprehensive care plan, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, closed medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of seven sampled residents (Resident 1). * The facility failed to follow the physician's order to perform I/O (in and out), for PVR (post volume residual) greater than 250 cc for Resident 1; * The facility failed to notify the physician about Resident 1 was still retaining urine on 1/18/26, and the procedure to perform I/O for a residual of 337 cc was not performed; and * The facility failed to monitor Resident 1 after the resident was identified to have retained urine on 1/18/26. These failures had the potential to negatively impact the resident's well-being.Findings: Review of the facility's P&P titled Physician Orders revised 5/2019 showed whenever possible, the licensed nurse receiving the order will be responsible for documenting and implementing the order. Review of the facility's P&P titled Bowel and Bladder Retraining dated 2/2023 showed the interdisciplinary…

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, closed medical record review, and facility P&P review, the facility failed to ensure the timely intervention for one of seven sampled residents (Resident 1) identified with weight loss. * The facility facility failed to address Resident 1's significant weight loss of seven lbs. in nine days, then five lbs. weight loss eight days after, totaling 12 lbs. weight loss in less than a month. This failure had the potential to result in continued nutritional decline and negative outcomes.Findings: Review of the facility's P&P titled Weight Management revised 12/2024 showed the following:- residents who have a sudden change in nutritional intake and are at risk for significant weight loss or exhibited gradual weight loss/gain;- residents who have lost or gained 5 lbs. since the last recorded weight;- residents who have lost or gained greater than 5% of their body weight in the last month;- residents who have lost or gained greater than 7.5% of their body weight in the last three months;- residents who…

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, medical record and facility document review, the facility failed to provide respiratory care services for two of six sampled residents (Residents 2 and 3). * The facility failed to ensure Resident 2's nebulizer mask and tubing was bagged and labeled with the resident's name and date. In addition, the facility failed to ensure the oxygen in use signage was placed on the outside of Resident 2's door. * The facility failed to ensure Resident 3's oxygen tubing was properly stored when not in use. In addition, the facility failed to ensure oxygen in use signage was placed on the outside of Resident 3's door.These failures had the potential for the residents to not receive the appropriate respiratory care, increase the risks of infection and negatively affect the residents' well-being.Findings: 1. Review of the facility's P&P titled Nebulizer (Aerosol) Therapy dated January 2026 showed after the completion of the nebulization therapy under infection control consideration:- to take care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of five sampled residents (Resident 2) was free from unnecessary restraints. * The facility failed to ensure there was a physician's order and informed consent for the use of a lap buddy and pressure pad alarm for Resident 2's wheelchair. Additionally, there was no care plan developed for the use of the lap buddy and pad alarm. These failures posed the risk of compromising the resident's independence and psychosocial well-being.Findings: Review of the facility's P&P titled Respect and Dignity - Physical Restraints revised 3/2023 showed the following:- Physical Restraints are any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body (e.g. leg restraints, arm restraints, hand mitts, soft ties or vests, lap cushions, and lap trays 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, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable well-being for two of five sampled residents (Resident 2 and 3). * The facility failed to ensure Resident 2's abnormal Neurological Assessment findings were reported to the physician. * The facility failed to ensure Resident 3 was monitored post fall on 12/2/25, for the morning and night shifts. These failures posed the risk of the residents not receiving appropriate care and the potential for a delay in providing care to the residents.Findings: Review of the facility's P&P titled Neurological Exam revised 3/2023 showed the following:- A neurological exam, also called a neuro exam, is an evaluation of a person's nervous system that can be completed in the healthcare setting;- The licensed nurse completes the neurological assessment flow record in accordance with documented time intervals;- Results will be documented in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to report an allegation of abuse to the Administrator of the facility, CDPH L&C Program, Long-Term Care Ombudsman, and local law enforcement in a timely manner for one of four sampled residents (Resident 10) reviewed for abuse allegations. * The facility's staff reported allegations of abuse to the administrator of the facility, CDPH L&C Program, Long-Term Care Ombudsman, and local law enforcement, around eight hours after the staff from the Acute Care Hospital had voiced concerns about Resident 10's allegation of abuse and mistreatment in the facility. This failure had the potential to delay the investigation of the alleged abuse and for the staff not to take prompt and appropriate corrective actions to prevent the alleged abuse.Findings: Review of the facility's P&P titled Abuse Prohibition and Prevention Program revised April 2024 showed the facility shall ensure that all alleged violation involving abuse, neglect,…

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, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen and resident food storage areas. * The facility failed to ensure the resident carafes were air dried. * The facility failed to ensure the food in the cold and dry storage areas were labeled, dated, and the expired items were thrown out. * The facility failed to ensure the food preparation equipment was clean and free from damage. * The facility failed to ensure the freezer in Refrigerator A, located in Dining Room A and Refrigerator B, located in Dining Room B were monitored for the temperatures and recorded in the temperature log. * The facility failed to ensure the resident's food items in Refrigerators A and B were properly labeled and dated. Additionally, the resident's food items of Resident 13 and 735's personal refrigerators were not properly labeled and dated. * The facility failed to ensure the temperature of the personal refrigerator 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, medical record review and facility P&P review, the facility failed to ensure one nonsampled resident (Resident 8) was provided with the necessary care in the manner which promoted dignity and respect. * The facility staff failed to knock and request for permission before entering Resident 8's room. This failure resulted in the resident feeling exposed and disrespected. Findings: Review of the facility's P&P titled Dignity And Respect effective June 2018 showed each resident shall be cared for in a manner that promotes dignity and respect, and staff will knock and request permission before entering the residents' rooms. Medical record review for Resident 8 was initiated on 4/21/25. Resident 8 was readmitted to the facility on [DATE]. Review of Resident 8's MDS assessment dated [DATE], showed the resident was cognitively intact. On 4/23/25 at 1518 hours, an interview was conducted with Resident 8. Resident 8 stated she had concerns with her privacy being respected as the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to determine and clarify whether two of four final sampled residents (Residents 123 and 785) reviewed for advanced directives had formulated an advance directive for healthcare. * Resident 123's medical record showed conflicting documentation as to whether the resident had formulated an advance directive. * The facility failed to determine if Resident 785 had formulated an advanced directive. These failures had the potential for the residents' decisions regarding their healthcare and treatment options not being honored. Findings: Review of the facility's P&P titled Advanced Directive revised 1/2025 showed the residents have the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Advance care planning is an integral aspect of the facility's comprehensive care planning process and assures re-evaluation 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the Level I PASRR contained accurate information for two of two final sampled residents (Residents 92 and 135) reviewed for PASRR screening. * Resident 135 had a diagnosis of unspecified psychosis (a symptom or feature of mental illness typically characterized by radical changes in personality, impaired functioning, and a distorted or nonexistent sense of objective reality) and major depressive disorder (a mental disorder characterized by persistent feelings of sadness, loss of interest or pleasure in activities, and other symptoms that significantly impair daily functioning) and was prescribed olanzapine (an antipsychotic medication); however the Level I PASRR showed Resident 135 had no serious mental illness and was not prescribed any psychotropic medications. * Resident 92 had a diagnosis of major depressive disorder and was prescribed citalopram (an antidepressant medication); however, the Level I PASRR showed…

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, medical record review, and facility P&P review, the facility failed to ensure the comprehensive care plans were developed or implemented for three of 35 final sampled residents (Residents 13, 80, and 143). * The facility failed to implement Resident 143's care plan specific to the PICC line management. * The facility failed to develop a care plan problem to address Resident 13's use of an e-cigarette and safe smoking practices. * The facility failed to develop a care plan problem addressing Resident 80's LUA midline catheter use. These failures placed the residents at risk for not being provided appropriate, consistent, and individualized care. Findings: Review of the facility's P&P titled Comprehensive Care Plans-Timing revised 1/2025 showed each resident has a person-centered, comprehensive care plan, developed, reviewed, and revised by the facility interdisciplinary team including the resident and resident representative. 1. Medical record review for Resident 143 was initiated…

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, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the highest physical well-being for two of 35 final sampled residents (Residents 44 and 77). * The facility failed to ensure the TLSO brace was applied to Resident 44 as per the physician's order. * The facility failed to ensure Resident 77's physician was notified when the resident had the blood sugar levels between 351- 400 mg/dL as ordered. These failures had the potential to affect Resident 44 and 77's well-being. Findings: 1. On 4/21/25 at 1034 hours, Resident 44 was observed lying in her bed and sleeping. There was a TLSO brace observed on her wheelchair. Medical record review for Resident 44 was initiated on 4/21/25. Resident 44 was admitted to the facility on [DATE]. Review of Resident 44's Order Summary Report dated 4/24/25, showed a physician's order dated 4/9/25, to apply the TLSO brace while up on the wheelchair; and may remove when in bed 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, medical record review, and facility P&P review, the facility failed to ensure one of three final sampled residents (Resident 13) and one nonsampled resident (Resident 40) remained free from accidents and hazards. * Resident 40's room had items cluttered on multiple surfaces of her room, including the floor. This failure had the potential for injury related to resident care and obstacles when a quick and safe evacuation of the resident was needed in an emergency. * The facility failed to ensure Resident 13 was evaluated to determined if the resident required supervision and could safely store their own e-cigarette. These failures had the potential to put the residents at an increased risk for serious injuries and negative health outcomes. Findings: 1. Review of the facility's P&P titled Free of Accident Hazards/Supervision/Devices revised January 2025 showed the following: - The facility will provide an environment free from accident hazards including in the resident's environment…

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, medical record review, and facility P&P review, the facility failed to ensure the nursing staff provided the necessary care for one of three final sampled residents (Resident 985) reviewed for indwelling urinary catheter (a flexible tube that drains urine from the bladder) use. * The facility failed to ensure Resident 985's suprapubic indwelling urinary catheter bag was placed below the bladder and covered with a privacy bag. This failure had the potential to result in inadequate care and risk for adverse complications for the residents with an indwelling urinary catheter. Findings: Review of the facility's P&P titled Urinary Catheter Care revised 12/24 showed urinary drainage bags should be maintained in a position to avoid contact with the floor to reduce the risk of developing a urinary tract infection to the extend possible. Urinary drainage bags should be placed in a privacy bag to preserve resident dignity. Medical record review for Resident 985 was initiated on 4/21/25.…

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, medical record review and facility P&P review, the facility failed to timely respond and follow up on the weight loss for one of four final sampled residents (Resident 169) reviewed for nutrition. In addition, the facility failed to review the resident's nutritional status during the weekly weight management IDT meetings. These failures had the potential for adverse nutritional outcomes and to negatively affect the resident's well-being. Findings: Review of the facility's P&P titled Weight Management revised December 2024 showed the weight management committee, consisting of the key members of the IDT, meets weekly and will include residents who have lost five lbs since their last recorded weight, and a lost of 5% or more of their body weight in the last month. Medical record review for Resident 169 was initiated on 4/22/25. Resident 169 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 169's Order Summary Report showed a physician's order dated 4/21/25, 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, medical record review, and facility P&P review, the facility failed to ensure the PICC line assessments were performed and documented for two of two final sampled residents (Residents 80 and 143) reviewed for IV management. * The facility failed to ensure the nurse obtained measurements of Resident 143's arm circumference and PICC line external catheter length in accordance with the physician's orders and the facility's P&P. * The facility failed to ensure the arm circumference and external catheter length measurements were measured on admission and during the PICC line change for Resident 80's PICC line. These failures posed the risk for the residents developing complications related to the use of the PICC line. Findings: Review of the facility's P&P titled Assessment of the Patient Receiving IV Therapy dated 2011 showed to measure the external length of the central venous access device and compare to the length documented at insertion, during each dressing change and when…

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, medical record review, and facility P&P review, the facility failed to ensure three of four sampled residents (final sampled residents, Residents 109, 143, and 155) reviewed for respiratory care were provided with the appropriate respiratory care and services when: * The facility failed to ensure Resident 109 received the continuous oxygen therapy via the nasal cannula (flexible tube to deliver oxygen into the nose) as per the physician's order. In addition, the facility failed to ensure the nasal cannula oxygen tubing was not touching the floor mat on the ground. * Resident 143's nebulizer oxygen tubing was improperly stored, having been found lying on top of a sock on the resident's end table. * The facility failed to ensure a physician's order was obtained for Resident 155's use of oral suctioning equipment. Additionally, the facility failed to ensure Resident 155's oral suctioning equipment was labeled when changed. These failures had the potential to affect the respiratory…

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, medical record review, and facility P&P review, the facility failed to provide the appropriate pain management for two of two final sampled residents (Residents 18 and 69) reviewed for pain management. * The facility failed to accurately document the monitoring of pain for Residents 18 and 69 and administer the pain medications according to the physician's order. In addition, the facility failed to ensure the non-pharmacological interventions for pain were provided to Residents 18 and 69 prior to the administration of the pain medications as per the physician's order. These failures had the potential to put Residents 18 and 69 at risk for ineffective pain management and adverse effects related to the use of unnecessary pain medication. Findings: Review of the facility's P&P titled Pain Assessment and Management revised 1/2025 showed the facility provides pain management to residents who require such services, consistent with the professional standards of practice, the comprehensive…

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, medical record review, and facility P&P review, the facility failed to ensure the pharmaceutical services were provided to meet the needs for one of 35 sampled residents (Resident 60) and two nonsampled residents (Residents 73 and 685). * The facility failed to ensure Resident 73's omeprazole (acid reflux medication) medication bottle was shaken well prior to administering the medication as per the instruction on the bottle. * The facility failed to ensure the narcotic medication for Residents 60 and 685 were accurately signed out and documented as per the facility's P&P. These failures had the risk for negative health outcomes to the residents and the potential to result in medication diversion (the illegal use or distribution of a prescription medication that was not originally intended by the prescriber) and unsafe handling of the narcotic medications. Findings: Review of the facility's P&P titled Administering Medications revised 3/2023 showed the medications must be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of 35 final sampled residents (Resident 81) was free from the unnecessary medications. * The facility failed to follow the physician's order to hold the amlodipine, metoprolol, and hydralazine (antihypertensive medications) medications when Residents 81's systolic blood pressure (the top number in a blood pressure measurement) was less than 110 mmHg. This failure had the potential for Resident 81 to develop significant side effects. Findings: Review of the facility's P&P titled Administering Medications revised 3/2023 showed the medications must be administered in accordance with the orders. Medical record review for Resident 81 was initiated on 4/21/25. Resident 81 was admitted to the facility on [DATE]. Review of Resident 81's physician's order dated 11/3/24, showed to administer amlodipine 10 mg via GT once a day for hypertension and to hold the medication for a systolic blood pressure less than 110 mmHg.…

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, medical record review, and facility P&P review, the facility failed to ensure six of seven final sampled residents (Residents 9, 56, 69, 135, 155, and 985) reviewed for the unnecessary medications were free from the unnecessary psychotropic drugs. * The facility failed to ensure Resident 69's orthostatic blood pressure was monitored for the use of the quetiapine (antipsychotic) medication as per the care plan. In addition, the facility failed to implement the non-pharmacological interventions for Resident 69's observed behaviors for the use of the quetiapine and sertraline (antidepressant) medications. * The facility failed to ensure Resident 135's orthostatic blood pressure was accurately monitored as ordered by the physician and per the care plan, for the use of the olanzapine (antipsychotic) medication. In addition, the facility failed to implement the non-pharmacological interventions for Resident 135's use of the olanzapine, lorazepam (antianxiety), and citalopram (antidepressant)…

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, medical record review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure the proper storage and disposal of the medications as evidence by the following: * The facility failed to ensure the oral and suppository medications in Medication Cart D were stored separately. * The facility failed to ensure the opened and expired medications and medical supplies in Medication Cart E were properly disposed. * The facility failed to ensure the expired medical supplies were removed from Medication Room B. * The facility failed to ensure Resident 81 and 95's latanoprost 0.005% (glaucoma medication) eye drops were labeled with the opened date; and failed to discard Resident 95's latanoprost 0.005% eyedrop after the beyond-use by date in Medication Cart C. * The facility failed to ensure the opened collagen powder and opened hydrofera blue (antibacterial foam) dressing were discarded after opening in Medication Cart F. * The facility failed to…

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

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure 45 of 171 residents who received food from the kitchen received the proper diets when the facility's menu was not followed. * The facility failed to ensure 45 residents who were on CCHO diets (diets for diabetics) and three residents who were on renal diets (specialized diet designed to support kidney health) received the homemade barbeque (BBQ) sauce with their oven BBQ beef roast as per the menu and recipe. This failure had the potential for the residents' nutritional needs not being met, which could result in medical complications. Findings: Review of the Diet Order Tally Report dated 4/21/25, showed 171 of 182 residents received food from the kitchen. Review of the Diet Order Tally Report - All Special Diets dated 4/21/25, showed 45 residents were on CCHO diets and three residents were on renal diets. Review of the facility's P&P titled Menus revised 9/2021 showed the facility provides meals to the residents that meet requirements of the Food and Nutrition Board 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 interview and facility P&P review, the facility failed to ensure the facility staff responsible for handling food brought for the residents from the outside and family/visitors who brought food for the residents from the outside were educated on safe food handling procedures. This failure posed the risk for food borne illness in residents who consume food from outside sources. Findings: Review of the facility's P&P titled Use and Storage of Food Brought to Resident revised 3/2023 showed the facility has procedures to ensure safe and sanitary storage, handling, and consumption of the foods brought to the residents by the family and other visitors. The facility strives to support each resident's right to safe food storage, handling, and preparation. To ensure safe food practices and the prevention of foodborne illness, the facility shall provide safe and sanitary storage of food brought to the residents by the family and visitors for a period not to exceed 48 hours, and in accordance with the following guidelines. The facility helps the family and visitors to understand safe…

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, medical record review, and facility P&P review, the facility failed to ensure the medical records were complete and accurately maintained for four of 35 final sampled residents (Residents 56, 80, 81, and 163) and one nonsampled resident (Resident 40). * Resident 81 had conflicting orders for holding Resident 81's enteral feeding via GT, specific to the residuals. * The facility failed to ensure the accurate and complete medical record for Resident 56. * The facility failed to ensure the medication routes for Resident 163 with GT were accurate. * The facility failed to ensure the documentation on the IV MAR was completed for Resident 80. * Resident 40's consult psychiatrist's progress note was not part of the resident's medical record. These failures had the potential for not providing necessary care and services due to inaccurate medical records. Findings: 1. Medical record review for Resident 81 was initiated on 4/21/25. Resident 81 was admitted to the facility on [DATE]. 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, medical record review, facility document review, and facility P&P review, the facility failed to maintain the infection control practices to help prevent the development and transmission of diseases and infections for two of 35 final sampled residents (Residents 143 and 985) and one nonsampled resident (Resident 37) as evidence by the following: * The facility failed to ensure the EBP was maintained for Resident 143 with a PICC line during an IV medication administration observation. * The facility failed to ensure the visitors wore PPE in a contact isolation room for Resident 985. * During the medication administration observation for Resident 37, LVN 6 failed to perform hand hygiene in between glove use. * The clean laundry room had the facility staff's personal belongings and a Sani-cloth disinfectant wipe container with the clean linen. * Resident 985's did not have a trash bin with a lid in their room, when the resident had a MDRO. These failures had the potential to result…

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

Based on observation, interview, and facility document review, the facility failed to ensure the facility equipment was maintained in the safe operating condition. * For Medication Cart C, the glucometer's (a device that measures the amount of sugar in the blood) serial number did not match the serial number for the glucometer tested on the quality control log. In addition, the facility failed to ensure the corrective actions were taken when the quality control results for the glucometer were out of range. * The facility failed to ensure the serial number on the glucometer and on the Quality Control Record matched for Medication Cart B. * The facility failed to ensure the quality control checks were performed for the glucometers in Medication Cart A and B. These failures had the potential risk of inaccuracy for the residents' blood glucose test results. Findings: Review of the Assure Platinum (blood glucose monitoring system), User Instruction Manual (undated) showed to perform control solution tests in accordance with the state regulatory guidelines. To use the Assure Dose Control…

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, medical record review, and the facility P&P review, the facility failed to provide the necessary care and services to maintain the highest practicable well -being for one of two sampled residents (Resident 2). * The facility failed to ensure Resident 2 had a physician's order for suctioning as per the discharge order from the acute care hospital. * The facility failed to weigh daily and provide the Lasix medication to Resident 2 as per the physician's instructions. * The facility failed to notify the physician and responsible party of Resident 2's continued refusals of the medications and supplements. * The facility failed to provide Resident 2's indwelling urinary foley catheter care, and wound care treatments as ordered by the physician. These failures had the potential to negatively affect the resident's well-being as the necessary care and services were not provided. Findings: Closed medical record review for Resident 2 was initiated on 3/5/25. Resident 2 was admitted to the facility 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable well-being for one of three sampled residents (Resident 1). * The facility failed to follow up with the hospice for the latanoprost eye drop (to treat glaucoma) order for Resident 1. This failure had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Hospice Services revised March 2023 showed the nursing home staff may obtain the orders for care from the designated hospice physicians and communicate the necessary changes initiated by the hospice provider to the resident's attending physician/practitioner in a timely manner. The nursing home shall communicate changes in orders provided by the resident's attending physician/practitioner in the facility if he/she is not the resident's designated physician on the hospice team. Review of the facility's Hospice and Nursing…

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, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of four sampled residents (Resident 4). * The licensed nurse failed to prime Resident 4's Tresiba (insulin pen injection) prior to administering the insulin medication as per the manufacturer's instructions for the use of insulin pen medication. This failure posed the risk for complications related to the resident not receiving the correct amount of the prescribed medication. Findings: Review of the facility's P&P titled Insulin Administration effective 2/2024 showed the nursing staff will have access to specific manufacturer's instructions on all forms of insulin delivery system prior to their use. Under the section for Insulin Delivery, the forms of insulin delivery include the pens containing insulin cartridges to deliver insulin subcutaneouslythrough a needle. Review of the Manufacturer's Instruction for Use for Tresiba (insulin degludec) injection revised…

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, medical record review, and facility P&P review, the facility failed to ensure 10 of 35 final sampled residents (Residents 55, 58, 94, 151, 154, 167, 420, 421, 423, and 425) and three nonsampled residents (Residents 146, 160, and 872) were provided with the appropriate respiratory care when: * The facility failed to ensure Resident 154's oxygen nasal cannula (flexible tube to deliver oxygen into the nose) tubing was labeled and dated as per the physician's order. * The facility failed to ensure Resident 425 had a physician's order for administration of oxygen and oxygen nasal cannula tubing was labeled and dated. * The facility failed to ensure Resident 420's nebulizer mask, tubing, and oxygen tubing were labeled and dated. * The facility failed to ensure Resident 421's oxygen nasal cannula tubing and CPAP (continuous positive airway pressure, a machine used to help keep breathing airways open while sleeping) facemask and tubing was labeled and dated. * The facility failed 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, medical record review, and facility P&P review, the facility failed to ensure proper labeling and storage of medications according to the facility's P&P and/or manufacturer's specifications when: * Medications were not properly labeled and stored in five of eight inspected medication carts and two of two inspected medication rooms. This deficient practice had the potential for inadequately monitored medications, which could lead to unsafe and ineffective medications for the residents, unsafe and reduced efficacy from being used past their discard date, and medication errors due to medication not being labeled. Findings: Review of the facility's P&P titled Labeling of Biologicals and Storage of Biologicals dated 3/23 showed in part, drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable . For medications designed…

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 facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen and in patient food storage areas. * The facility failed to ensure food preparation equipment was air dried. * The facility failed to ensure the resident food equipment was stored clean. * The facility failed to ensure the food cutting boards were in good condition. * The facility failed to ensure the resident food in the cold and dry storage areas were labeled and dated. * The facility failed to ensure the resident food in the third floor community refrigerator was labeled and dated. * The facility failed to ensure the food items stored in the residents' personal refrigerator for Residents 146, 160, 520, 870, and 872 were properly labeled and dated. * The facility failed to ensure the temperatore of the personal refrigerators for Residents 96, 160, 870, 871, and 872 were checked and recorded daily. * The facility failed to ensure Resident 160's personal refrigerator was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to determine if it was safe for four of 35 final sampled residents (Residents 151, 422, 425, and 520) and one nonsampled resident (Resident 110) to self-administer the medication left at the bedside. * Resident 110 was observed with bottles of vitamin B12 (supplement), vitamin E (supplement), fish oil (supplement), vitamin D3 (supplement), and PreserVision (supplement) medications at the bedside. Resident 110 did not have the assessment, physician's order, and care plan problem addressing the resident's self-administration of medication. * A bottle of polymix B sulfate and trimethoprim ophthalmic solution (eye drops antibiotic), a medication cup filled with white cream, and one Dulcolax suppository were observed at Resident 422's bedside table. Resident 422 had self-administered the eye drop antibiotic without being assessed for self-administration of medications. * An albuterol sulfate HFA inhalation aerosol…

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, medical record review, and facility P&P review, the facility failed to obtain and maintain the copy of the advance directive (legal document that stats a person's wishes about receiving medical care if that person is no longer able to make medical decisions) for two of 35 final sampled residents (Residents 91 and 151). This failure had the potential for the resident's decisions regarding their healthcare and treatment options not being honored. Findings: Review of the facility's P&P titled Advance Directives revised 2/1/17, showed upon admission, the admission Staff or designee will obtain a copy of a resident's advance directive. A copy of the resident's advance directive will be included in the resident's medical record. 1. Medical record review for Resident 91 was initiated on 12/4/23. Resident 91 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], showed resident was cognitively intact. Review of Resident 91's POLST dated 8/3/23, showed Resident 91 did not have 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 interview, observation, medical record review, facility document review, and facility P&P review, the facility failed to notify and promptly resolve a written filed grievance for one of 35 final sampled residents (Resident 6). Resident 6 had missing personal photos from her room after she was moved to another room and requested for reprinting he photos; however, no staff had followed up with her regarding reprinting her personal photos. As a result of this failure, Resident 6 stated she felt depressed and angry. Findings: Review of the facility's P&P titled Grievance Policy revised March 2023 showed the facility will make prompt efforts to resolve grievances the resident may have. The Grievance Official will, as necessary, take immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated. Review of the facility's P&P Theft Prevention revised 9/1/21, showed upon completion of the investigation, the Administrator or designee is…

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, medical record review, and the facility P&P review, the facility failed to develop the comprehensive plans of care to reflect the individual care needs for five of 35 final sampled residents (Residents 91, 135, 154, 424, and 520). * The facility failed to develop a care plan problem for Resident 154's use of oxygen and Resident 424's use of PICC line (peripherally inserted central catheter - intravenous access used for a prolonged period of time). * The facility failed to ensure Resident 520's care plan was personalized to address safe smoking practice. * The facility failed to develop and implement a person-centered care plan for Resident 91's buspirone. * The facility failed to develop a care plan problem to address Resident 135's use of bilateral 1/4 side rails. These failures posed the risk of not providing appropriate, consistent, and individualized care to these residents. Findings: Review of the facility's P&P titled Develop-Implement Comprehensive Care Plans revised March 2023 showed…

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 medical record review, the facility failed to provide an individualized and ongoing activity program to meet the needs and interests of two of 35 final sampled residents (Residents 33 and 76). * The facility failed to provide activities for Residents 33 and 76 to meet the residents' identified interests. The facility only provided activity programs to Residents 33 and 76 on 11/9, 11/20, 11/23, and 12/2/23, for November and December 2023. This failure had the potential for the residents to experience feelings of social isolation and frustration. Findings: 1. On 12/5/23 at 1454 hours, 12/6/23 at 1300 hours, and 12/7/23 at 0900 and 0949 hours, Resident 76 was observed in bed and awake. There was no in-room sensory stimulation observed. The TV and radio were turned off. Medical record review for Resident 76 was initiated on 12/4/23. Resident 76 was readmitted to the facility on [DATE]. Review of Resident 76's MDS dated [DATE], showed Resident 76 had a severe cognitive impairment.…

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, medical record review, facility record review, and facility P&P review, the facility failed to provide the necessary services to attain or maintain the highest practicable well-being for one of 35 final sampled residents (Resident 10). * Resident 10 was not administered hydralazine (antihypertensive; used to treat high blood pressure) medication when the resident's SBP was more than 150 mmHg as per the physician's order. This failure had the potential for Resident 10 to develop health complication from high blood pressure. Findings: Medical record review for Resident 10 was initiated on 12/4/23. Resident 10 was readmitted to the facility on [DATE]. Review of Resident 10's Order Summary Report showed the following physician's orders dated: - 1/4/23, to administer hydralazine 25 mg every six hours as needed to give if SBP more than 150 mmHg; and - 9/24/23, to monitor blood pressure every six hours. May administer hydralazine if SBP more than 150 mmHg. Review of Resident 10's MAR for November…

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, medical record review, and facility P&P review, the facility failed to ensure the resident was evaluated for safe smoking practices for one of 35 sampled residents (Residents 520). * Residents 520 was not evaluated to determine if the resident required supervision and could safely store their own cigarettes or lighters. This failure posed the risk for unsafe environment. Findings: Review of the facility's P&P titled Smoking Policy - Residents revised 3/2023 showed following: - Facility will recognize the residents' right to smoke; however, this right is strictly in accordance with the interdisciplinary team assessment of a resident's ability to smoke safely, in a designated smoking area; - To promote the safety of the smoking resident, the IDT may require a resident to smoke under the direct supervision. Resident were responsible for proving all smoking material. Such materials will be labeled and maintained in a safe area by the facility staff; - Smoking material (s) 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, medical record review, and facility P&P review, the facility failed to provide the necessary GT care and services for two of final sampled residents (Residents 3 and 76) and one nonsampled resident (Resident 871). * The facility failed to ensure Resident 76 was positioned safely at least 40 degrees during feeding administration via GT as ordered. * The facility failed to ensure Resident 33 was administered the water flush via GT pump as ordered. *The facility failed to ensure Resident 871's enteral formula container was labeled with the time when it was hung, and the water flush container was labeled and dated when hung. These failures posed the risk for developing complications related to GT. Findings: Review of the facility's P&P titled Enteral Feeding - Pump revised 3/2023 showed to raise the head of the bed at 30 to 45 degrees for feeding, unless medically contraindicated. The P&P also showed to document the initials, date, and time the formula was hung/administered 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, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the intravenous accesses for one of 35 final sampled residents (Resident 424). The facility failed to ensure the PICC line external catheter and arm circumference measurements were performed and documented in the medical record for Residents 424. This failure had the potential to delay identification of catheter related complications for the resident. Findings: Review of the facility's P&P titled Assessment of the Patient Receiving IV therapy dated September 2022 showed to measure the external length of the midline or central venous access device, and compare to the length documented at insertion, during each dressing change and when catheter dislodgment is suspected. Medical record review for Resident 424 was initiated on 12/5/23. Resident 424 was admitted to the facility on [DATE]. Review of Resident 424's Order Summary Report dated 12/5/23, showed 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, medical record review, and facility P&P review, the facility failed to ensure the dialysis care was provided for three of 35 final sampled residents (Residents 10, 86, and 126). * The facility failed to ensure the physician's order for 1000 ml fluid restriction (a diet which limits the amount of daily fluid consumption) per 24 hours was followed and carried out accordingly for Resident 126. * The facility failed to ensure the water pitcher was not in Resident 126's room when on a fluid restriction as per the facility's P&P. * The facility failed to ensure the dressing on the dialysis access site was removed four hours after dialysis treatment. Resident 86 was observed with a dressing on the left forearm dialysis access two days after dialysis treatment. * The facility failed to ensure Resident 10's pre-dialysis assessment of dialysis access and post-dialysis documentation of return date and time were accurate. These failures had the potential for the residents not being provided…

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, facility P&P, and document review, the facility failed to * Ensure accountability for controlled medications (medications that have some potential for abuse or dependence) for one of 35 sampled Residents (Resident 135), when the controlled medication was signed out of the resident's narcotic record but was not documented as administered. This failure had the potential for exposing residents to ineffective treatment, medication errors, and the potential for diversion of controlled medications. * Ensure used refrigerated emergency medication kit was replaced timely. This failure had the potential for medication not to be available when needed, which may result in poor resident's outcome. Findings: 1. Review of the facility's P&P titled Ordering and Receiving Controlled Medications dated 1/23 showed the pharmacy or the nursing care prepares an individual resident-controlled substance record/receipt/log for each controlled substance medication prescribed for a resident as applicable…

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, medical record review, facility document review, and facility P&P review, the facility failed to ensure the Pharmacy Consultant's recommendations were acted upon for three of 35 final sampled residents (Resident 91, 92, and 135). * The Pharmacy Consultant's recommendation for a duration of therapy for the prescribed heparin (anticoagulant; used to decrease the clotting ability of the blood) medication for Resident 92 was not acted upon. This failure had the potential to put Resident 92 at risk for adverse consequences related to the medication. * The facility failed to ensure the consultant pharmacist identified the medication-related irregularities during the monthly drug regimen review; when adverse effects of lamotrigine medication used to treat mood swings by Resident 91 was not being monitored and it was not identified by the consultant pharmacist. This failure resulted in inadequate medication monitoring for the resident which has the potential to compromise their health. * The Pharmacy…

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, medical record review, facility document review, and facility P&P review, the facility failed to ensure four of 35 final sampled residents (Residents 55, 91, 94, and 425) were free from the unnecessary psychotropic drugs (any drug that affects brain activity associated with mental processes and behavior). * The facility failed to monitor the specific behavior manifestation for Resident 94's use of clonazepam (use to treat anxiety). * The facility failed to ensure Resident 55's orthostatic blood pressure (measure the blood pressure while laying down and sitting) was monitored as ordered by the physician related to the use of an antipsychotic medication. * The facility failed to ensure Resident 425's orthostatic blood pressure (measure the blood pressure while laying down and sitting) was monitored as ordered by the physician related to the use of an antipsychotic medication. * The facility failed to implement non-pharmacological intervention for quetiapine, mirtazapine,…

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 facility P&P review, the facility failed to ensure the infection control practices were maintained. * The facility failed to ensure the residents' clothing and blankets from the laundry were transported and delivered in a clean and sanitary manner. The facility failed to ensure the residents' clothing and blankets were inside a fully covered linen cart during transportation. * The facility failed to ensure the staff practiced the contact precaution when entering Resident 75's room that had a posted signage outside the room for contact precaution. In addition, the facility failed to ensure the correct special precautions for Resident 75 were posted. * The facility failed to ensure Resident 925's uncovered urinal was not placed next to a drinking water cup. These failures posed the risk of potential transmission of communicable diseases to other residents in the facility. Findings: 1. Review of the facility's P&P titled Laundry Services revised 7/1/15, showed 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, medical record review, facility document review, and facility P&P review, the facility failed to accurately determine whether five nonsampled residents (A, 22, 41, 128, and 159) who were prescribed antibiotics had met the McGeer's criteria. As a result, the facility failed to inform the residents' physicians that the residents did not meet McGeer's criteria for true infections and potentially inhibited the residents' physicians from discontinuing the unnecessary antibiotics. This failure had the potential to result in the adverse reactions associated with antibiotics and the development of antibiotic resistant bacteria. Findings: According to the Centers for Disease Control and Infection, an estimated 70% of nursing home residents receive one or more courses of antibiotics during a year. Studies have shown that 40% to 75% of the antibiotics prescribed in nursing homes may be unnecessary or inappropriate. Frail and older adults are at significant risk of harm from antibiotic overuse including increased adverse drug events, increased drug interactions and infection…

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, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were completed and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of bed rails for four of 35 sampled residents (Residents 5, 92, 167, and 422). These failures had the potential to negatively impact the residents' well-being. Findings: According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment dated March 10, 2006, showed the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 1) was free from abuse when the Activity Assistant yelled, held Resident 1's wristdown, and raised her hand in a fist above Resident 1 in a threatening manner. This failure had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Abuse Prevention and Prohibition Program revised 10/2022 showed the facility has zero tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, misappropriation of resident property, or deprivation of goods necessary to attain or maintain physical, mental, and psychosocial well-being. Review of the facility's SOC 341 form dated 11/7/23 at 1621 hours, showed CNA 2 overheard Activity Assistant 1 raise their voice and grab the arm 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.