West Gardena Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for the assessment and application of splints (a device used to restrict, protect, or immobilize a part of the body to support function and increase ROM) for one of six sampled residents (Resident 27). The facility failed to: 1.Ensure the Director of Rehab (DOR) who was a Physical Therapist (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) performed an assessment to determine the appropriateness, fit, and splint wear time tolerance (length of time and frequency a person can tolerate wearing the splint for safety, comfort, and maximal benefits) of Resident 27's right knee splint. 2.Ensure the Occupational Therapist (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) performed an assessment to determine the appropriateness, fit, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 7) who was assessed as being at risk for pressure ulcer ( localized damage to the skin and/or underlying tissue usually over a bony prominence) development was provided a pressure relieving barrier to be placed between Resident 7's overlapping, contracted (loss of motion of a joint associated with stiffness and joint deformity) toes of the right foot per facility's policy and procedure titled Prevention of Pressure Injuries. This failure had the potential for Resident 7 to develop pressure ulcers on the right foot. Findings: During a review of Resident 7's admission Record, the admission Record indicated the facility initially admitted Resident 7 on 12/7/2020 and re-admitted on [DATE] with diagnoses including type 2 diabetes mellitus ( a disorder characterized by difficulty in blood sugar control and poor wound healing), contractures (condition of shortening and hardening of muscles, tendons,…

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 one sampled resident's (Resident 31) humidifier bottle (a medical device used with oxygen therapy to add moisture to dry oxygen) was dated with the last change date.This failure had the potential for Resident 31 to receive oxygen through equipment that may not have been maintained according to infection control standards.Findings:During a review of Resident 31's admission Record, the admission Record indicated Resident 31 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including encephalopathy (any disorder that affects the brain's function or structure), muscle weakness, difficulty in walking, acute respiratory failure with hypoxia (low levels of oxygen in your body tissues), and dependence on supplemental oxygen.During a review of Resident 31's quarterly Minimum Data Set (MDS - assessment tool) dated 9/5/2025, the MDS indicated Resident 31 needed oxygen therapy.During a review of Resident…

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

Based on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 5 diluted potassium chloride oral solution (a medication used to treat and prevent low potassium levels) prior to administration per physician order for one of three sampled residents (Resident 22).This failure had the potential to cause adverse effects, which may impact the resident's health condition.Findings: During an observation on 9/30/2025 at 9:24 a.m., LVN 5) was preparing medications for Resident 22. LVN 5 poured 30 milliliters (ml, unit to measure volume) of potassium chloride 20 milliequivalents (mEq, unit to measure mass) per 15 ml into a medication cup to a line marked 30 ml. During a medication administration observation on 9/30/2025 at 9:59 a.m., Resident 22 was observed having difficulty taking 30 ml of potassium chloride oral solution directly from a medicine cup. Observed Resident 22 displayed an unpleasant facial expression. During an observation on 9/30/2025 at 10:03 a.m., Resident 22 was observed consuming 30 ml of potassium chloride oral solution.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide dental services for one of two sample residents (Resident 62) in a timely manner by failing to:1. Refer Resident 62 to the dentist for recurrent toothache.2. follow up Resident 62 dental x-rays (a special camera that takes pictures of the inside of the mouth, teeth and jaw) result.These failures had the potential to put Resident 62 for unnecessary pain and increased risk of gum disease.Findings:During a review of Resident 62's admission Record, the admission Record indicated the resident was admitted on [DATE] to the facility with diagnoses including myocardial infarction (MI- heart attack), angina pectoris (chest pain caused by reduced blood flow to the heart muscle), heart failure (heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen) and hyperlipidemia (high level of fats in the blood).During a review of Resident 62's History and Physical (H&P) dated 10/8/2025, the H&P indicated the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the lunch meal for one of six sampled residents (Resident 3) was fortified (foods have protein, carbohydrates, and/or fats added to increase the total nutritional value of the food) as ordered by the physician.This failure had the potential to result in inadequate caloric and nutritional intake which could lead to unplanned weight loss, decreased strength, and a decline in overall health status.Findings:During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted on [DATE] and was readmitted on [DATE] with diagnoses including encephalopathy (any disorder that affects the brain's function or structure), muscle weakness, dysphagia (difficulty swallowing), type 2 diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), and unspecified protein-calorie malnutrition (poor nutrition).During a review of Resident 3's quarterly Minimum Data Set…

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

Based on interview and record review, the facility failed to implement their protocol for Antibiotic Stewardship (refers to a set commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use) for one of two sampled residents (Resident 64). This deficient practice had the potential for Resident 64 to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use.Findings:During a review of Resident 64's admission Record, the admission Record indicated Resident 64 was admitted to the facility 10/14/2025 with diagnoses including dementia (a progressive state of decline in mental abilities) and Diabetes Mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 64's Minimum Data Set (MDS- a resident assessment tool) dated 10/21/2025, the MDS indicated Resident 64's cognition (ability to think, understand, learn, and remember) was moderately impaired and was dependent (helper does all the…

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

Based on observation, interview, and record review, the facility failed to ensure that the therapy mat (a padded surface used for therapeutic treatment) in the Rehabilitation Gym (Rehab Gym) was maintained in a clean and unobstructed condition. The mat was observed to be cluttered with various miscellaneous items, including multiple cardboard boxes, a cushion pad, inflatable balls, a large paper towel roll, bags, splints (rigid devices used to support and immobilize a broken bone or impaired joint), a wooden device with plastic rings, folded linen, and personal belongings of staff. This failure had the potential to limit the availability and use of therapeutic equipment, reduce usable treatment space for residents during rehab therapy. Findings: During an observation of the Rehab gym on 9/30/2025 at 4:10 p.m., observed four cardboard boxes, a blue cushion pad, two inflatable balls, a large paper towel roll, a large bag containing splints, two sets of leg splints, a wooden device with plastic rings, folded linen, a personal carrying bag, cell phone, eye glasses, and an eyeglass case…

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 sanitary conditions were maintained when cockroaches were observed in the kitchen. This deficient practice resulted in the facility's kitchen being closed for use to the residents and had the potential to spread bacteria and viruses that cause illness, affecting the population of residents in the facility (44) who resided in there and who received food from the facility's kitchen by consuming potentially contaminated food.Findings: During an observation on 7/11/2025, at 2:19 p.m., of the facility's dry food storage area in their kitchen, in the presence of the Dietary Services Supervisor (DSS), a medium sized dark brown cockroach was seen running out of a box of white powdered thickener that was inside an open plastic bag. During an observation on 7/11/2025, at 2:26 p.m., of the facility's dry food storage area in their kitchen, in the presence of the Dietary Services Supervisor (DSS), a medium sized dark brown cockroach was seen…

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 two of three sampled residents (Resident 4 and 19) was provided their activities of choice (preference). This failure had the potential for Resident 4 and 19 to have no mental and emotional interaction that could negatively impact their quality of life. Findings: During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including cardiomyopathy (diseases of the heart muscle, where the walls of the heart chambers have become stretched, thickened, or stiff), depression (a common mental health condition that causes a persistent feeling of sadness and changes in how you think, sleep, eat and act), and atrial fibrillation (an irregular or abnormal heart beat and often very rapid heart rhythm). During a review of Resident 4's Minimum Data Set ([MDS] MDS - a federally mandated resident assessment tool) dated 9/13/2024, the MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY During an interview and record review the facility failed to ensure one of 12 sampled resident (Resident 25) advance directive (a legal document that specifies what actions should be taken for your health if you are no longer able to make decisions for yourself) had a signature of a witness when it was signed by Resident 25. This failure had the potential to cause conflict with the residents' wishes regarding health care in the event residents became incapacitated (unable to participate in a meaningful way in medical decisions) or unable to make medical decisions that would not be identified and/or carried out by the facility staff. Findings: During a review of Resident 25's admission Record. the admission Record indicated, Resident 25 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including chronic kidney disease (a condition where the kidneys are damaged and cannot filter the blood properly), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide appropriate safety precautions to residents at risk for fall and seizures (involuntary muscle movement) for two of three sampled residents (Resident 246, 4). Facility failed to ensure: a. Resident 246, who was on fall risk precaution with one floor mat placed on the left corner of the bed had no foot metal bedside table on top of the floor mat. b. Resident 4, who was placed on fall precautions and seizure precaution with a floor mat by the left corner of the bed had no big sized wheelchair placed on top of the floor mat. This deficient practice had the potential for injury when Residents 246 and 4 would fall out of bed and hit their head on the metal equipment placed on top of the floor mat. Findings: During a review of Resident 246's admission Record, the admission Record indicated Resident 246 was admitted to the facility on [DATE], with diagnosed including muscle weakness, lack of coordination (impairment in movement), fracture…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to assess for pain before wound care treatment on one of three sampled residents (Resident 246) who had a skin tear on right upper knee. This failure had the potential for Resident 246 to experience unrelieved pain during wound care treatment. Findings: During a review of Resident 246's admission Record, the admission Record indicated Resident 246 was admitted to the facility on [DATE], with diagnoses including muscle weakness, lack of coordination (impairment in movement), fracture (broken bone) of other part of pelvis (hip bones). During a review of Resident 246's Minimum Data Set (MDS, ([MDS] a federally mandated resident assessment tool) dated 9/23/24, indicated Resident 246 had severe cognitive (ability to think, understand, learn, and remember) impairment. During a review of Resident 246's Physician Order dated 9/16/24, the Physician Order indicated to clean the wound with normal saline (NS-cleaning solution for the wound), pat dry,…

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: 1. Clarify physician order for Combivent (generic name - ipratropium bromide and albuterol sulfate Inhalation Aerosol [a medication in form of inhalation spray to treat chronic obstructive pulmonary disease {COPD} - a chronic lung disease causing difficulty in breathing) in accordance with manufacturer's specifications for one of ten sampled residents (Resident 14) during medication administration. 2. Ensure availability of Combivent as ordered by the prescriber for one of ten residents (Resident 14). These failures had the potential to cause duplication of therapy and/or result in worsening of COPD symptoms such as difficulty breathing, and hospitalization. Findings: During a review of Resident 14's admission Record, dated [DATE], the admission Record indicated, Resident 14 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including COPD and sleep apnea (a sleep disorder that causes people to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure two facility exit doors, the lobby door (Door 1) and front door (Door 2), were secured to prevent the elopement (an unauthorized departure of a resident without the facility's knowledge and supervision) of one of four sampled residents (Resident 1), a resident who had a history of elopement and assessed as high risk for elopement. As a result of these deficient practices, Resident 1 eloped from the facility on 7/3/2024 and was without his medications including olanzapine (medication to treat schizophrenia) 15 milligrams twice a day for ten days. Resident 1 was located by facility staff on 7/13/2024 and subsequently transferred to a general acute care facility (GACH) for further evaluation. At the GACH, Resident 1 was admitted with a diagnosis including acute psychosis (collection of symptoms that affect the mind, where there has been some loss of contact with reality), severe anemia (not enough red blood cells in the body), 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 and record review, the facility failed to implement one of four sampled resident ' s (Resident 1) care plan to ensure Resident 1 was wearing his Wander guard (bracelets that residents wear, sensors that monitor doors and a technology platform that sends safety alerts in real time), and that Resident 1 was not going to leave the premises unassisted. As a result of these deficient practices, Resident 1 eloped from the facility on 7/3/2024 and was without his medications including olanzapine (medication to treat schizophrenia) 15 milligrams twice a day for ten days. Resident 1 was located by facility staff on 7/13/2024 and subsequently transferred to a general acute care facility (GACH) for further evaluation. At the GACH, Resident 1 was admitted with a diagnosis including acute psychosis (collection of symptoms that affect the mind, where there has been some loss of contact with reality), severe anemia (not enough red blood cells in the body), and Resident 1 received a blood transfusion (process…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement one of four sampled resident ' s (Resident 1) care plan to ensure Resident 1 was wearing his Wander guard (bracelets that residents wear, sensors that monitor doors and a technology platform that sends safety alerts in real time), and that Resident 1 was not going to leave the premises unassisted. As a result of these deficient practices, Resident 1 eloped from the facility on 7/3/2024 and was without his medications including olanzapine (medication to treat schizophrenia) 15 milligrams twice a day for ten days. Resident 1 was located by facility staff on 7/13/2024 and subsequently transferred to a general acute care facility (GACH) for further evaluation. At the GACH, Resident 1 was admitted with diagnoses including acute psychosis (collection of symptoms that affect the mind, where there has been some loss of contact with reality), severe anemia (not enough red blood cells in the body), and Resident 1 received a blood transfusion (process…

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

Based on interview and record review, the facility failed to ensure a plan of care was developed and implemented for one of five sampled residents (Resident 1) addressing Resident 1's laceration (a wound that occur when skin or muscle is torn or cut open) on the forehead. This deficient practice had the potential to result in an infected laceration that could pose as a threat to Resident 1's overall health and wellbeing. Findings: During a review of Resident 1's admission Record (Face sheet), the face sheet indicated Resident 1 was admitted at the facility on 7/12/2024 with a diagnosis that included chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), hypertension (a blood pressure [force it takes for blood to circulate in the body] higher than normal) and dementia (a condition when the loss of cognitive function such as thinking, remembering and reasoning interferes with a person's daily life and activities). During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool,…

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

Based on interview and record review, the facility failed to ensure one of five sampled resident's (Resident 1) laceration (a wound that occur when soft tissue such as skin or muscle is torn or cut open) on the forehead had documented monitoring for signs and symptoms of infection and complications after the resident sustained a fall on 2/29/2024. This deficient practice had the potential to result in an infected laceration that could pose as a threat to Resident 1's overall health and wellbeing. Findings: During a review of Resident 1's admission Record (Face sheet), the face sheet indicated Resident 1 was admitted at the facility on 7/12/2024 with a diagnosis that included chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), hypertension (a blood pressure [force it takes for blood to circulate in the body] higher than normal) and dementia (a condition when the loss of cognitive function such as thinking, remembering and reasoning interferes with a person's daily life and activities). During a review of Resident 1's…

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

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, distributed, and served food in a sanitary manner to prevent foodborne illness (also called food poisoning caused by eating contaminated food or eating food not kept at appropriate temperatures) by failing to: 1.Ensure dishes were washed and rinsed at the correct temperature of 120-140 degrees Fahrenheit ([ °F] a scale of temperature) on a low temperature dishwasher. 2.Ensure frozen health shakes have been thawed by immersing under running water 3.Ensure cream pies and pastries were properly sealed, stored in the freezer and labeled with an open date. These deficient practices had the potential to result in foodborne illnesses with symptoms including upset stomach, stomach cramps, nausea (feeling of sickness with an inclination to vomit), vomiting (eject matter from the stomach through the mouth), diarrhea (loose stool), and fever and can lead to other serious medical complications and hospitalization for 49 residents residing in the facility. Findings: 1. During a concurrent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed obtain recommended Level II preadmission screening and resident review evaluation ([PASARR]-a mental health evaluation done to determine if an individual can benefit from specialized mental health services) for two of 12 sampled residents (Resident 4 and Resident 38) This deficient practice placed Resident 4 and Resident 38 at risk of inappropriate placement, not receiving necessary care, and unidentified specialized services. Findings: a. During a review of Resident 4's admission Record (Face Sheet), indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including schizophrenia (a serious mental disorder that affects how a person thinks, feels and behaves), dementia (a decline in memory, language, problem-solving and other thinking skills that affect a person's ability to perform everyday activities), and epilepsy (a brain disorder that cause recurring seizures (a sudden uncontrolled burst of electrical activity in the brain). During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 24) received proper assistive devices to maintain hearing abilities by not assisting in arranging for audiologist (diagnose, manage, and treat patients who have hearing, balance, or related problems) referral consults to replace missing hearing aids. This deficient practice resulted in delay of services and Resident 24 not able to hear adequately during a conversation, and provision of care. Findings: During an observation on 9/29/2023 at 9:45 a.m. in Resident 24's room, observed Resident 24 lying in bed with no hearing aids in both ears. During a review of Resident 24's admission Record (Face Sheet) dated 10/24/2021, indicated Resident 24 was admitted to the facility with diagnoses including blindness of the left eye, hypertension (high blood pressure) and stage 4 pressure ulcer (damage to the skin and tissue loss, reaching into muscle and bone). During a review of Resident 24's Minimum Data…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of eight sampled residents (Resident 5) who was admitted to the facility with an indwelling suprapubic urinary catheter (tube inserted into the bladder through the stomach to drain urine) received appropriate care, services and followed physician orders to send a urine specimen for urinalysis (UA -urine test) and urine culture and sensitivity (urine C/S- used to diagnose a urinary tract infection [UTI] an infection in any part of the urinary system, the kidneys, bladder, or urethra) when Resident 5 complained of burning sensation on urination. This deficient practice resulted in continued discomfort to Resident 5 and had the potential for Resident 5 to experience continued signs and symptoms of UTI and the potential to have a kidney or prostate (a gland in the male reproductive system) infection that could lead to sepsis (blood stream infection). Findings: During a review of Resident 5's admission Record (Face Sheet) the Face Sheet indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to: 1. Check residents' identification band (wrist band) prior to medication administration for four of five sampled residents (Resident 17, 21, 23 and 37). This deficient practice had the potential for medication error including administering medication to the wrong resident. 2. Ensure Licensed Vocation Nurse (LVN) 3 signed narcotics reconciliation record ( a record of narcotic or controlled substance inventory) after taking the controlled (a medication with a high abuse potential) medication for one of one sampled residents (Resident 99) according to facility's policy and procedure. This deficient practice had the potential for loss of accountability, which affected the controls against drug loss, diversion, or theft. Findings: 1. During a review of Resident 17's admission Record (Face Sheet) indicated Resident 17 was admitted to the facility on [DATE] with diagnoses including essential hypertension, diabetes mellitus and dysphagia…

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.