Autumn Hills Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of two sampled resident (Resident 63) who was a high risk for developing pressure ulcer (a skin injury due to prolonged unrelieved pressure or friction on the skin and body areas of the body) provided with bilateral (both sides) heel protector (a soft material designed to offload pressure from the heels, to prevent pressure ulcers) as ordered by the physicians order and in accordance with the facility's policy and procedures titled Pressure Ulcer/Injury Preventive Measures. This deficient practice had the potential to result in development of pressure ulcer and/or skin breakdown, which could negatively affect Resident 's quality of life.During a review of Residents 63's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included dementia (decline in mental abilities severe enough to interfere with daily life), muscle weakness, and muscle wasting and atrophy shrinking, and loss of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect a resident's right to privacy and dignity when staff photographed the resident without their permission while the resident was in a vulnerable position. This deficient practice resulted in Resident 1 verbalizing feelings of embarrassment and crying.FINDINGS: During a review of Resident 1's admission Record (AR), the AR indicated the Resident was admitted to the facility on [DATE], with a diagnosis that included type 2 diabetes mellitus ( the body doesn't make enough insulin or can't use it well causing high blood pressure), chronic kidney disease(long -term condition where the kidneys slowly stop working properly) , and paraplegia(loss of movement and felling in the lower half of the body) . During a review of Resident 1's History and Physical (H&P) dated 11/25/2025, the H&P indicated this resident has the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and 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, and record review, the facility failed to ensure one of five sampled residents (Resident 1) was free from physical abuse in accordance with the facility's Policy and Procedure, titled Abuse and Neglect Clinical Protocol, by failing to: 1.Identify physical abuse after Physical therapist (PT) 1 slapped Resident 1 on the right thigh on 2/23/2026. 2. Implement abuse protocols by not immediately reporting the incident to the Administrator (ADM). 3. Monitor Resident 1 immediately after the incident occurred on 2/23/2026. 4. Protect Resident 1 from PT 1 after PT 2 witnessed PT 1 slap Resident 1 on the right thigh and PT 2 continued to provide physical therapy services to Resident 1while PT 1 remained in the therapy room. These failures resulted in Resident 1 being slapped on the right thigh by PT 1 and verbalized feelings of being shocked and upset, and for Resident 1 to not be immediately protected by the facility from PT 1. During a review of Resident 1's admission Record ( AR) , 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 observations, interviews and record reviews, the facility failed to immediately report physical abuse by Physical therapist (PT) 1 towards Resident 1 to the Administrator (ADM) within two (2) hours for one of five sampled residents, in accordance with the facility's policy and procedure (P&P) titled, Abuse Prevention Program. On 2/23/2026 while Resident 1 was beginning physical therapy, Resident 1 entered the rehabilitation (rehab) room and touched PT 1 on the back of the head. PT 1 reacted by slapping Resident 1 on the right thigh. PT 2 was also in the room. Neither PT 1 or PT 2 reported this incident on 2/23/2026 to the ADM. This deficient practice resulted in the facility not immediately reporting a witnessed physical abuse to the Administrator and delayed the investigation and protection for Resident 1 from further abuse. During a review of Resident 1's admission Record ( AR) , the AR indicated the facility admitted the resident to the facility on [DATE], with a diagnosis including Hemiplegia…

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 interviews and record reviews, the facility failed to ensure that the resident's authorized practitioners (Medical Doctor [MD] 1 and Nurse Practitioner [NP] 1) adequately supervised and managed the medical care of Resident 1 as required under physician services for one of three sampled residents. The facility failed to: 1. Ensure licensed nursing staff and MD 1 reviewed and addressed the General Acute Care Hospital (GACH) discharge orders, including the need to reorder fingerstick blood sugar monitoring (AC & HS) upon readmission for Resident 1 with Type 2 Diabetes Mellitus (DM) at the facility on 1/11/2026. 2. Ensure that MD 1's verbal decision to the licensed nursing staff to discontinue the GACH discharge order for blood sugar monitoring for Resident 1 upon readmission on [DATE]-despite the resident's uncontrolled diabetes and risk for unstable blood glucose levels-and the rationale for this decision were documented in the medical record and communicated to NP 1. 3. Ensure the physician or…

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

Based on observations, interviews and reviews, the facility failed to ensure monitoring and supervision was provided to one of three sampled residents (Resident 1), who was assessed as a high-fall-risk resident, by failing to: Develop and implement individualized care plan interventions to minimize the occurrence of falls in accordance with the Policy and Procedure (P&P) titled Falling Star Program. Identify specific monitoring required while Resident 1 was on the Falling Star Program. Conduct resident observations in accordance with the P&P for the Falling Star Program.Perform and document scheduled safety round as indicated by the P&P for the Falling Star Program. Determine and identify the type and frequency of supervision required in accordance with the facility's P&P for Safety and Supervision. Ensure interventions were implemented and documented in accordance with the facility's P&P for Safety and Supervision. These deficient practices resulted in Resident 1 sustaining two unwitnessed falls at the facility on 12/15/2025 and 1/25/2026, with the second fall requiring transfer 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 observation, interview, and record review, n 12/14/2025, the facility failed to ensure one of two sampled residents ( Resident 1) received timely assistance with activities of daily living (ADLs), specifically incontinence care (timely assistance with personal hygiene, support , maintaining comfort, dignity, skin integrity, and health). This deficient practice resulted in Resident 1 experiencing moisture - associated skin damage ( MASD a medical term for inflammation, redness, and erosion of the skin from prolonged contact with moisture (urine, sweat, wound drainage, saliva, stool), often worsened by friction, pH, or microbes, leading to skin breakdown, especially in folds or around stomas/wounds0 and having the potential for further skin breakdown, pain, discomfort, and possible infection.During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was originally admitted to the facility on [DATE], with a diagnosis of Heart failure( heart is not able to pump blood as well as it…

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 infection prevention and control practices (IPCP, a set of measures designed to protect patients and healthcare workers from avoidable infections) was implemented for one of three sampled residents (Resident 1) who was diagnosed with scabies (an itchy skin condition caused by a tiny bug, mite, that burrows into the skin), by failing to: 1. Place Resident 1 under contact precaution (infection control measures used to prevent the spread of infectious agents that can be transmitted through direct or indirect contact with a patient or their environment) on 5/13/25 when Resident 1 was diagnosed with scabies. Resident 1 was not placed under contact precaution until 5/15/25, two days after confirmed diagnosis. 2. Monitor and assess close contact residents who were exposed to Resident 1, that included, Resident 1's roommates, Resident 2 and Resident 3 and facility staff who had direct contact with Resident 1. 3. Implement MD 1order 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 that a comprehensive care plan was completed for three out of three sampled residents (Resident 37, 9, and 64) in accordance to the facility's policy and procedure (P&P) for Comprehensive Plan of Care by failing to: 1. Ensure a care plan for the use of side rails was developed for Resident 37. 2. Ensure a care plan was implemented to apply side rails pads for Resident 9 who has diagnosis of seizure ( an abnormal electrical activity in the brain that cause uncotrolled jerking movements, loss of consciousness). 3. Ensure a care plan was developed for Resident 64 who was admitted with diagnosis of dementia (a progressive state of decline in mental abilities). This deficient practice had the potential for residents to sustian injuries and not receive care and services specific to their needs. Findings: 1. During a review of Resident 37's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE] with…

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

Based on observation and interview and record review the facility failed to follow its policy and procedure and the professional standards of practice on food storage and safety by failing to label the date the bag was opened and when to use by date an open plastic bag with 6 hashbrowns. This deficient practice had the potential to result in food contamination, growth of microorganisms (disease causing organism) that could cause foodborne illness (food poisoning or food illness due to pathogens (harmful organism that cause illness such as bacteria, viruses, or parasites) and toxins that contaminate food and negatively affect the health of the residents who consumes it. Findings: During a concurrent initial kitchen tour observation and interview on 6/3/2025 at 8:05 AM with the Dietary Service Supervisor (DSS) the freezer had an open plastic bag with 6 hashbrowns without an opened date and when to be used by date. The DSS stated, foods in the kitchen should be labeled with an opened date and with a used by date as per facility policy. If the bag was opened, it shortens the shelf life…

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 obtain an informed consent for psychotropic/psychotherapeutic (any drug that affects behavior, mood, thoughts, or perception) drug for one of one sampled resident (Resident 5) who was prescribed Quetiapine (medication used to treat a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions), and Divalproex (medication used to treat mental/mood conditions). This deficient practice had violated Resident 5's rights to be informed when choosing the type of care or treatment to be received, make decisions on alternative measures the resident or responsible party preferred, which can negatively affect Resident 5's quality of life. Findings: A review of the admission record indicated Resident 5 was admitted to the facility on [DATE] with diagnoses that included dementia (a group of related symptoms associated with an ongoing decline of the brain and its abilities), psychotic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide a homelike environment for two of two sampled residents (Residents 61 and 42) by failing to ensure: 1. Resident 61 ' s wall clock in the room indicated the accurate time of the day. 2, Resident 42 was provided a wall clock. These deficient practices had the potential to affect the quality of life and cause disorientation for both residents and led to Resident 42's verbalization of feelings of frustration. Findings: 1. A review of Resident 61's admission Record indicated the facility admitted Resident 61 on 5/2/2025 with diagnoses that included dementia (progressive decline in cognitive function, memory, and thinking abilities that can impact daily life), depression (a mental health condition that causes persistent sadness, a loss of interest in activities, and can affect how you think, feel, and act), and muscle wasting and atrophy. A review of Resident 61's Minimum Data Set (MDS - a resident assessment tool), dated 5/1/2025,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a baseline care plan within 48 hours of resident ' s admission to address the resident ' s medical and physical needs for one of one sampled resident (Resident 241) who was admitted on [DATE] with diagnoses that included chronic congested hear failure (CHF) (heart doesn't pump enough blood for your body's needs), history of pneumonia (an infection of the lungs) and history of acute respiratory failure with hypoxia (lungs cannot release enough oxygen into your blood, which prevents your organs from properly functioning). Resident 241 had a physician order for oxygen inhalation at two liters per minute (a unit that expresses flow rate) via nasal cannula (lightweight tube with two prongs that go gently inside your nostrils) as needed for shortness of breath (SOB) and albuterol (medication used to treat breathing difficulties) as needed for SOB. This deficient practice had the potential for delayed care and services that could…

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 safe and hazard free environment to two of 3 sampled residents (Resident 12 and 9) by failing to: 1. Ensure to place a bed pad alarm (a weight sensor pad used to alert staff when resident gets out of bed which is the most effective tools for reducing falls within the elderly population) Resident 12 who was at high risk for fall as indicated on physician order and comprehensive care plan. 2. Ensure to place a sheep skin on the side rails and confirm placement every shift as indicated in the care plan and physician's order for Resident 9 who has a diagnose of epilepsy (a neurological disorder characterized by recurrent seizures (eratic electrical activity in the brain that causes uncontrolled movement of body). This deficient practice had the potential for the resident to sustain severe injuries and result a decline the residents well being during a fall or seizure. Findings: 1. During a review of Resident 12's Face Sheet (admission…

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 necessary respiratory care to one of four sampled residents (Resident 8) as indicated in the physician ' s order and consistent with professional standard of practice by failing to ensure: 1. Nursing staff properly assessed and documented Resident 8 ' s baseline SpO2 level (oxygen saturation level/O2 [oxygen] a measurement of how much oxygen the blood is carrying as a percentage). 2. Ensure the oxygen tubing was not compressed in the side rail to ensure oxygen flow to the resident. 3. Perform respiratory assessment, and document signs and symptoms (S/S) of respiratory distress or shortness of breath (SOB) when providing oxygen therapy to the resident. The deficient practice had the potential to cause over oxygenation (too much oxygen in the lungs) to Resident 8 who has a diagnosis of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) that can lead to dangerous hypercapnia (too much…

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 Licensed Vocational Nurse (LVN) 3 did not document on the Medication Administration Record (MAR) and the Controlled Drug Record prior to the administration of the medication hydrocodone-acetaminophen (medication to control pain) for one of three sampled residents (Resident 314). This deficient practice had the potential for inaccuracies or discrepancies when administering medications. Findings: During a review of Resident 341 ' s admission Record (AR), the AR indicated the resident was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included rheumatoid arthritis (chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility), artificial hip joint, and history of falling. During a review of Resident 341 ' s History and Physical (H&P), dated 5/7/2025, the H&P did not indicate if the resident has the capacity to understand and make…

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 protect and ensure the residents right to access and use of a telephone by failing to: 1. Ensure Station B ' s portable phone was available forresidents to use. The portable phone was missing. 2. Ensure LVN 1 did not use her personal phone to contact residents ' families 3. Provide in services for staff including LVN1 that there was an additional cell phone available for residents to use in case the portable phone was not available (in use by other Residents, not working, or had a poor connection). These failures had the potential to negatively affect residents ' psychosocial wellbeing. Findings: During a review of Resident 1 ' s Face Sheet (admission record), the face sheet indicated the resident was admitted to Facility on 12/14/2018 and readmitted on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing ), Parkinson Disease (progressive disease of the nervous system…

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 three sampled residents (Resident 1) was treated with dignity and respect in accordance with the facility ' s policy and procedure (P&P), titled Quality of life – Dignity while being assisted by certified nurse assistant (CNA)1, and ensure CNA 1 did not come in contact with Resident 1 after Resident 1 reported an incident that happened on 11/24/24, on 11/25/24 to the Administrator, when the Administrator brought CNA 1 to her room on 11/25/24, to make CNA 1 apologize to Resident 1 in accordance to the facility ' s P&P titled Abuse Prevention Program, and Abuse, Neglect, & Exploitation Prohibition. These deficient practices resulted in Resident 1 verbalizing feelings of being embarrassed and upset, and had the potential to place Resident 1 at risk for further abuse. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to facility on 11/12/2022, with a diagnosis of diabetes (a disease that occurs when your blood sugar is too high) with diabetic…

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 three sampled residents (Resident 1), who had a diagnoses of type 2 diabetes mellitus (a chronic condition where the body does not use insulin properly or does not produce enough insulin to regulate blood sugar levels) and required blood sugar checks, was provided with care and services by the licensed nurse (LN) in accordance to the facility ' s policy and procedure (P&P) titled Blood Glucose Test. This deficient practice had the potential for Resident 1 ' s blood sugar results to not be obtained properly and resulting in an inaccurate reading. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to facility on 11/12/2022, with a diagnosis of diabetes (a disease that occurs when your blood sugar is too high) with diabetic neuropathy (a nerve problem that causes pain and numbness). During a review of Resident 1 ' s Minimum Data Set (MDS- a resident assessment tool) dated 9/12/2024, the MDS indicated the resident ' s cognition (mental processes)…

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 report an incident of unusual occurrence to the California Department of Public Health (CDPH) according to the facility ' s policy and procedure for one of three sampled residents (Resident 1). This deficient practice resulted in the facility underreporting allegations of abuse and placing Resident 1 at risk for further abuse. Findings: During a review of Resident 1 ' s admission Record (AR), the AR indicated the facility admitted the resident on 11/14/2022, with a diagnosis of major depressive disorder (a persistent feeling of sadness and loss of interest) and paraplegia (loss of muscle function that affects the legs). During a review of Resident 1 ' s History and Physical Examination (HPE, a comprehensive physician ' s note regarding the assessment of the resident ' s health status) dated 9/25/2024, indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set (MDS, a federally mandated assessment tool) dated 9/12/2024, indicated the resident ' s cognition…

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 develop a resident- centered care plan for one of three sampled residents. This deficient practice had the potential to delay care and services provided to Resident 1 according to Resident 1 ' s specific needs. Findings: During a review of Resident 1 ' s admission Record (AR), the AR indicated the facility admitted the resident on 11/14/2022, with a diagnosis of major depressive disorder (a persistent feeling of sadness and loss of interest) and paraplegia (loss of muscle function that affects the legs). During a review of Resident 1 ' s History and Physical Examination (HPE, a comprehensive physician ' s note regarding the assessment of the resident ' s health status) signed by the attending physician on 9/25/2024, the HPE indicated that Resident 1 had the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set (MDS, a federally mandated assessment tool) dated 9/12/2024, indicated the resident ' s cognition (thought process) was intact. During a review of Resident 1 ' s Situation,…

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 4. A review of Resident 79's admission Record (Face Sheet), indicated the facility originally admitted Resident 79 on 7/6/2023 and readmitted on [DATE] with diagnoses that include metabolic encephalopathy (a chemical imbalance that affected the brain and made it harder to think clearly and remember things), upper gastrointestinal bleed (bleeding that occurs anywhere in the esophagus [a muscular tube that food passes from the throat to the stomach], stomach, or upper part of the small intestine [long tube organ that helps digest food from the stomach]), and unspecified dementia (a loss of memory, language, and problem solving that is severe enough to interfere with daily life). A review of Resident 79's History and Physical (H&P, a comprehensive physician ' s note regarding the assessment of the resident's health status), dated 2/24/2023 and 5/23/2024, indicated Resident 79 sometimes had the capacity to understand and make decisions, however, Resident 79 was only oriented to himself. A review of Resident 79'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 one kitchen staff was wearing a hair net prior to entering the kitchen and when properly storing foods in the refrigerator. 1. There were 26 applesauce containers not labeled or dated in the food storage. 2. There was one gallon of milk without a label on when it was opened. These deficient practices had the potential to result in food contamination (foods that are spoiled or tainted because of microorganisms, such as bacteria or parasites, or toxic substances that make them dangerous for consumption) and result in the resident to be exposed to food borne illnesses ( an illnesses contracted from eating contaminated food or beverages). Findings: 1. During an initial kitchen tour on 6/3/2024 at 8:23AM with the Dietary Supervisor (DS), Refrigerator 1 was observed to have prepared applesauce in a cups or bowl without labels or dates and one gallon of milk that was open and had no date on when it was opened. The DS stated that the applesauce should have been all labeled to identify the contents 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.

Based on observation, interview, and record review, the facility failed to ensure respect and dignity was provided for one of two sampled residents (Resident 12), by ensuring the Certified Nursing Assistant 2 (CNA 2) had eye contact while sitting and feeding the resident. This deficient practice had the potential to result in feelings of decreased self-esteem and self-worth to Residents 12. Findings: During a review of Resident 12's admission Record indicated the facility originally admitted Resident 12 on 1/22/21 and readmitted her on 2/23/24 with diagnoses that included dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and hypertension (high blood pressure). During a review of Resident 12's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 10/6/23, indicated Resident 12 had severely impaired memory and cognition (ability to think and reasonably) impairment. The MDS indicated Resident 12 required supervision or touching assistance with eating, partial/moderate…

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 one of two sampled resident's call light was within reach (Resident 25) during an observation conducted on 6/3/24 at 8:55 AM, inside the resident's room, in accordance with the facility's policy titled Call Lights-Answering Of. This deficient practice had the potential to harm Resident 25 (e.g., falling out of bed due to an unassisted transfer) by not being able to call for assistance when needed. Findings: A review of Resident 25's admission Record indicated the facility initially admitted the resident on 10/7/22 and readmitted the resident on 4/12/24 with diagnoses including anxiety disorder (a mental health disorder characterized by feelings of fear that are strong enough to interfere with one's daily activities). A review of Resident 25's History and Physical assessment, dated 4/15/24, indicated that the resident did not have the capacity to understand and make decisions. A review of Resident 25's Minimum Data Set (MDS - a standardized assessment and screening tool), dated 4/16/24, 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 and interview, the facility failed to ensure that one of three sampled residents (Resident 79) was free of involuntary physical restraints (methods to purposefully limit or obstruct a person's freedom of movement) by failing to remove the overbed (an adjustable table designed to roll over a bed and provide a flat and stable surface with lockable wheels) table over the Resident 79 after breakfast. This failure resulted in Resident 79 restrained in his bed and unable to have freedom of movement with his overbed table over him. Findings: A review of Resident 79's admission Record (Face Sheet), indicated the facility originally admitted Resident 79 on 7/6/2023 and readmitted on [DATE] with diagnoses that include metabolic encephalopathy (a chemical imbalance that affected the brain and made it harder to think clearly and remember things), upper gastrointestinal bleed (bleeding that occurs anywhere in the esophagus [a muscular tube that food passes from the throat to the stomach], stomach, 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 observation, interview, and record review, the facility failed to implement interventions to prevent development of new pressure ulcer (skin injury due to prolonged unrelieved pressure or skin friction) or worsening of existing pressure ulcer for two of five sampled residents (Resident 56, and 76) in consistent with professional standards of practice and facility's policy and procedure by failing to: 1. Set the Alternating Pressure Mattress (APM) (mattress that provides pressure redistribution by filling and un-filling air cells within the mattress so that contact points with the body are reduced) according to the resident's weight as indicated in the manufacturer ' s recommendation for Resident 56. 2. Provide a heel protector (a device to minimize the risk of pressure damage to heels by off-loading) to Resident 76 who had a physician order to apply heel protector to both heels to high risk for pressure ulcer. This deficient practice had the potential for Resident's 56 and 76 to develop, worsened or new…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident maintained an acceptable parameters of nutritional status for one of two sampled residents (Resident 56) by failing to address and implement care plan interventions to monitor resident's food intake and hydration due to resident's significant weight loss of more than 5% in 30 days and monitor food intake for the month of May 2024. Resident 56's weights on April 2024 was 84.4 pounds and on May 2024 the resident's weight was 79.8 pounds a total of 4.6 pounds in a month. This deficient practice had the potential for Resident 56 to continue to lose weight that could result in medical complications such as tissue and organ failure. Findings: A review of Residents 56's admission Record indicated the resident was originally admitted , on 4/11/2022 and readmitted on [DATE], with diagnoses that included diabetes (lifelong condition that causes a person's blood sugar level to become too high), protein calorie malnutrition ( poor…

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 (Resident 51) who required respiratory care and services was provided with the necessary respiratory care consistent with professional standards of practice by failing to: 1. Ensure the licensed nurses follow Resident 51 ' s physician order dated 5/5/2024, to administer oxygen of 3 liters per minute (LPM) as needed for shortness of breath and may titrate up to 5 LPM, and as indicated in the resident ' s plan of care titled At risk for decreased cardiac output. 2. Ensure Resident 51 ' s oxygen (odorless and colorless gas needed for animal and plant life) tubing was free of any obstruction to provide consistent oxygen therapy (treatment to provide a person with extra oxygen to treat or prevent the symptoms of hypoxia [decrease oxygen flow to the tissues]), in accordance with the facility ' s policy titled Oxygen Administration. These failures resulted in Resident 51 receiving less oxygen than required,…

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 that the Social Services Director (SSD) confirmed that the physician filled out the Physician Orders for Life-Sustaining Treatment (POLST, a form that communicates the individual's wishes regarding life-sustaining treatment and resuscitation) form completely for one of four sampled residents (Resident 46). This deficient practice had the potential for the facility not to fulfill the resident's end-of-life wishes when he stops breathing. Findings: A review of Resident 46's admission Record indicated that the facility initially admitted the resident on [DATE] and readmitted the resident on [DATE] with diagnoses that included a history of traumatic brain injury (a brain dysfunction caused by an outside force, usually a violent blow to the head). A review of Resident 46's Minimum Data Set (MDS - a standardized assessment and screening tool), dated [DATE], indicated that the resident ' s cognition (mental action or process of acquiring knowledge 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 ensure the Hospice binder (a binder that contains the care and services provided and being provided to residents under hospice care [end of life care]) was completed by the hospice nurses and used to communicate with the facility staffs) was completed by the hospice nurses during their visits and reviewed by the facility staffs for 2 of 2 sampled residents (Resident 59 and Resident 77). The Hospice binder contains hospice nurse sign-in sheet, weekly calendar visits and hospice nurse ' s notes, care plans and treatment recommendations. This deficient practice had the potential for the residents not to receive appropriate hospice care which could negatively affect the delivery of care and services related to the resident ' s change of health (including but not limited to pain, shortness of breath, spiritual and psychosocial needs related to dying), and result in the resident ' s personal needs for the end of life issues not to be met. Findings: 1.…

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

Based on observation and interview and record review, the facility staff failed to provide a safe environment for residents by leaving a Hoyer Lift (a device that allows a person to be lifted and transferred with minimum physical effort) unattended in the resident ' s room. This had the potential for residents to be placed at risk for accidents and injury. Additionally the staff will have limited space in the room to comfortably provide care to the residents. Findings: During an observation on 6/3/2024 at 10:01 AM, a Hoyer lift was left unattended near by a resident ' s bed. During an interview on 6/3/2024 at 10:05 AM with Certified Nursing Assistant (CNA 3) 3, CNA 3 stated that she had left the Hoyer lift unattended it in the resident ' s room while assisting a resident to get up to a wheelchair and taking the resident to the dining area. CNA 3 stated the Hoyer lift should not be left in the resident ' s room unattended because the residents in the room might trip over the device and get injured. CNA stated the Hoyer lifts had to be put in the proper storage area when not in use.…

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 four sampled residents (Resident 1), who had severely impaired cognition (thought process)who required extensive (means when a resident is totally dependent or requires weight - bearing support while performing part of an activity), two plus person physical assistance during transfer (how resident moves between surfaces Including to or from: bed, chair, wheelchair, standing position), and was at risk for falls was provided an environment free of hazard, assistance by facility staff, and a nursing care plan to decrease resident's risk of fall and injury. On 9/27/2023, Certified Nursing Assistant (CNA) 1 attempted to transfer the resident, who required maximum assist 2 people assist for transfer, from bed to wheelchair by herself. This deficient practice resulted in Resident 1 fall on 9/27/2023 at 11:00 AM. On 9/27/2023 at 3:01 PM Resident 1 ' s X-ray (a photographic or digital image of the internal composition of a part of the body) 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.