Glendale Post Acute Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure two of 2 sampled residents (Resident 23 and 101) were provided care in a manner that maintained dignity and respect when: 1.Licensed Vocational Nurse (LVN) 6 left Resident 23 was lying in bed uncovered and exposed without replacing the blanket or gown to maintain the resident's privacy after care was provided. 2.The Treatment Nurse (TN1) was standing next to Resident 101 while assisting the resident to eat during dinner. This failure had potential to negatively affect the residents sense of dignity and respect during the care. Findings: 1. During a review of Patient 101's admission Record (AR), the AR indicated the facility admitted the patient on 8/26/2025 with diagnosis that included but not limited to moderate protein-calorie malnutrition (a condition from not getting enough nutrients) and dysphagia (difficulty or pain during swallowing food or liquids). During a review of Patient 101's MDS (Minimum Data Set-a resident assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents call lights (a device used by residents to signal his or her needs for assistance) were within reach for two of two sampled Residents (Resident 88 and 127) for reasonable accommodation of needs. Resident 88 who was legally blind and Resident 127 were at risk for accident and fall. This deficient practice had the potential for Residents to be unable to call for assistance in an emergency which could lead to a fall and/or injury.Findings: 1. During review of Resident 88's admission Record indicated Resident 88 was admitted to the facility on [DATE] with diagnoses that included peripheral vascular disease (circulation disorder caused by narrowing, blockage or spasms in a blood vessel), legal blindness (severe vision loss where you see so poorly that you can't perform normal daily tasks, even with glasses) and absence of left great toe. During a review of Resident 88's History and Physical Examination (H&P), dated 6/19/2025,…

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 provide a homelike environment for two of two sampled residents (Residents 100 and Resident 42) by ensuring Resident 100 and 42's wall clock in the room displays the accurate time of the day at all times. This deficient practice had the potential to cause disorientation, that could negatively affect Resident 100 and Resident 42's quality of life.Findings: 1.During a review of Resident 100's admission Record indicated the facility admitted Resident 100 on 10/15/2025 with diagnoses that included hemiplegia and hemiparesis (paralysis or severe weakness), hypertension (high blood pressure), and lack of coordination. During a review of Resident 100's Minimum Data Set (MDS - a resident assessment tool), dated 10/19/2025, indicated Resident 100's cognitive status (ability to think and reason) was severely impaired. Resident 100 was dependent (helper does all the effort) with toileting, bathing, dressing and personal hygiene. 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 to ensure that the facility informed one of eight residents (Resident 129) reviewed for resident's rights. Resident 129 and/or the representatives were not informed in writing the facility's policy on bed hold and return ( the facility keeps the resident's bed/room saved for up to 7 days while the resident is temporarily out of the facility) and keeps the document in the resident's clinical record that the resident was placed on bed hold at the time of transfer to the General Acute Care Hospital (GACH) on 9/9/2025 in accordance with the facility's policy and procedure (P&P) titled Bed-Holds and Returns, This deficient practice had the potential for residents' bed not to be appropriately held during hospitalization and to lose their room or their right to return to the same bed. Findings: A review of the admission record indicated Resident 129 was originally admitted to the facility on [DATE] with a diagnosis of pressure ulcer of sacral region (localized…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (CP) for two of seven residents (Resident 55 and 35) reviewed for comprehensive care plan by failing to: 1. Develop a CP to ensure Resident 55 received necessary care and interventions while receiving Ambien (a medication used to treat insomnia (a sleep disorder that can make it hard to fall asleep or stay asleep). 2. Develop a CP to ensure Resident 35 received necessary care and intervention while on hospice care (an end-of-life care). These deficient practices placed Resident 55 at risk of not receiving appropriate interventions to prevent the unnecessary use of psychoactive medications, which could result in adverse side effects (undesired effects). Additionally, these practices had the potential to compromise individualized care and negatively impact the quality of services provided to Resident 35. 2.During a review of Resident 35's admission Record (AR), the AR indicated…

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

Based on observation, interview and record review, the facility failed to ensure the peripheral Intravenous (IV-small catheters inserted into a vein used to administer fluids, blood and medications) sites for one of eight (Resident 52) on the right and left arms peripheral IV dressings were dated and initialed by the staff who changed the dressing in accordance with the facility's policy and procedure titled Peripheral and Midline intravenous and the physician's order. This deficient practice had the potential to increase the risk for result IV infection, IV site skin breakdown, IV infiltration (IV fluid leaking out from the veins and into the tissues causing swollenness, pain and tissue damage) Findings: A review of the admission records indicated Resident 52 was admitted originally on 11/04/2025, with a diagnosis of acute embolism ( a blockage in the blood vessel caused by something that has traveled there through the bloodstream such as a blood clot) and thrombosis (a blood clot ) of left femoral vein (a large vein in the upper leg/groin area) , respiratory failure (when lungs…

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 Resident 102 was free from significant medication error by failing to administer the correct dose of Retacrit ( a stimulating agent used to increase red blood cell production used to treat anemia (not enough healthy red blood cells that carry oxygenated blood to the tissues) reducing the need for blood transfusions) as ordered by the physician. This deficient practice had the potential to further worsened Resident 102's anemia and compromise resident's well-being and that may lead to the need for urgent blood transfusion and hospitalization. Findings: A review of the admission record indicated Resident 102 was admitted to the facility originally on 11/05/2025, with a diagnosis that included hemiplegia(paralysis affecting one side of the body) and hemiparesis (weakness or inability to move on one side of body) , anemia, and diabetes (Chronically high blood glucose ( sugar) levels). A review of resident 102's History and Physical (H&P), dated 11/06/2025, indicated Resident 102 had the capacity 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, and record review, the facility failed to maintain a safe and sanitary environment for one of four sampled residents (Resident 55) as evidenced by having dust with white debris, a drinking cup, a medication cup, a piece of cotton swab, a pack of food condiments, and old dry liquid stains on the floor under the resident's bed. This deficient practice had the potential to result in Residents 55's non homelike environment that affects the resident's quality of life and self-image. During a review of Resident 55's admission Record (AR), the AR indicated the facility admitted Resident 55 on 1/16/2025 with diagnoses that included type II diabetes mellites (a condition that happens when your blood sugar is too high) and hypertension (high blood pressure). During a review of Resident 55's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 10/16/2025, the MDS indicated Resident 55 had intact cognition (ability to understand and make decisions) and memory that required setup or clean-up assistance with eating, and supervision 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 interviews and record reviews, the facility failed to notify the medical doctor (MD 1) of clinical issues for one of two sampled residents (Resident 1) when Registered Nurse (RN) 2 and RN 3 did not inform MD 1 when they were unable to initiate an intravenous (IV) line (a thin, flexible tube inserted into a vein to deliver fluids, medications, blood, or nutrition directly into the bloodstream) and were therefore unable to administer Dextrose (sugar) 5% in Water (D5W - a fluid used to provide hydration through an IV line) ordered by MD 1 on 10/31/2025 for hydration. These failures had the potential to result in serious harm, including cardiac arrhythmias (when the heart beats too fast, too slow, or in an uneven way), worsening of Resident 1's condition, or death due to untreated low potassium levels and delayed fluid therapy. (Cross Reference F684)During a review of Resident 1's History and Physical (H&P) from the General Acute Care Hospital (GACH), dated 10/9/2025, timed at 11:20 PM, the H&P 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 interviews and record reviews, the facility failed to provide care in accordance with professional standards of practice for one of two residents sampled for quality of care (Resident 1) when:1. Licensed Vocational Nurse (LVN) 1 did not notify Resident 1's medical doctor (Medical Doctor [MD] 1) or assess Resident 1 for a change in condition when LVN 1 was informed of Resident 1's low blood potassium (an electrolyte that is essential to the normal functioning of muscles such as the heart) level of 2.7 mEq/L (milliequivalent per liter- a unit of measure; normal levels between 3.5 to 5.2 mEq/L) on [DATE] from 1:57 pm to 5:00 pm.2. LVN 2 and Registered Nurse (RN) 2 did not administer Resident 1's Potassium 40 mEq (milliequivalent- a measure of chemical concentration used in medicine) that was ordered by MD 1 in response to the resident's low blood potassium level on [DATE], as soon as the medication was made available in the facility's emergency drug kit (e-kit- a kit that contains essential medications…

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 specific care plan was initiated for one of three sampled resident (Resident 1), when Resident 1 verbalized feelings of being upset, angry and threatened during an incident that occurred on 9/7/25 after Responsible Party 1 told Resident 1 to lower the telephone volume. This deficient practice had the potential to result in Resident 1 not being monitored adequately by facility staff and not meeting Resident 1's specific needs.During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] , with a diagnosis of End Stage Renal Disease (ESRD - the kidneys can no longer filter waste and extra fluid from the blood the way they should) and dependence on renal dialysis (a process that uses a machine to clean the blood and remove extra fluid in order to stay alive). During a review of Resident 1's History and Physical (H&P), dated…

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 :1-Provide adequate Certified Nursing Assistant (CNA) staff to respond to requests for assistance with toileting and activities of daily living (ADL) in a timely manner , for three of four sampled residents (Resident 2, Resident 3,and Resident 4).2- Implement the Facility Assessment and All facility Letter (AFL) 21-11 to meet requirement Direct Care Service Hours Per Patient Day (DHPPD) for CNA for minimum of 2.4 hours.This deficient practice resulted in Resident 2 sustaining a fall on 7/27/25 in the facility hallway, Resident 4 stated feeling helpless after facility staff did not address the call light timely to assist Resident 4 with his wheelchair, and Resident 3 waiting for two hours to assist with ADL's.This deficient practice resulted in not meeting the minimum requirements for CNA's to provide adequate care and necessary services needed for each resident in the facility.During a review of Resident 2's admission Record (AR), the AR indicated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of four sampled residents (Resident 1 and Resident 2) who were at risk for falls, were provided supervision to prevent further fall instances, by failing to: 1. Ensure Resident 1, who had severely impaired cognition (thought process) was frequently monitored as indicated on Resident 1's Care Plan.2. Accurately document and assess Resident 2's Fall Risk Assessment after Resident 2 fell on 5/25/25 and 7/27/25.This deficient practice resulted in Resident 1 sustaining a fall on 7/27/2025.This deficient practice resulted in Resident 2 sustaining a fall on 5/25/2025 and 7/27/2025 and Resident 2 not receiving appropriate preventative measures to prevent future falls. During a review of Resident 1's admission Record (AR), the AR indicated that resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hypertension ( high blood pressure), Traumatic Subdural Hemorrhage without loss of consciousness (a serious…

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 notify the physician and the responsible party (RP) for one of five sampled residents (Resident 1) when Resident 1 had a change of condition of new skin redness between the skin folds of the lower abdomen (belly). This deficient practice had the potential to result in worsening of Resident 1's skin condition and delayed provision of necessary care and services to maintain skin integrity and prevention of infection. During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 5/15/2023 and readmitted her on 7/3/2023 with diagnoses that include dementia (A group of thinking and social symptoms that interferes with daily functioning) and difficulty in walking. During a review of a Minimum Data Set (MDS, a resident assessment tool), dated 4/24/2025, indicated Resident 1 had severely impaired cognition (ability to understand and make decisions) and memory. The MDS indicated Resident 1 required setup or clean-up assistance with eating, partial/moderate assistance 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, interview and record review, the facility failed to ensure one of five sampled residents (Resident 1)'s was provided with a safe and functional wheelchair with brakes that prevented the wheelchair from moving when activated. This deficient practice had the potential to result in falls or injuries for Resident 1 f during transfers and while stationary. During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 5/15/2023 and readmitted her on 7/3/2023 with diagnoses that include dementia (A group of thinking and social symptoms that interferes with daily functioning) and difficulty in walking. During a review of a Minimum Data Set (MDS, a resident assessment tool), dated 4/24/2025, indicated Resident 1 had severely impaired cognition (ability to understand and make decisions) and memory. The MDS indicated Resident 1 required setup or clean-up assistance with eating, partial/moderate assistance with oral hygiene and personal hygiene, substantial/maximal assistance with chair/bed-to-chair transfer and 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 interview and record review, the facility failed to document medications administered for three of five sampled residents (Resident 1, 3, and 4) onto the Medication Administration Record (MAR) on 6/15/2025 during the 3 PM to 11 PM. This deficient practice had the potential to result in medication errors for Resident 1, 3 and 4 and negatively impact the delivery of services for the residents. 1.During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 5/15/2023 and readmitted her on 7/3/2023 with diagnoses that include dementia (A group of thinking and social symptoms that interferes with daily functioning) and seizure (a sudden, uncontrolled surge of electrical activity in the brain that can cause changes in behavior, movements, sensations, or levels of awareness). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 4/24/2025, indicated Resident 1 had severely impaired cognition (ability to understand 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.

Based on observation, interview and record review, the facility failed to provide a sanitary environment for one of the five sampled residents (Resident 2) by not ensuring the wheelchair for Resident 2 was clean. This deficient practice had the potential to result in Resident 2' discomfort and the spread of infection. During a review of Resident 2's admission Record (AR), the AR indicated the facility originally admitted Resident 2 on 12/17/2018 and readmitted her on 1/15/2019 with diagnoses that include Alzheimer's Disease (a progressive brain disorder that gradually destroys memory and thinking skills) and hypertension (high blood pressure). During a review of a Minimum Data Set (MDS, a resident assessment tool), dated 6/3/2025, indicated Resident 2 had severely impaired cognitive (ability to understand and make decisions) skills for daily decision making. The MDS indicated Resident 2 required supervision or touching assistance with eating, substantial/maximal assistance with oral hygiene and personal hygiene, was dependent with chair/bed-to-chair transfer, toileting hygiene 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 accurately account for controlled medications (medications with a high potential for abuse) affecting six out of seven residents (Residents 2, 3, 4, 5, 6 and 7) in one of two inspected medication carts (Station 2 Cart 3) in accordance with the facility's policy and procedures for controlled medications by failing to: 1. Document in the Controlled Medication Count Sheet (CMCS, a log signed by the nurse with the date and time each time a controlled substance was administered to a resident) when the medication was removed from the medication supply of the residents and administered to Residents 2, 3, 4, 5, 6 and 7. 2. Remove and securely store the medications in the medication cart of Resident 3 who was transferred to the hospital and Resident 7 who had expired. This deficient practices increased the risk loss of controlled medication, medication errors for current residents (Residents 2, 4, 5, and 6), accidental administration of controlled…

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

Based on observation, interview, and record review the facility failed to ensure one of three sampled residents (Resident 1) received Restorative Nursing Assistant (RNA) services to increase, maintain, or prevent a decline in range of motion (ROM – the extent of movement of a joint) mobility per physician ' s orders, by failing to: 1. Initiate RNA services until 1/26/2025 (16 days after RNA services were ordered) as indicated on the physician ' s order dated 1/10/2025 for Resident 1 ' s left upper extremity (UE) elbow extension (a device, like a brace or splint, that helped extend or straighten the elbow joint after an injury, surgery, or to assist with recovery or rehabilitation) and left hand-roll. 2. Initiate RNA services until 1/27/25 (17 days after RNA services were ordered) as indicated on the physician ' s order dated 1/10/2025 for Resident 1 ' s left UE passive range of motion (PROM, exercises where a physical therapist or equipment moved a patient ' s joint through range of motion [ROM], helping to maintain or regain movement after injury or surgery, without the patient…

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 prevent weight loss for one of three sampled residents (Resident 1) who was fed via gastrostomy tube (G-tube, a surgically placed feeding tube that delivers nutrition directly into the stomach through a small opening in the abdomen, used when someone could not eat or swallow safely or adequately) by failing to: 1. Perform weekly weights upon admission and on 1/18/2025 when recommended on Resident 1 ' s Registered Dietician (RD) Nutrition Care Recommendation. 2. Follow RD recommendations from 12/20/2025 and 1/18/2025 for the physician to consider new complete blood count (CBC – a common blood test that provided information about the different components of the blood)/basic metabolic panel (BMP, measures eight different substances in your blood), increase free water (FWF, the amount of water in an enteral formula [tube feeding] that was not part of the nutritional components, but rather was the actual water used as an ingredient) to 300 milliliters (ml, 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 interview and record review, the facility failed to follow physician orders for Laboratory Services and implemented fall care plan interventions for one of three sampled residents (Resident 1), who has a diagnosis of dementia (mental decline of memory, thinking and reasoning) and assessed at high risk for falls, by failing to: 1. Ensure to have a Fall Protocol (a system of rules that explain the correct conduct and procedures to be followed in formal situations) and Fall Prevention Program in place, as indicated in the facility ' s Fall Care Plan Interventions developed for Resident 1 on 2/4/2025 and 2/15/2025, and physician orders on 2/17/2025 and 2/18/2025. In an interview, the Assistant Director of Nurses (ADON) stated the facility did not have a fall protocol or fall prevention program in place. 2. Follow up with the facility ' s Laboratory Services, when the facility ' s Laboratory (Lab) Technician (LT) could not obtain Resident 1 ' s blood sample on 2/5/2025, as indicated with physician orders 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 interview and record review, the facility failed to ensure the management of Resident 1 ' s psychotropic medications met the psychotropic medication requirements, in accordance with the facility ' s policy and procedures (P&P) titled Medication Utilization and Prescribing - Clinical Protocol, Psychotropic Medication use, and Appendix 3: Medication Issues Of Particular, Relevance In Older Adults by failing to: 1. Ensure Resident 1 ' s Depakote (brand name as divalproex sodium, used to treat epilepsy and bipolar disorder, medication works by affecting chemicals in the brain) use from 12/11/2024 to 12/18/2024 was given only when necessary to treat a specific diagnosed and documented clinical condition, that was based upon a clinical assessment of the resident ' s condition and consistent with clinical standards of practice. Resident 1 was administered Depakote from 12/11/2024 to 12/18/2024 for the treatment of seizures, despite the resident not having a seizure disorder or diagnosis. 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 interview, and record review the facility failed to ensure the facility ' s Quality Assurance Performance Improvement ([QAPI] takes a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes) committee failed to identify facility and resident care issues, develop, and implement appropriate plans of action to implement the facility ' s infection prevention and control program (IPCP), in accordance with the facility ' s policy and procedures on Continuous Quality Improvement Program (QAPI), by failing to: 1. Ensure the QAPI committee systematically implemented and evaluated preventative measures to address an outbreak (a greater number of disease cases than expected in a specific area or group of people over a given time period) of gastrointestinal (GI) illness (conditions affecting your digestive system) among residents and staff in the facility. 2. Ensure the QAPI Commitee conducted appropriate follow through in placing for 26 of 106 sampled residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 ,11,…

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 comprehensive care plan was specific for one of two sampled residents (Resident 1) who had diagnosis of anxiety. This failure had a potential to result in Resident 1 ' s inadequate and incomplete provision of care. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included bipolar bipolar disorder (a serious mental illness that causes extreme shifts in mood, energy, and activity levels), anxiety disorder (a condition that causes excessive worry and fear that interferes with daily life), and malignant neoplasm (a cancerous tumor, or abnormal tissue growth that spreads to other parts of the body) of unspecified kidney (one of a pair of organs in the abdomen that take waste out of the blood and make urine). During a review of Resident 1 ' s History and Physical (H&P), dated 1/10/2024, the H&P indicated Resident 2 had…

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

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of one of three sampled residents (Resident 1) in accordance with the facility's policy and procedure by failing to administer Resident 1 ' s medications on 11/4/24, 11/5/24, and 11/12/2024 at 9am as ordered by the physician. This deficient practice had the potential for Resident 1 to experience high blood pressure (when your blood pressure is consistently higher than normal), high blood sugar and decline in overall health status. Findings: During a review of Resident 1 ' s admission Record, dated 11/13/2024, the face sheet indicated the facility admitted Resident 1 on 7/3/2024 with diagnoses including diabetes mellitus (elevated sugar in the blood), and hypertension (a long-term medical condition in which the blood pressure in the arteries is persistently elevated). During a review of Resident 1's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 11/1/2024, indicated the cognitive (the ability to think and process information) skills…

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 Resident 1 who was transferred to a General Acute Care Hospital (GACH) via 911 emergency services for a change in condition, was provided written information regarding the facility ' s bed-hold policies and permitted to be readmitted back to the facility on the first available bed, in accordance with the facility ' s policy and procedure titled Bed-Holds and Return, and the California Standard admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities for one of three sampled residents (Resident 1). Resident 1, who was transferred to the GACH from Skilled Nursing Facility (SNF) 1 on 10/17/2024 due to a change in condition and was medically stable to be discharged back to SNF 1 on 10/22/2024, had to stay in the GACH setting for six additional days (from 10/22/24 to 10/28/24) when Resident 1 was transferred and admitted to SNF 2 due to SNF 1 refusing to readmit Resident 1 back. This deficient practice had the potential 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 interview and record review, the facility failed to ensure two out of two licensed nurses (Registered Nurse [RN] 3 and Licensed Vocational Nurse [LVN] 3) in the facility completed their annual competency assessment and evaluation (a process that assess and evaluates an employees skills, knowledge and performance) for the appropriate job category, in accordance with the facility ' s policy and procedure. This deficient practice placed the residents at risk for receiving care and services that was not within the standard of practice appropriate and safe which could result in abuse and decline in the resident's quality of life and care. Findings: A review of RN 3 ' s employee file records indicated the facility hired RN 3 on 1/16/2023. RN 3 ' s employee records included a Skills Check List dated 1/16/2023 signed by employee and the Director of Nursing (DON). A review of LVN 3 ' s employee file records indicated the facility hired LVN 3 on 3/27/2023. LVN 3 ' s employee records included a Skills Check List dated 03/27/2024 signed by employee and the DON. During an interview 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.

Based on observation, interview and record review, the facility failed to follow their policy and procedure guidelines to prevent food contamination and the spread of foodborne illness for one of one kitchen when: 1.Multiple opened dry food items in the kitchen ' s dry goods storage area were not sealed and labeled. 2.Two boxes containing 229 unpasteurized eggs were found in the kitchen and were being used as ingredients to foods served to residents. These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead hospitalization. Findings: 1. During an observation on 10/11/2024 at 8:55 AM in the facility ' s kitchen, the following opened food items were observed wrapped inside a transparent plastic wrap that were unlabeled: 4 Pasta bags 1 Gelatin Powder bag 4 [NAME] gravy bags During a concurrent observation and interview on 10/11/2024 at 9:10 AM in 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, and record review, the facility failed to implement the facility ' s policy and procedure for infection control related to Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs, Bacteria that resist treatment with more than one antibiotic]) due to presence of multiple wounds and use of a foley catheter (an indwelling medical device that consists of a hollow tube inserted into the bladder to drain or collect urine) for one of eight sampled residents (Resident 13). Certified Nursing Assistant (CNA) 1 was observed providing care to Resident 13 without wearing the proper personal protective equipment (PPE). This failure placed Resident 13 and other residents to contract and or transmit the infectious organisms to other vulnerable residents and result in the spread of infection in the facility. Findings: A review of Resident 13 ' s admission Record indicated the resident was originally admitted 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, and record review, the facility failed to ensure one of one sampled resident (Resident 103) was treated in a dignified and respectful manner when a certified nursing assistant (CNA 2) did not provide body coverage when transporting Resident 103 through the hallway in a shower chair, in accordance with the facility ' s policy and procedure titled Dignity. This deficient practice had the potential to cause psychosocial (mental and emotional well-being) decline, resident ' s individuality, self-esteem, and self-worth. Findings: A review of Resident 103 ' s Face Sheet (front page of the chart that contains a summary of basic information about the resident) indicated Resident 103 was admitted to the facility on [DATE], with diagnoses that included Parkinson ' s disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), depression (a mental health disorder characterized by persistently depressed mood or loss of interest in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility IDT (Interdisciplinary Team- team of facility staff that plans the care for the residents) did not accurately assess on of one resident (Resident 90) to ensure safely self-administer 17 bottles of medications that were stored the bedside which were not prescribed or ordered by the physician to self administer by failing to: Conduct an Interdisciplinary Team (IDT) meeting to assess if Resident 90 had the cognitive and physical abilities to self-administer medications. Review if any of the medications were expired, discontinued, or recalled. Document time when Resident 90 self-administered her medications. Ensure the medications were stored in a secure place, and not easily accessible to other residents besides Resident 90. This deficient practice put Resident 90 and other residents in the facility that could access the medications to be at risk for potentially harmful side effects (undesirable effect of medication) and adverse reaction (an untoward…

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 accommodate the needs of three sampled residents (Residents 26, 83, and 314) by ensuring the residents call light (a device used to alert staff to the resident ' s room) within their reach (within arm ' s reach). This deficient practice had the potential for the residents not to receive or receive delayed care and services that could result in accidents and falls. Findings: 1. During a review of Resident 83 ' s admission Record indicated the resident was admitted on [DATE] with diagnoses that included muscle wasting, cerebral infarction (stroke, loss of blood flow to a part of the brain), and contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion). During a review of Resident 83 ' s History and Physical (H&P), dated 2/21/2023, indicated the resident does not have the capacity to understand and make decisions. During a review of Resident 83 ' s Minimum Data Set (MDS - a federally mandated 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 interview and record review the facility failed to ensure that a current copy of a resident ' s advance directive was in the resident ' s medical record for two of three sampled residents (Resident 21 and 53). This deficient practice had the potential to result in misinformation of medical care and treatment and not honoring resident ' s wishes in cases where the resident and/or responsible party was unable to participate in making healthcare decisions. Findings: 1. During a review of Resident 53 ' s Face Sheet (front page of the chart that contains a summary of basic information about the resident) indicated an admission to the facility on [DATE] with diagnoses that included of metabolic encephalopathy (brain disease that alters brain function or structure), end stage renal disease (ESRD-irreversible kidney failure), and lobar pneumonia (an infection/inflammation in the lungs). A review of Resident 53 ' s History and Physical [H&P] dated 09/02/2024, the H&P did not indicate if Resident 53 had the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to notify the resident ' s physician and resident representative(s) for one of two sampled residents (Resident 21) with significant weight loss (when you lose more than 5% of your body weight over a period of six to 12 months) of 23 pounds (lbs.) in a period of 15 days. These deficient practices had the potential for the resident not to receive the necessary interventions to prevent further weight loss and negatively affect the provision of necessary care and services. Findings: A review of Resident 21 ' s admission Record indicated the facility admitted the resident on 7/1/2021, with diagnoses including Parkinson ' s disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), cognitive communication deficit (difficulty with communication that was caused by a disruption in cognition), and heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes…

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 initiated facility initiated discharges on two of four sampled residents (Resident 320 and 111) when: 1. Resident 320 was informed by the Social Services Director [SSD] that she did not meet the criteria to stay admitted at the facility on 7/25/2024, after being admitted to the facility on [DATE]. Resident 320 was provided an option to pay out of pocket for Rehabilitation Services or sign the Against Medical Advice [AMA] on 7/25/2024. The facility did not provide adequate discharge planning for Resident 320, resulting in an unsafe discharge against medical advice [AMA] on 7/25/2024. Resident 320 was not provided with the information of the resident's rights to appeal and stay at the facility while an appeal is pending. 2. Resident 111, who had moderately impaired cognition (ability to reason and thought process), was not allowed to remain in the facility after the resident went out-on-pass on 7/27/2024 (OOP, a temporary permission of a resident to leave 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 interview and record review the facility failed to develop and revise the resident ' s care plan for one (1) of 3 residents, (Resident 38) by failing to revise Resident 38 ' s care plan for pain management when the resident continued to complain of pain everyday to indicate alternative interventions to relieve the resident ' s pain experience. This deficient practice resulted in Resident 38 to continue experiencing pain everyday that affected her quality of life. Findings: A review of Resident 38 ' s admission Record indicated the facility initially admitted the resident on 3/6/2018 and readmitted the resident on 10/31/2023, with diagnoses including chronic congestive heart failure (CHF - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), hypothyroidism (when the thyroid [a small, butterfly-shaped gland in the neck that produces hormones that regulate the body ' s metabolism, growth, and development] gland did not produce enough thyroid hormones), and anemia (a condition where the body did not have enough healthy…

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 assist Resident 72 in receiving proper treatment and assistive devices to maintain vision when Resident 72 reported his prescription glasses (glasses prescribed by a doctor based on the resident ' s ability to see or vision) were broken by facility Certified Nursing Assistant (CNA). This deficient practice could lead to Resident 72 experiencing a decline in his everyday quality of life while at the facility. Findings: A review of Resident 72 ' s Face Sheet (front page of the chart that contains a summary of basic information about the resident) indicated the resident was admitted to the facility on [DATE] with diagnoses that included cellulitis ( a bacterial infection that affects the skin and underlying tissue) of upper limb, major depressive disorder (a mental health condition that causes a low mood and loss of interest in activities). A review of Resident 72 ' s History and Physical assessment dated [DATE], indicated Resident has the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to administer oxygen therapy (treatment that provides supplemental, or extra, oxygen) with a physician order of the amount of oxygen and with the parameter to when or when not to administer oxygen in accordance to acceptable standards of clinical practice and accordance with the facility ' s policy and procedure for one of two sampled residents (Resident 47). This deficient practice could result in Resident 47 to receive too much or not sufficient oxygen to meet the body ' s demand and place the resident at risk for shortness of breath and/or hypoxia (low levels of oxygen in the body tissues) which can lead into serious injury or death. Findings: A review of Resident 47 ' s Face Sheet (front page of the chart that contains a summary of basic information about the resident) indicated the resident was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes mellitus (a condition when the body doesn ' t produce enough…

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 conduct a Medication Regimen Review (MRR- a thorough evaluation of a patient's medications to identify and resolve issues, and to promote positive outcomes) to one of three sample residents (Resident 90) who consumed 17 bottles of medications kept at bedside that were not prescribed by the physician. This deficient practice put Resident 90 and other residents in the facility that could access the medications to be at risk for potentially harmful side effects (undesirable effect of medication) and adverse reaction (an untoward reaction to a medication) of the drug to the current drug regimen of the resident that could result in hospitalization and death. Findings: During a review of Resident 90 ' s admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included leg fracture (break in the bone), malignant neoplasm (cancerous tumor that develops when cells grow and divide abnormally) of the kidney…

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 maintain complete and accurate documentation of medical records for one (1) of 11 sampled residents (Resident 80) by failing to update the contact phone number of the representative of Resident 80 in the admission Record. The contact number listed in Resident 80 ' s chart was out of service. This deficient practice had the potential to interrupt provision of care and services for Resident 80 that could lead to delayed interventions to the resident especially during an emergency. Findings: A review of Resident 80 ' s admission Record indicated the facility admitted the resident on 8/3/2023, with diagnoses including palliative care (a specialized medical care that helps people with serious illnesses feel better and improve their quality of life), anemia (a condition where the body did not have enough healthy red blood cells), and end stage renal disease (ESRD – irreversible kidney failure). The admission Record indicated the resident ' s representative Family 1 (FAM) 1 was the responsible party for Resident 80 but the contact…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to maintain to keep the electric wheelchair of one of one sampled resident (Resident 40) in safe and functional condition. Resident 40 stated her electric wheelchair (a battery-powered device that helps people with mobility challenges move around) had been broken for two years and was waiting for the facility to fix the electric wheelchair. Resident 40 stated she was very frustrated that the electric wheelchair was broken and needs the electric wheelchair to go outside and be able to do things. This deficient practice resulted in the resident ' s feeling frustration that limits her ability to mobilize in and out of the room to socialize and do outside activities which negatively affected her quality of life that could affect her mental/emotional/psychological state. Findings: During a review of Resident 40 ' s admission Record indicated the facility initially admitted the resident on 6/12/2018 and readmitted the resident on 8/26/2023, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure a sufficient preparation and orientation (sufficient preparation and orientation means the facility informs the resident where he or she is going and takes steps under its control to minimize anxiety) to a safe and orderly discharge was conducted for one of four sampled residents (Resident 1), who had fluctuating capacity to understand and make decisions and required continuous use of oxygen due to chronic obstructive pulmonary disease (COPD- lung disease causing restricted airflow and breathing problems). The facility did not provide adequate discharge planning for Resident 1, resulting in an unsafe discharge against medical advice on 9/25/2024. On 9/27/2024 (two days after the resident was discharged home), Resident 1 was transferred to the General Acute Care Hospital [GACH] due to severe shortness of breath, acute COPD exacerbation and acute hypercapnic [a life-threatening emergency of having too much carbon dioxide in the blood 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.

Based on interview and record review the facility failed toensure one of three sampled residents (Resident 3) was free from misappropriation of property (the unauthorized, improper, or unlawful use of funds or other property for purposes other than for which intended) by failing to: 1. Protect Resident 3 ' s personal belonging/ valuables. Resident 3 ' s wallet was not accounted for on the Residents ' Clothing and Possession Form (inventory list), and Resident 3 was missing debit cards, two hundred dollars cash and a watch. 2. Accurately document on Resident 3 ' s Clothing and Possession Form personal belongings and valuables brought into the facility by Resident 3 and revise the form upon readmission and as needed. 3. Immediately report and investigate Familymember2 ' s (FM2) allegation of abuse of Resident 3 ' s missing personal belongings/valuables. 4. Implement the facility ' s Policy and Procedure on Investigating Incidents of theft and /or Misappropriation of Resident Property. These deficient practices resulted in the misplacement of Resident 3 ' s wallet, two hundred dollars…

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 report an allegation of misappropriation of property ( the illegal use of the property or funds of another person for one ' s own use unauthorized purpose) for one of three sampled residents (Resident 3) to the California Department of Public Health (CDPH), within two hours by telephone and written report, in accordance with the facility ' s Policy and procedure titled Abuse investigation and reporting - Investigation Incidents of theft and or misappropriation of resident Property. This deficient practice had the potential to result in unidentified abuse in the facility and the risk of further abuse to residents. Findings: A review of Resident 3 ' s admission Record indicated the facility admitted the resident on 6/19/2024, with diagnoses that included but not limited to Malignant neoplasm (Cancerous tumors) of lung. A review of Resident 3 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 6/17/2024, indicated Resident 3 had serve cognitive impairment (severe issues 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide safety to one of two sample residents (Resident 1) who was at high risk for injury as indicated in the facility ' s policy and procedure titled Falls and Fall Risk, Managing and resident ' s care plan by failing to: 1. Ensure Resident 1 was assisted by two persons while performing activities of daily living (ADL). While Certified Nursing Assistant (CNA) 3 assisted Resident 1 to change clothes, Resident 1 turned to scratch the back and started to slide down the bed. CNA 1 grabbed Resident 1 under the neck and back and eased Resident 1 to the floor. 2. Implement fall precautions immediately by monitoring the resident for low bed position and safety after Resident 1 ' s fall on 8/20/24. These deficient practices resulted in Resident 1 ' s all with injuries which included a left distal tibia-fibula fracture (a serious injury that occurs when the tibia and fibula, the two long bones in the lower leg, break due to too much pressure)…

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 residents were kept clean and assisted with activities of daily living, when the facility failed to provide incontinent care and ADL assistance for 5 of 6 sampled residents (Resident 1, 2, 3, 4 and 5). These deficient practices resulted in the residents feeling frustrated, embarrassed, and angry due to lack of or delay in receiving sufficient services to maintain incontinent care and had the potential to lead to skin breakdown and psychosocial distress. Findings: During a review of Resident 1 ' s admission Record indicated the facility admitted the resident on 8/30/23, with diagnoses pathological fracture (broken bone done by direct or indirect force) and anxiety disorder (excessive worry and feelings of fear). 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 dated 1/10/24,…

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 sufficient nursing staff to provide nursing care and related services to assure resident safety, assist residents in activities of daily living (ADL) and prevent falls for 6 out of 6 sampled residents (Residents 1, 2, 3, 4, 5, and 6) who required staff assistance for ADLs. This deficient practice resulted in a delay in response to resident needs and resulted in the increased of fall in the facility for the month of July 2024. The facility had a total of 11 falls for July 2024. Three residents falls resulted with injuries. Findings: During a review of Resident 1 ' s admission Record indicated the facility admitted the resident on 8/30/23, with diagnoses pathological fracture (broken bone done by direct or indirect force) and anxiety disorder (excessive worry and feelings of fear). During a review of Resident 1 ' s History and Physical Examination (HPE, a comprehensive physician ' s note regarding the assessment of the resident ' s…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a safe environment free of environmental hazards and provide adequate supervision to prevent accidents for one of three sampled residents (Resident 1). These deficient practices resulted in Resident 1 sustaining repeated falls, a total of two falls from 3/30/2024 to 7/10/2024 and was identified with injuries on one fall as follows: On 7/10/2024, Resident 1 fell in Shower room [ROOM NUMBER] and sustained 2 centimeters (cm) vertically X 0.5 cm head wound laceration (a deep cut or tear in skin or flesh). Resident 1 was transferred to the General Acute Care Hospital (GACH) via 911 emergency services on 7/10/2-24 and came back on the same day with five staples in the head. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 1/21/2020 with diagnoses including dementia (impaired ability to think and remember interfering with doing everyday activities), wandering (to go from place to place…

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 two sampled resident ' s representative (Resident Representative 1 [RP 1]) whose a family member of Resident 1, that did not have capacity to understand and make decisions, was informed and involved during Resident 1 ' s admission in the facility, including review and signing of facility required admission paperwork, that included consents for the following: -MDS Transmission Notification -Consent to Treat -Advanced Healthcare Directive Acknowledgement form This deficient practice had the potential for Resident 1 ' s rights to be violated and not have sufficient knowledge of documents before signing, and RP 1 not to be informed of Resident 1 ' s care and documents signed in the facility. Findings: A review of Resident 1 ' s admission Record indicated the facility was last readmitted to the facility on [DATE], with diagnoses that included Unspecified Dementia (the loss of memory, language, problem-solving and other thinking abilities 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 interview and record review, the facility failed to implement the facility ' s policy and procedure titled Abuse Prevention Program and Abuse Investigation and Reporting by failing to protect Resident 1 during an abuse investigation when Certified Nursing Assistant (CNA) 1, who matched the description of an alleged abuser as described by one of three sampled residents (Resident 1), was not prevented from coming in physical contact with Resident 1 after Licensed Vocational Nurse (LVN) 1 was already informed of the allegation of abuse on 5/31/24 at 7:30 PM. This deficient practice had the potential to cause further abuse and negatively affect the psychosocial well-being of Resident 1. Findings: A review of Resident 1 ' s admission record indicated the resident was admitted to the facility on [DATE] with diagnoses that included Parkinson ' s Disease (brain disorder in which there is a lack of the chemical messenger dopamine, which helps control muscle movement; leads to muscle stiffness, weakness, 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 provide Resident 1 ' s responsible party/representative (RP 1) access to Resident 1 ' s records within 48 hours (excluding weekends and holidays) of the initial request for one of two sampled residents (Resident 1), in accordance with the facility ' s policy and procedure titled Release of Information dated November 2009. This deficient practice caused a delay in releasing Resident 1 ' s records in a timely manner. Findings: A review of Resident 1 ' s admission Record indicated the facility originally admitted the resident on 1/5/2024, and was readmitted on [DATE], with diagnoses that included hypertensive chronic kidney disease, Gastro -esophageal reflux disease without esophagitis (inflammation of your esophagus). The admission Record indicated RP 1 is Resident 1 ' s designated Responsible Party. A review of Resident 1 ' s History and Physical (H&P) dated 3/7/2024, indicated Resident 1 did not have the capacity to understand and make decisions. 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 develop and implement individualized person-centered care plans with measurable objectives, timeframes and interventions for one of two sampled residents (Resident 1) by failing to: 1. Develop a comprehensive, resident centered care plan for Resident 1 when a DTI was found by Treatment Nurse 2 on 1/9/2024. On 2/17/2024, Physician Assistant (PA) 1 indicated DTI to Resident 1 ' s right heel. There was no documented evidence that care plan was developed for Resident 1 ' s right heel skin concern. 2. Develop care plan interventions for peripheral vascular disease (PVD - a circulatory condition characterized by the narrowing or blockage of blood vessels outside the heart and brain. It primarily affects the arteries and veins in the arms, legs, and organs, leading to reduced blood flow and potential tissue damage), timely on 2/27/2024, when Wound Physician 1 indicated in the wound assessment that the wound type for Resident 1 ' s right heel 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 interview, observation and record review the facility failed to: 1. Ensure Resident 1 ' s skin was reassessed by the treatment nurse 24 to 48 hours after being newly admitted to the facility on [DATE]. Resident 1 ' s skin was reassessed by the treatment nurse on 1/9/2024 and found a right heel deep tissue injury (DTI- a pressure-related injury to subcutaneous tissues under intact skin), six days after admission. 2. Develop a comprehensive, resident centered care plan for Resident 1 when a DTI was found by Treatment Nurse 2 on 1/9/2024. 3. Follow and notify the physician of the interdisciplinary team (IDT) treatment recommendations made on 1/9/2024 to put in physician order to treat Resident 1 ' s DTI to the right heel with betadine everyday. The treatment order to apply betadine daily to the right heel was not started, until 1/15/2024 (6 days after IDT recommendation). 4. Develop care plan interventions for peripheral vascular disease (PVD - a circulatory condition characterized by the narrowing 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 provide privacy for one of three sampled residents (Resident 1) while treatment nurse (TN)1 provided wound care treatment. This failure had the potential for Resident 1 to be in view of passerby ' s in the facility hallway and affecting Resident 1 ' s self-worth and dignity. Findings: A review of the admission Record indicated Resident 1 was re-admitted to the facility on [DATE] with diagnoses including but not limited to, history of falling, difficulty walking, lack of coordination, chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), gastroesophageal reflux disease (a condition that occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach), and a right femur fracture (a break in the thighbone). A review of Resident 1's Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool), dated 4/4/24, indicated Resident 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident was assessed for pain before, during, and after wound care treatment for one of 3 sampled residents (Resident 1). This deficient practice resulted to Resident 1 experiencing unnecessary pain during wound care treatment. Findings: A review of the admission record indicated Resident 1 was re-admitted to the facility on [DATE], with diagnoses including but not limited to, history of falling, difficulty walking, lack of coordination, chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), gastroesophageal reflux disease (a condition that occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach), and a right femur fracture (a break in the thighbone). A review of Resident 1's Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool), dated 4/4/24, indicated the resident had mildly impaired cognitive…

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 one out of nine residents (Resident 1) from potentially developing a wound infection when Treatment Nurse (TN) 1 failed to stop and restart a wound treatment after Resident 1 ' s right heel deep tissue injury (a serious form of pressure injuries [localized damage to the skin as well as underlying soft tissue, usually occurring over a bony prominence or related to medical devices]) wound touched her wheelchair ' s footrest. This failure placed Resident 1 at risk of developing an infection on her right heel wound. Findings: A review of Resident 1 ' s admission Record indicated the resident was originally admitted to the facility on [DATE] and was recently re-admitted again on 3/3/24 with diagnoses that included history of falling, difficulty walking, and right leg fracture (break in the bone). A review of Resident 1 ' s History and Physical (H&P), dated 1/6/24, indicated the resident had 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 interview and record review, the facility failed to thoroughly investigate an allegation of sexual abuse made by the resident ' s family member (FM 1) on 3/31/24, that alleged two men, came during the night shift of 3/30/24 and rubbed the resident ' s private part that caused bleeding for one of four sampled residents, in accordance with the facility ' s policy and procedure titled, Abuse Investigation and Reporting. In addition, the facility failed to suspend Certified Nurse Assistant (CNA) 2 and Licensed Vocational Nurse (LVN) 2, who performed perineal care to Resident 1 during the night shift of 3/30/24, when the facility administrator and the director of nurses (DON) was notified of the sexual abuse allegation on 3/31/2024, pending the completion of the investigation. These deficient practices had the potential to place Resident 1 at risk for further abuse. Findings: A review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included…

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 interviews and record reviews, the facility failed to allow one sampled resident (Resident 1) to return to the facility after hospitalization leave as outlined in the facility ' s policy and procedure. In addition, the facility failed to show evidence that the facility made efforts to provide reason of what services they are not be able to provide Resident 1. As a result, Resident 1 remained at the General Acute Care Hospital (GACH) Emergency Department from 3/9/24 to 3/18/24, for nine days while waiting for acceptance from Recuperative Care Center (facility that provides short-term residential care for individuals who need to heal from injury or illness). Findings: A review of Resident 1 ' s Face sheet (admission record) indicated Resident 1 was admitted to the facility from GACH 1 on 3/8/2024 with diagnosis of chronic obstructive pulmonary disease (inflammation of the lungs), asthma (condition that inflames and narrows the airways in the lungs), hypertension (high blood pressure) and unspecified malignant neoplasm of the breast (cancerous tumor) and unilateral…

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 proper use of bed side rails (adjustable metal or rigid plastic bars that attach to the sides of the bed) for one of six sampled residents (Resident 4), as indicated in the facility's policy and procedure titled Bed Safety and Bed Rails, by failing to: -Assess Resident 4 for risk of entrapment (an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail). -Obtain an informed consent from Resident 4 or Resident 4 ' s representative and review the risks and benefits prior to installing bed rails. These deficient practices had the potential to result in inappropriate use of bed rails for Resident 4 and can lead to accidents such as strangulation. Findings: A review of Resident 4 ' s admission Record, indicated Resident 4 was admitted to the facility on [DATE], with diagnoses that included left femur (bone in the leg) fracture (broken bone) and history of falling. A review of Resident 4 ' s…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that a system was in place to provide a safe resident environment for one of three sampled residents in the facility, identified as active smokers (Resident 1, 2, and 3), and to ensure non-smoking residents of the facility were kept safe, comfortable and free from the hazards of second hand smoke, as indicated in the resident ' s written plans of care and the facility ' s policy and procedure on Smoking. These deficient practices had the potential for residents to acquire unexpected burns, fire hazard and /or injuries caused by unsafe smoking and exposed non-smoking residents and visitors to secondhand smoke. Findings: During an interview on [DATE] at 10:10 AM, Resident 1 stated since it had been raining, Resident 1 smoked inside the courtyard patio in the early morning of [DATE] or [DATE] around 6 AM. During an interview on [DATE] at 10:16 AM, Housekeeping Staff stated she observed Resident 1 and Resident 3 smoke early 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 observation, interview, and record review, the facility failed to respect the resident's choice and preference for one of three sampled residents (Resident 1) rights by assigning a male CNA and having a male CNA assist Resident 1 after Resident 1 and Resident 1's Family Member (FAM) 1 requested a female CNA to be assigned to Resident 1, in accordance with the facility's policy on Dignity. This deficient practice violated Resident 1's rights to have a female CNA care for her and has the potential to negatively affect Resident 1's psychosocial well-being, self worth and self-esteem. Findings: A review of Resident 1's Face Sheet (admission record) indicated the resident was admitted to the facility on [DATE], with diagnoses including encephalopathy (brain disease that alters brain function or structure. Result in declining ability to reason and concentrate, memory loss, personality change, seizures, and twitching are common symptoms), hypertension (high blood pressure), and Type II Diabetes (a condition of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to put measures in place to ensure the safety of two of two sampled residents (Residents 1 and 2) who were assessed as elopement (an act or instance of leaving a safe area or safe premises, done by a person with a mental disorder or cognitive impairment) risk. The facility staff failed to supervise Resident 1 who eloped from the facility on 10/21/2023, by failing to ensure: 1. Resident 1 who had a diagnosis of dementia (loss of memory, language, problem-solving and other thinking abilities) and was assessed to be at risk for elopement had an order to place a wander guard (purpose of keeping wanderers safe, preventing them from straying too far) on the resident ' s wrist left lower extremity to alert the staff when resident is attempting to leave the facility without supervision and an order to monitor proper placement and function of the wander guard every shift on 6/23/2023. 2. The facility monitored the maintenance of the wander guard door…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse when Resident 1, who had a behavior of randomly grabbing things and staff was not monitored for behavior to identify risk factors for abuse for one of two sampled Residents (Resident 1). This deficient practice resulted in Resident 1 being physically abused by Resident 2 during a resident -to-resident altercation on 10/22/23. Resident 1 sustained a bruising (bluish-dark discoloration) under the left eye, when Resident 2 (Resident 1's roommate) hit Resident 1, after Resident 1 grabbed Resident 2's jacket, as he walked away. Findings: A review of Resident 1's admission Record indicated the resident was initially admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease (brain disorder that gets worse over time), mental disorders (disorders that affect the mood, thinking and behavior) due to known physical disorders and metabolic encephalopathy (condition in which brain…

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, record review, the facility failed to report immediately within two hours, in accordance with the facility's policy on abuse reporting, a suspicion of physical abuse for one of two sampled residents (Resident 1). Resident 1 was physically abused by Resident 2 during a resident -to-resident altercation on 10/22/23. Resident 1 sustained a bruising (bluish-dark discoloration) under the left eye, when Resident 2 (Resident 1's roommate) hit Resident 1, after Resident 1 grabbed Resident 2's jacket, as he walked away. Certified Nurse Assistant (CNA) 1 observed Resident 1's left eye discoloration on 10/22/23 at around 8 AM and did not report it immediately to the Abuse Coordinator. Licensed Vocational Nurse (LVN) 1 observed Resident 1's left eye discoloration on 10/22/23 at around 10: 30 AM and did not report it immediately to the Abuse Coordinator. Registered Nurse (RN) 2, reported it to the State Agency and other appropriate agencies The police were notified on 10/22/23 at 1:30 PM (5.5…

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 the facility's policy and procedure titled Preparation and General Guidelines to ensure the systems of records in disposing expired medications and accurate accounting of controlled drugs (drugs that are subject to high levels of regulation because of government decisions about those drugs that are especially addictive and harmful) for four of four residents (Resident 16, 29, 30 and 80). The facility failed to ensure: 1. The medication cart drawer for controlled drugs did contain Morphine Sulfate (a controlled drug used for pain relief) belonging to Resident 16, who passed away on 10/14/23. 2. Resident 80's-controlled drugs count did not match the Controlled Drug Record for Percocet tablet (a drug given to relieve pain) 5-325 mg Oxycodone-acetaminophen (a controlled drug given to relieve moderate to severe pain) give 1 tablet by mouth every 8 hours as needed, and Pregabalin capsule (a drug used given to relieve nerve pain 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.

Based on observation, interview and record review, the facility failed to follow the facility's policies & procedures on food storage by: 1. Not unpacking the contents of 24 of 24 corrugated (a material shaped into alternate ridges and grooves) shipping boxes and placing those boxes directly onto the shelf in the dry storage room. This failure had the potential to introduce insects such as cockroaches (small insects that cause spread of bacterial infection) into the food storage environment from the corrugated cardboard shipping boxes, which may result in vector-borne diseases (diseases that result from an infection transmitted to human by insects and cockroaches). 2. Not labeling and covering food items in two of two cool storage areas (freezer and walk-in refrigerator). This failure had the potential for residents to be at risk of a food-borne illness (illness caused by food contaminated with bacteria). Findings: During an observation on 10/16/23 at 8:30 AM in the dry storage room, 24 corrugated cardboard shipping boxes, filled with dry goods were not unpacked and stored on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement the facility's policy and procedure for infection control for five of five sampled residents (Residents 43, 45, 58, 165 and 264) by failing to ensure: 1. The Certified Nursing Assistant 2 (CNA 2) followed the Enhanced Standard Precautions guideline (precautions that require the use of PPE [equipment such as isolation gown, gloves, face mask and/or shield worn to minimize exposure to hazardous fluids that cause serious illnesses] and hand washing or use Alcohol Based Hand Rub (ABHR) during high-contact resident care activities) when providing care to Resident 264 with wound and Foley Catheter (Foley catheter [brand name] for urinary indwelling catheter a flexible tube inserted into the bladder that remains there to provide continuous urinary drainage) 2. The Treatment Nurse 2 (TXN 2) and Licensed Vocational Nurse 1 (LVN 1) followed the Novel Respiratory Precautions (an isolation that requires health care providers to don (put 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 interview and record review, the facility failed to ensure the resident's clinical records were updated for one out of 2 sampled residents (Resident 66) by failing to maintain a current copy of the resident's advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) in Resident 66's clinical record. This deficient practice had the potential to cause conflict with Resident 66's wishes regarding health care treatment. Findings: A review of Resident 66's admission Record, dated 10/19/23, the admission Record indicated, Resident 66 was admitted to the facility on [DATE], with diagnoses of, but not limited to, acute respiratory failure (sudden onset of condition that not enough oxygen passes from the lungs into the blood), dementia (a severe decline in mental ability that can interfere with daily functioning/life), hypertension (HTN - elevated blood pressure), and 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 observation, interview, and record review, the facility failed to follow through with the Preadmission Screening and Resident Review (PASARR- The State is required to ensure that every person entering a Medicaid Certified Nursing Facility (NF) receives a Level I Screening and if necessary a Level II Evaluation to ensure that their NF residence is appropriate and to identify what specialized services they may need) recommendation to obtain a PASARR Level II Evaluation for one of 2 residents (Resident 81). This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 81. Findings: A review of Resident 81's admission Record, dated 10/18/23, the admission Record indicated, Resident 81 was initially admitted to the facility on [DATE] with diagnoses of, but not limited to, dementia (a severe decline in mental ability that can interfere with daily functioning/life), psychotic disorder (a severe mental disorder) with delusions (false 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 assess comprehensively, develop a care plan and evaluate one or two residents (Resident 64) with the ability to smoke cigarette safely with or without supervision when smoking in the facility premises. This deficient practice had the potential to result in accidental burn or injuries and fire hazard or harm in the facility that affects Resident 64, other residents, staffs and visitors. Findings: A review of Resident 64's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus (high blood sugar), hypertension (high blood pressure and acute kidney failure (kidneys fails to filter out dangerous accumulation of fluids and waste or toxin in the body). A review of Resident 64's Minimum Data Set (MDS, a standardized assessment and care planning screening tool), dated 8/23/23, indicated Resident 1 had the capacity to make needs known and understand others with intact 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement the facility's policy and procedure for pain management titled Pain Assessment and Management and Pain-Clinical Protocol, to ensure one of two residents (Resident 52), was assessed for pain and provided interventions for pain relief or control in a timely manner. This failure resulted in Resident 52 experiencing delayed pain management and control of pain that could affect the inability to maintain the highest practicable level of well-being and healing process. Findings: During a review of Resident 52's admission Record, indicated, Resident 52 was admitted to the facility on [DATE] with diagnoses that included stage 4 pressure ulcer (a skin injury due to unrelieved pressure and being in one position for prolonged period of time that resulted in full thickness skin and tissue loss with exposed bone, tendon, or muscle.) of sacral region (bone at the end of the spine), peripheral autonomic neuropathy (nerve damage), peripheral…

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 the hemodialysis (a process of removing toxins and excess fluid in the blood using a machine) emergency kit (kit used in the event bleeding was observed in the hemodialysis site) for two of three residents (Residents 53 and 64 who received hemodialysis. This deficient practice had the potential to delay or unable to immediately provide interventions in an event of emergency to Resident 53 and Resident 64 for complications such as trauma, and bleeding on the dialysis access site (a surgically created vein used to remove and return blood to the body during hemodialysis) that could lead to a significant blood loss and decline in the resident's wellbeing. Findings: 1.A review of Resident 53's admission record indicated the resident was originally admitted to the facility on [DATE] with diagnoses that included subdural hematoma (collection of blood that forms on the surface of the brain), end stage renal disease (failure of the kidney…

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

Based on observation, interview and record review, the facility failed to provide a dental follow up appointment for one of two sampled residents (Resident 39) as per doctor's order. This failure had the potential to result in Resident 39 developing an infection from not receiving a dental assessment after being diagnosed from the hospital with dental caries (permanently damaged areas in teeth that develop into tiny holes cause by bacteria, snacking, sipping sugary drinks and poor teeth cleaning). Findings: During a concurrent observation and interview on 10/16/23 at 10:09 AM with Resident 39 in his room, Resident 39 was observed to have full upper dentures and his bottom teeth appeared to be broken and missing. Resident 39 stated that his teeth aren't what they used to be and the last time he saw a dentist was four months after he arrived at the facility. During a record review of Resident 39's ongoing orders dated 8/25/22, the order indicated the facility to provide a dental consultation for treatment as needed. During a record review of Resident 39's progress note dated 7/16/23…

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

Based on observation, interview and record review, the facility failed to ensure one of two outside garbage dumpster lids were fully closed per facility policy and procedure (P&P), titled Food-Related Garbage and Refuse Disposal . This failure had the potential to attract pests and insects to the facility and cause a wide spread of diseases and infection to the faciltity that affects the residents, staffs and visitors. Findings: During an observation on 10/16/23 at 11:55 p.m., in the facility's parking lot, one of the dumpster's lids was open because of it was overflowing with trash bags. During an observation on 10/17/23 at 04:55 p.m., in the facility's parking lot, one of the dumpster's lids was wide open and not closed. During a concurrent observation and interview on 10/18/23 at 12:05 p.m. with the Director of Food Service (DFS) in the kitchen, through the window the outside dumpster's lid was observed propped open with a wooden stick. DFS stated that, it should not be propped. During a review of the facility's P&P titled, Food-Related Garbage and Refuse Disposal dated 2001,…

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 agency documented and coordinated with the facility staffs regarding the plan of care, the interventions implemented and if the interventions were effective to meet the care needed by one of two residents (Resident 112) under hospice care (a specialized care for people whose prognosis is poor and reaching end of life with the focus on providing comfort care). Resident 112 had a fall incident and noted with discoloration on the forehead on [DATE], after three days Resident 112 expired on [DATE] without a documentation from the hospice care agency the plan of care provided after the resident fall. This deficient practice resulted in Resident 112 not to receive the care and interventions necessary under hospice care and services related to the residents change of health conditions after a fall. Findings: A review of Resident 112's admission Record indicated the resident was admitted to the facility on [DATE] with the diagnoses 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 interview, and record review, the facility failed to respond to requests for assistance with toileting, transfer, and activities of daily living (ADL) in a timely manner which resulted for three of three sampled residents (Resident 1, Resident 2, and Resident 3) to feel negatively about self and their situations. Findings: A review of Resident 1's Face Sheet (admission record) indicated the resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including pressure ulcer sacral region (skin injuries that occur in the sacral region of the body, near the lower back and spine)stage 4 (muscles, bones, and/or tendons may also be visible at the bottom ) ,paraplegia (loss of muscle function in the lower half of the body, including both legs ),and mood disorder due to known physiological condition (general emotional state or mood is distorted or inconsistent with circumstances and interferes with ability to function). A review of Resident 1's History and Physical (H&P) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide adequate staffing to provide quality of care that meets the individualized needs of the facility ' s resident population. The facility failed to ensure: 1. To meet the 2.4 Certified Nursing Assistant (CNA) direct care hours as required in the Direct Care Services Hours Per Patient Day (DHPPD) staffing requirement. 2. A Registered Nurse (RN) was consistently assigned to work for night shift (11 PM to 7 AM), to meet the resident ' s needs, in accordance with the facility ' s Facility Assessment. These deficient practices resulted to inadequate staffing assigned to respond to requests for assistance with toileting and activities of daily living (ADL) in a timely manner for three of three sampled residents interviewed on 8/8/23(Resident 1, Resident 2, and Resident 3) and had the potential to further result in affecting other residents ' quality of life and feeling of self-worth. Findings: A review of Resident 1's Face Sheet (admission record)…

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.