Griffith Park Healthcare Center

Based on observation, interview and record review, the facility failed to implement infection control practices in accordance with the facility's Policy and Procedure (P&P) titled Oxygen Administration and Departmental (Respiratory Therapy) for a one of two sampled residents ( Resident 1) by failing to : Ensure Resident 1's oxygen tubing (a flexible plastic tube, often green, that delivers supplemental oxygen from a tank or concentrator to a patient via nasal prongs) was labeled with a date the oxygen tubing was last changed.Ensure Resident 1's breathing nebulizer (a device that converts liquid medication into a fine mist for inhalation) was changed within seven (7) days. The nebulizer was last dated 1/5/2026.Document oxygen set- up, which included the date and time the procedure was performed in Resident 1's medical record. These deficient practices had the potential to increase the risk and spread of infections. Findings: During a review of Residents 1's admission Record (AR), the AR indicated Resident 1 was admitted to facility on 08/08/2026, with a diagnosis of chronic…

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 care and services to three of three (Resident 1, 2 and 3) who needed assistance with ADL (activities of daily living) by not answering the call lights (a button or touch pad device that residents use to communicate assistance from the nursing staff) in a timely manner in accordance with the facility's policy and procedure by failing to assist: 1.Resident 1 and Resident 2 reported it took the facility one (1) to two (2) hours to respond to their call light when their adult briefs needed to be changed. 2.Resident 3 reported he waited about one (1) hour in the bathroom for a nurse to assist in cleaning him after having a messy bowel movement. As a result of this deficient practice, the residents were placed at risk for infection, skin breakdown and discomfort. Findings: 1.During a review of Resident 1 admission Record (AR), the facility admitted Resident 1 on 7/23/2025 with diagnoses that included encephalopathy (any disease, damage,…

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

Based on observation, interview, and record review, the facility failed to provide Orajel 2X Toothache & Gum Mouth/Throat Gel 20-0.26% (Orajel cream, topical cream applied to gums to relieve pain and discomfort) as for three days that was ordered by the physician to manage and relieve pain for one of three sample residents (Resident 1) who complained of upper left jaw toothache (pain around the tooth). As a result of this deficient practice Resident 1 reported experiencing consistent pain at 8 of 10 pain on the numerical number scale (a way of rating pain intensity, ranging from 0 - no pain to 10 - worst pain felt) and difficulty eating from 12/27/2025 to 12/29/2025 which could lead to weigh loss and/or prevents the resident to prevent in participation in activities of daily living that affects the quality of life. Findings: During a review of Resident 1 admission Record (AR), the facility admitted Resident 1 on 7/23/2025 with diagnoses that included encephalopathy (any disease, damage, or malfunction that may cause altered brain function), epilepsy (an abnormal burst of electrical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to provide care in a manner that maintained or enhanced residents' dignity and respect in full recognition of their individuality for three (3) of six sampled residents (Residents 32, 69, and 81) by failing to: 1. Ensure Occupational Therapist (OT 1) was seated at eye level while assisting Resident 32 with the use of an adaptive utensil during meals. 2. Ensure Staff were at eye level while assisting with feeding; specifically, certified nurse assistant (CNA) 1 was observed standing over Resident 69 while feeding her. 3. Ensure Staff provided assistance with attention to safety, comfort, and dignity; specifically, CNA 2 was observed removing Resident 81 from the dining room without assisting with personal hygiene or cleaning noticeable phlegm (mucus produced by the cells lining the upper airways and lungs) after Resident 81 coughed. This failure did not support a respectful, person-centered approach to care and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews, the facility failed to ensure that Resident 34 received appropriate pain management for open wounds on the right and left temporal areas by failing to: 1. Monitor and document Resident 34's pain before, during, and after wound treatments on 5/5/2025, 5/26/2025, 7/24/2025, 8/23/2025, and from 12/1/2025 to 12/13/2025, in accordance with physician orders and the resident's care plan. 2. Reevaluate Resident 34's pain management and notify Physician 1 (Attending Physician) of the resident's refusal of wound care treatments due to pain and sensitivity in the right and left temporal wounds, as required by the facility's policy and procedure (P&P) titled Pain - Clinical Protocol and care plan for refusal of treatments. 3 Monitor and document the probable causes of each pain episode, including pain characteristics and relieving factors, every shift and as needed. The facility also failed to monitor, record, and report any signs and symptoms of non-verbal pain…

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 continuous communication and collaboration for Resident 34's overall medical management between Physician 1 (Attending Physician), Physician 2 (Wound Care Specialist, physician who specializes in Wound Care and management), Physician 3 (Dermatologist, physician who specializes in skin care and management), and Physician 4 (Oncologist, physician who specializes in cancer and cancer management). This failure resulted in the breakdown of communication and collaboration between Resident 34's physicians which led to the lack of direction for Resident 34's overall medical care and management. Cross Reference F697 Findings: During a review of Resident 34's admission Record (AR), the facility admitted Resident 34 on 12/2/2023 and readmitted Resident 34 on 11/22/2025 with diagnoses that include squamous cell carcinoma (skin cancer) of skin of other parts of face, open wound of right cheek and temporomandibular (area connecting jawbone to skull in front…

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 sufficient number of staff to provide quality care that meets the individualized needs of the resident population, in accordance with the facility's policy and procedures (P&P) titled Staffing, dated August 2022 and as outlined in its Facility Assessment, revised dated 9/8/2025, by failing to: 1.Provide adequate Certified Nursing Assistants (CNA) coverage for the 7:00 AM-3:00 PM, 3:00 PM-11:00 PM, and 11:00 PM-7:00 AM shifts for multiple days in September and December 2025. 2.Assign a Treatment Nurse (TXN) for two days in September 2025 and two days in October 2025, as required in accordance with the Facility assessment dated [DATE]. These deficient practices resulted in inadequate staffing to respond to residents' requests for assistance with Activities of Daily Living (ADLs) and nursing care in a timely manner for three of three sampled residents (Residents 80, 69, and 34). This failure had the potential to negatively impact other…

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

Based on observations, interviews, and record review, the facility failed to implement the facility's policies and procedures, titled storage of Food and Supplies, Procedures for Refrigerated Storage, professional standards of practice on food storage, food service safety, sanitation and handling practices to prevent the outbreak of foodborne illness (food poisoning) by failing to ensure: 1. Labeled and stored food indicated the use-by-date or expiration date, including: one-gallon bottle of liquid oil, one-gallon of barbecue sauce, four opened cans and a dozen of unopened soup base stock powders, and one bulk container in the dry storage room filled with white powder labeled as Food thickener. 2. Followed appropriate hygiene and sanitary procedures and did not leave ice scooper uncovered to prevent contamination. 3. Frozen foods were stored properly, and raw meat were not stored over vegetables. These deficient practices had the potential to result in food contamination (transfer of harmful bacteria or other germs to food, surfaces, or utensils) that placed residents at risk 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 Facility Assessment tool, dated 12/10/2025, was updated by failing to indicate the specific staffing needs such as the Certified Nurse Assistants (CNA) and Treatment Nurse (TXN) for each resident unit in the facility and each shift. This deficient practice had the potential for the residents not to receive care and treatment services as needed due to inadequate staffing. Cross Reference with F725 Findings: During a review of the facility's policy and procedure titled Facility Assessment, dated October 2018, the P&P indicated that the facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day-to-day operations. During a record review of the facility's Facility Assessment, dated 12/10/2025, the Facility Assessment indicated the following: - For the 7 AM to 3 PM shift, 1 Registered Nurse (RN)/Desk nurse to 3 Charge Nurses - For the 3 PM to 11 PM shift, 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 interview and record review, the facility failed to provide the pneumococcal vaccine (PCV2) as required and appropriate for three of five residents sampled for immunizations (Resident 68, Resident 42, and Resident 66) when: 1. Resident 68 was not consented for the PCV20 vaccine five days after admission into the facility as per the facility's policy and procedure (P&P). 2. Resident 42 was consented for the PCV20 vaccine but not administered the vaccine within 30 days of admission into the facility as per the facility's P&P. 3. Resident 66 was consented for PCV20 vaccine but was not administered the vaccine within 30 days of admission into the facility as per the facility's P&P. This deficient practice had the potential to result in Resident 68, Resident 42, and Resident 66 contracting, transmitting, and experiencing complications related to pneumococcal diseases such as pneumonia (an infection in the lungs), meningitis (inflammation of brain and spinal cord membranes), and sepsis (a life-threatening…

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 the COVID -19 vaccine as required and appropriate for one of five residents sampled for immunizations (Resident 66) when Resident 66 consented to receive the COVID-19 vaccine but was not administered the vaccine. 2. Failed to maintain documentation related to staff COVID-19 vaccination status when the newly hired Infection Preventionist (IP) was not endorsed a list of staff members immunized or consented for the COVID-19 vaccine. This deficient practice had the potential to result in the facility's staff and residents contracting, transmitting, and experiencing complications related to COVID-19 such as difficulty breathing, persistent pain or pressure in the chest, or diarrhea. Findings: During a review of Resident 66's admission Record, the record indicated Resident 66 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities) and kidney failure. During a review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one out of three residents (Resident 64) who were sampled for self-administering medications was determined by the facility to safely self-administer medications when Resident 64 was observed in the resident's room with 3 bottles of medications at the bedside table. This failure had the potential to expose Resident 64, who was self-administering medications, to side effects and adverse effects of these medications that could go unmonitored by facility staff. Findings: During a review of Resident 64's admission Record indicated the resident was admitted on [DATE] with diagnoses that included depression (a mood disorder causing persistent sadness and loss of interest, a person's capacity to feel, think, and handle daily activities), hypertension (prolonged elevated blood pressure), atrial fibrillation (irregular heartbeat, causing irregular and rapid pulse), and obesity (a disease characterized by having too much body fat). During a…

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

Based on interviews and record reviews, the facility failed to ensure completion of the Advance Directive Acknowledgment (ADA- a document where a person confirms they have received information about their right to create an advance directive and understand their options for future medical decisions) and documentation of the resident's exercise of rights regarding advance directives, for 1 of 4 sampled residents reviewed (Resident 77) for Advance Directives. This failure has the potential to result in more than minimal harm because incomplete ADA documentation may prevent staff from being aware of and honoring the resident's treatment preferences in an emergency. Findings: During a review of Resident 77's admission Record (AR), the AR indicated the facility admitted Resident 77 on11/22/2025 with diagnoses that included End Stage Renal Disease (ESRD- irreversible kidney failure), atherosclerotic heart disease (a heart disease caused by thickening or hardening of the arteries), and hypertension (high blood pressure). During a review of Resident 77's Minimum Data Set (MDS, a 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 interview and record review, the facility failed to implement its policies and procedures titled Abuse Prevention/Prohibition and Abuse Reporting and Investigation for two of two sampled residents (Residents 45 and 46) by failing to protect, prevent, report, and investigate an alleged physical abuse incident that occurred between Residents 45 and 46 on 07/13/2025. Specifically, the facility failed to: 1. Identify the physical altercation between Residents 45 and 46 as a form of abuse, which was reported by Licensed Vocational Nurses (LVNs) 2 and 7 to the Administrator on 07/13/2025, and which resulted in a mark on Resident 45's upper left forehead. 2. Protect Resident 45 and prevent further physical abuse when licensed nurses did not develop a care plan after LVNs 2 and 7 were made aware of the allegation of physical abuse by Resident 46 toward Resident 45. 3. Report Resident 45's allegation of physical abuse by Resident 46 to the Department of Public Health (State Survey Agency), local law enforcement,…

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 report an alleged resident to resident altercation within 24 hours for two of two sampled residents (Resident 45 and Resident 46) to the California Department of Public Health (CDPH) in accordance with the facility's Policy and Procedure (P&P) titled, Abuse Reporting and Investigation. This deficient practice resulted in the facility underreporting allegations of abuse and Resident 45 sustaining a red mark in between the left frontal and temporal area (upper left portion of the forehead). Findings: 1.During a review of Resident 45's admission Record (AR), the AR indicated that Resident 45 was admitted to the facility on [DATE] with diagnoses including, bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), cognitive communication deficits (difficulty communicating because of injury to the brain that controls the ability to think.) During a review 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 interviews and record review, the facility failed to complete a Pre-admission Screening and Resident Review Level II (PASRR II)-a follow-up assessment that ensures residents with mental disabilities receive appropriate care-after the initial PASRR Level I assessment was completed for one (1) of three (3) sampled residents (Resident 26), in accordance with the facility's policy and procedure (P&P) titled PASRR Completion Policy. This deficient practice had the potential to put Resident 26 at risk of not receiving appropriate mental health care and placement to appropriate facility. Findings: During a review of the facility's P&P titled, Pre admission Screening and Resident Review (Level II) (PASRR) dated 10/2018 indicated that the facility will coordinate the recommendations from the Level II PASRR determination and the PASRR evaluation report with the resident's assessment, care planning and transition of care; if the PASRR level II evaluation is not available within five (5) days admission coordinator…

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 the musculoskeletal care plan was updated to reflect the current nursing interventions for one out of five residents (Resident 8) who were sampled for unnecessary medications. This deficient practice had the potential to cause Resident 8 to not receive services and nursing care to address the resident's musculoskeletal issues. Findings: During a review of Resident 8's admission Record indicated the resident was originally admitted on [DATE], and readmitted on [DATE], with diagnoses that included metabolic encephalopathy (brain dysfunction from a chemical imbalance, often from systemic illnesses like liver/kidney failure, diabetes, infections, or toxins, causing confusion, memory issues, personality changes, fatigue, or even coma), epilepsy (a brain condition that causes recurring seizures or uncontrolled and involuntary movement), and low back pain. During a review of Resident 8's History and Physical (H&P), dated 11/13/2025,…

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 ensure that one of five sampled residents for unnecessary medications (Resident 8) had physician orders for PRN (as needed) analgesics (pain reliever) that were clear, specific, and non-conflicting. The physician orders contained overlapping administration parameters, which created a risk for significant medication errors and did not comply with professional standards of quality. This deficient practice placed Resident 8 at risk for potential adverse effects associated with ambiguous pain medication parameters, including inconsistent medication administration, duplicate therapy, or failure to follow physician orders. Findings: During a review of Resident 8's admission Record indicated the resident was originally admitted on [DATE], and readmitted on [DATE], with diagnoses that included metabolic encephalopathy (brain dysfunction from a chemical imbalance, often from systemic illnesses like liver/kidney failure, diabetes, infections, 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 care and services in accordance with the resident's care plan and professional standards of practice for one of three residents sampled for quality of care (Resident 54) when: 1. Certified Nursing Assistant (CNA) 4 failed to turn Resident 54, who was bed bound, every two hours or as needed as stated in the resident's care plan. 2. Licensed Nurse (LN) 1 failed to inspect and ensure that Resident 54 had a dressing on her gastric tube (g-tube: a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) site as written in her care plan and ordered by the physician. 3. Licensed nurses failed to reconcile Resident 54's order for an abdominal binder (a stretchy support belt worn around the stomach to help protect a g-tube site by covering it securely and preventing the resident from pulling or dislodging the tube) after Resident 54 was readmitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to ensure that one of three sampled residents (Resident 92), who had an indwelling Foley catheter, and was reviewed for infections, received appropriate monitoring and documentation of intake and output (I&O) and assessment of urine characteristics as required by the physician's order, the resident's care plan, and facility policy. Specifically, staff did not document I&O from 12/1/2025 to 12/12/2025, did not record urine output in the Elimination section, and did not identify or report cloudy urine observed on 12/12/2025. This deficient practice resulted in the potential for undetected urinary tract infection (UTI-an infection in the bladder/urinary tract), catheter obstruction, or urinary retention, which could lead to complications such as sepsis or worsening of the resident's condition. Findings: During a review of the facility's Policy and Procedures (P&P) titled Catheter Care, Urinary, dated 9/2014, the P&P indicated that, to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that one out of one sampled resident (Resident 74) who had food preferences, was prepared a meal that honored the resident's dislikes when Resident 74's meal tray included green vegetables. This deficient practice had the potential to cause Resident 74 to lose his appetite, which could affect the resident's nutritional status. Findings: During a review of Resident 74's admission Record indicated the resident was originally admitted on [DATE], and readmitted on [DATE], with diagnoses that included dysphagia (difficulty in swallowing), diabetes mellitus (DM, prolonged elevated blood sugar levels), and malnutrition (a serious condition from an imbalance (deficiency or excess) of nutrients, including not enough calories, protein, vitamins, or minerals). During a review of Resident 74's History and Physical (H&P), dated 11/10/2025, indicated the resident does have the capacity to understand and make decisions. The H&P indicated 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 maintain medical records that are accurately documented for one of six residents sampled for accurate documentation (Resident 54). Specifically, Resident 54's treatment administration record indicated that wound care was provided at a time inconsistent with actual delivery of care. This deficient practice had the potential to compromise continuity of care by inadequately documenting tasks that were or were not completed. Findings: During a review of Resident 54's admission Record, the record indicated Resident 54 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), dysphagia (difficulty swallowing), and failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity). During a review of Resident 54's Minimum Data Set (MDS- a resident assessment tool)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to inspect and ensure that a dressing was in place on the gastric tube (g-tube: a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) of one of two residents (Resident 54) sampled for g-tube dressings. This failure placed Resident 54 at risk of developing an infection at her g-tube site and had the potential to cause the g-tube to become dislodged, further leading to hospitalization. Findings: During a review of Resident 54's admission Record, the record indicated Resident 54 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), dysphagia (difficulty swallowing), and failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity). During a review 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 initiate a person-centered care plan for one of two sampled residents (Resident 1) with a diagnosis of dysphagia (difficulty swallowing). This deficient practice resulted in the potential for Resident 1 to not receive individualized care and services necessary to address his swallowing difficulties, thereby placing him at risk for adverse outcomes such as aspiration (the inhalation of a foreign substance into the airway), choking, or inadequate nutrition and hydration.FINDINGS:During a review of Resident 1's admission Record indicated the resident was admitted on [DATE] with diagnoses that included epilepsy (abnormal electrical activity in your brain that temporarily affects your consciousness, muscle control and behavior), malnutrition (an imbalance between the nutrients your body needs to function and the nutrients it gets), encephalopathy (any disorder that affects brain function, leading to an altered mental state such as memory loss…

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 a person-centered comprehensive care plan to address the resident's medical and physical needs for one of three sampled residents (Resident 2), reviewed for pressure injury and prevention. Resident 2 who was admitted with a Stage 3 pressure injury (an open, full-thickness skin wound that extends into the fatty tissue but not into the muscle, bone, or tendon) on his sacrum (situated just above the buttocks) and a SDTPI (suspected deep tissue pressure injury) to the right and left heel, did not have a weekly treatment documentation from the facility's wound doctor (WMD) nor the treatment nurse (TN) of a risk assessment, that included measurements of each area of the skin breakdown. This deficient practice had the potential to result in the worsening of Resident 2's pressure injuries, by not having a wound doctor evaluate the pressure injury weekly and current treatments, which could negatively affect Resident 2's comfort 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's interdisciplinary team (IDT-a coordinated group of experts from several different fields who work together toward the care goals of the resident) failed to evaluate and assess residents mental and physical abilities for one of one sampled resident (Resident 1) to determine whether self-administering medications was clinically appropriate for the resident.Resident 1 was observed with five bottles of supplements at bedside which included vitamin C, calcium, vitamin D3, vitamin E and vitamin B12.This deficient practice had the potential to cause negative side effects to Resident 1's health.Findings: During a review of Residents 1's admission Record, the admission record indicated the resident was admitted to the facility on [DATE] with diagnoses including delusional disorders (a type of mental health condition in which a person cannot tell real from imagined), diabetes (blood sugar level to become too high), left and right eye blindness category 3…

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 three sampled residents (Resident 1) had a complete comprehensive assessment of a resident's needs, strengths, goals, and preferences, using Resident 1's Minimum Data Set (MDS, a resident assessment tool) document, within 14 calendar days after admission, per facility policy. Resident 1 was admitted on [DATE] and the MDS was due to be completed on 8/21/2025 but was completed on 8/25/2025 (four days late).This deficient practice potentially resulted in Resident 1, who had left and right eye blindness category 3 (means severe visual impairment that is worse than legal blindness but can still perceive some light) verbalizing feeling of frustration about her care.Findings: During a review of Residents 1's admission Record, the admission record indicated the resident was admitted to the facility on [DATE] with diagnoses including delusional disorders (a type of mental health condition in which a person cannot tell reality from…

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 three sampled residents (Resident 1) received care consistent with professional standards of practice to prevent pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence), when Resident 1, who was admitted with Moisture-Associated Skin Damage (MASD, skin irritation or breakdown caused by prolonged exposure to wetness from bodily fluids) to the buttocks extending to the groin area, did not have a weekly skin assessment, per facility policy.This deficient practice had the potential to result in worsening the MASD or infection and could negatively affect Resident 1's quality of life.Findings:During a review of Residents 1's admission Record, the admission record indicated the resident was admitted to the facility on [DATE] with diagnoses including diabetes (blood sugar level to become too high) and anemia (not having enough healthy red blood cells or hemoglobin to carry oxygen to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its policy and procedures titled Release of Resident's Personal Belongings , to prevent misappropriation (unauthorized or improper use of someone else property) of resident's property and ensure accurate accounting and safe keeping of resident's personal belonging for one of three sampled residents (Resident 1). This deficient practice had resulted in the violation of residents rights for Resident 1 and a potential for other residents in the facility to loose their personal items. CMS 2567 amended [DATE]Findings: During a review of Resident 1's admission Records (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hypertension (high blood pressure), Type 2 Diabetes (high blood sugar), and dementia (decline in mental ability which can interfere with daily activities). During a review of Resident 1's History and Physical (H&P, a comprehensive physician's note regarding…

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 treatment and services to attain the highest practicable mental and psychosocial well- being for Resident 1 who was diagnosed with major depressive disorder, anxiety and schizophrenia (a mental illness that affect how person think, feel, behave, mixed symptoms such as hallucination, delusion, disorganized thinking and who was identified as having behavioral issues and verbalization of wanting to go to the hospital on 6/16/2025 at 8:15 PM to 11 PM, in one of two sampled residents reviewed for behaviors (Resident 1), by failing to: 1. Ensure 1:1 sitter (provide one to one nursing or observation care to an individual patient for a period of time) intervention was put in place for Resident 1 whose behaviors were escalating on 6/16/2025. 2. Inform Resident 1 ' s physician of Resident 1 ' s complaint of pain or chest pain and fall on 6/16/2025 and request to go to the acute hospital. Follow up with Resident 1 ' s physician for any new order when…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect the resident ' s rights to be free from physical and verbal abuse for one of three sampled residents (Resident 2) by failing to protect Resident 2 from Resident 1, after Residents 1 and 2 had a prior physical altercation on 5/29/2025 at around 8 AM and 10 AM. This deficient practice resulted in Resident 2 experiencing physical and verbal abuse from Resideht 1 on 5/29/2025 and had the potential to result to physical injury and/or affect Resident 2 psychosocially. Findings: During a review of Resident 1 ' s admission Record (AR), the AR indicated a readmission to the facility on 4/9/2025 with diagnoses including schizoaffective disorder (a mental health condition including schizophrenia [a serious mental health condition that affects how people think, feel and behave] and mood disorder symptoms), hemiplegia (severe or complete loss of strength leading to paralysis on one side of the body) and hemiparesis (one-sided muscle weakness)…

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

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) and responsible party (RP) was provided written information regarding bed holds (a reservation that allows one to stay in, or return to, a care facility) upon Resident 1 ' s transfer to the General Acute Care Hospital (GACH) in accordance to the facility ' s Policy and Procedure (P&P) for Bed Holds and Returns. This deficient practice had the potential to result in Resident 1 and RP 1 being misinformed or unaware of Resident 1 ' s reservation of a bed and rights to return to the facility. Findings: During a review of Resident 1 ' s admission Record (AR), the AR indicated the facility initially admitted Resident 1 to the facility on 9/1/23 and readmitted the Resident on 5/22/25. Resident 1's diagnosis included Type 2 Diabetes (high blood sugar), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). The AR indicated Resident 1 had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) had a person-centered comprehensive care developed to address Resident 1 ' s behaviors related to bipolar disorder(mood swings that range from the lows of depression to elevated periods of emotional highs) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). This deficient practice had the potential for a delay in care and services specific to Resident 1 ' s needs. Findings: A review of Resident 1 ' s admission Record indicated the resident was originally admitted on [DATE], and readmitted on [DATE], with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). A review of Resident 1 ' s History and Physical (H&P), dated 5/2/2025, 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 implement their policy and procedure for abuse prevention and reporting when Resident 1 had a verbal altercation with Licensed Vocational Nurse (LVN) 1. The facility failed to: 1. Investigate the allegation of abuse between LVN 1 and Resident 1 on 2/11/2025. 2. Suspend LVN 1 on 2/11/2025, pending the results of the facility's investigation, as indicated in the facility's policy and procedure (P&P). 3. Prevent further contact between LVN 1 and Resident 1, following the incident of verbal altercation on 2/11/2025. This deficient practice placed Resident 1 and other residents at risk for potential abuse from LVN 1, which could cause physical, mental, and emotional harm. Findings: A review of Resident 1's admission Record indicated the resident was admitted on [DATE] with diagnoses that included lack of coordination, muscle wasting (loss of muscle mass and strength), and depression. A review of Resident 1's History and Physical (H&P), dated 11/6/2024,…

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 State Srvey Agency (SA) immediately or within two hours of an allegation involving abuse for one of two sampled residents (Resident 1) Resident 1 made an allegation of verbal abuse against Licensed Vocational Nurse (LVN) 1 by calling a Police Officer on 3/11/25 and arrived at the facility at 7:20 PM, as indicated in Registered Nurse (RN) 1's notes. RN 1 and LVN 1 did not notify the facility's Abuse Coordinator and/or the State Survey Agency (SA) within two hours after having knowledge of Resident 1's allegation of verbal abuse against LVN 1 on 3/11/25. This deficient practice had the potential for facility staff to under report all types of abuse allegations and placed Resident 1 at risk for further abuse and caused the facility to fail to address Resident 1's complaints of abuse. Findings: A review of Resident 1's admission Record indicated the resident was admitted on [DATE] with diagnoses that included lack of coordination, muscle wasting…

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 2. During a review of Resident 14's admission Record (Face sheet), the facility admitted Resident 14 on 1/13/2020 and readmitted him on 9/7/2023 with diagnoses of bipolar (a mental illness that causes extreme mood swings that range from lows of depression to elevated periods of emotional highs) schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) and nicotine (a highly addictive substance found in cigarettes, cigars, and e-cigarettes) dependence. During a review of Resident 14's Letter of Conservatorship (when a judge appointed another person to act and make decisions for a person who needs help), dated 2/22/2021, this document indicated that Resident 14 was still gravely disabled and was reappointed a conservator. During a review of Resident 14's History and Physical (H&P, a comprehensive physician's note regarding the assessment of the resident's health status), dated 6/29/2024, indicated Resident 14 did not have the capacity to understand and make decisions. During a review…

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

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 to address Resident 45's refusal to treat the long nails with [NAME] infection and for podiatric (a physician specialized in foot treatment) treatment on 10/7/2024. This deficient practice had a potential result in Resident 45's inadequate and incomplete provision of care and result in worsened foot infection. Cross Reference to F687. Findings: During a review of Resident 45's admission Record, indicated Resident 45 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included paraplegia (chronic condition that refers to the loss of muscle function in the lower half of the body, including the legs and sometimes the abdomen), primary osteoarthritis (arthritis that occurs when flexible tissue at the ends of bones wears down). During a review of Resident 45's Order Summary Report, indicated on 3/18/2024 Resident 45 had a physician order for podiatry…

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

Based on observation, interview, and record review, the facility failed to ensure that the facility had sufficient staffing to monitor and supervise 8 out of 23 sampled residents (Resident 2, 3, 9, 14, 18, 56, 67 and 136) while smoking during the scheduled and nonscheduled smoking time in the patio and monitor for residents that are at risk of elopement (leaving the facility without permission) from 1-2 PM on 10/21/2024. These failures could result in the residents to be at risk for accidental burn, fire and accidents that could result in major injuries and death. Findings: During an observation on 10/21/2024 at 11:10 AM (nonscheduled smoking time) in the smoking area, seven (7) unidentified residents were smoking in the patio without a staff present supervising the residents. During an observation on 10/21/2024 from 1PM to 2PM (scheduled smoking time) in the facility's designated smoking area, a total of 8 residents (Resident 2, 3, 9, 14, 18, 56, 67 and 136) were smoking without any staff supervision. During an interview on 10/21/2024 at 5:22 PM with the Activity Staff (AS) 1, AS 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 implement the facility's policy and procedure by ensuring to store all drugs and biologicals in a safe, secure, and orderly manner, under proper temperature, light, and humidity controls and controlled medications are stored in separately locked, permanently affixed compartments for four of five sampled residents (Residents 3, 66, 69 and 76). The facility failed to: 1. Store Glargine (a medication to treat diabetes [a group of disease that result in too much sugar in the blood]) Pen for Residents 3, 69, 76. 2. Store Lorazepam (a controlled medication to treat anxiety) oral (given by mouth) concentrate in a sanitary environment inside the medication refrigerator at the Medication room [ROOM NUMBER] for Resident 66. 3. Store Lorazepam oral concentrate within the required temperature range between 36 Fahrenheit degrees (°F, a unit of measurement of temperature) and 46 °F in the medication refrigerator in the Medication room [ROOM NUMBER]. 4.…

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 food were stored prepared and distributed of food under sanitary conditions to all the residents in the facility in accordance with the facility ' s policy and procedure by failing to: 1. Monitoring and documenting Sanitization Sink Solution Log. 2. Monitoring and documenting Cold Storage temperature Log. 3. Monitoring and documenting Sanitization Solution Log. These deficient practices placed the residents at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages). Findings: 1. During a concurrent observation and interview on 10/1/2024 at 9:33 AM during an initial Kitchen tour in the presence of Dietary Aid (DA), when asked about the three-compartment sink washing procedure, the DA stated he first removes all food particles by either soaking, scraping, or rinsing. The first compartment is for washing dishes, the second is for rinsing with hot water, and the third is for sanitizing. DA tested the water with the test strip, and it read 200ppm. 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 2. During a concurrent observation and interview on 10/23/2024 at 9:15 AM with the Maintenance Supervisor (MS), there was no documentation that the facility tested their water management system for Legionella. The MS stated, the facility conducted their own testing for Legionella with a minilab test kit. The MS stated, the water system was tested for Legionella, and the results were recorded in the previous administrator's phone. The MS stated the previous administrator was no longer employed by the facility and had been out for about two months. The MS stated, it was important to test for Legionella because Legionella can survive in water and grow in human-made water systems. The MS stated residents, staff, and visitors were at risk for developing Legionella because everyone uses the water system. During an interview on 10/23/2024 at 9:44 AM with the Director of Nursing (DON), the DON stated, it was important to test for water safety because it could affect everyone in the facility. During an interview on…

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

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program by ensuring the supply room containing enteral nutrition (a form of nutrition delivered through a tube into the digestive system as a liquid) and other food products did not have any cockroaches and pests. This failure had the potential for the residents to contract illnesses, including food borne illnesses [an illness that comes from eating contaminated (containing disease causing organism) food] brought in by the pest and cockroaches. Findings: During an observation on 10/23/2024 at 10:00 AM, the supply room had one large brown cockroach approximately two inches in length that was alive and was on the floor under a metal storage shelf rack containing boxes of canned enteral nutrition. During a concurrent observation and interview on 10/24/2024 at 10:05 AM with the Infection Preventionist (IP, a healthcare professional who works to prevent the spread of infections in healthcare facilities) inside the facility 's storage room, a large, live, brown cockroach was on…

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

Based on interview and record review, the facility failed to provide care that meets the professional standards of quality for one of five sampled residents (Resident 72) by failing to: 1. Document - Morphine Sulfate a controlled medication (a drug whose manufacture, possession, or use is regulated by a government) on the Control Drug Record on 10/10/2024 as administered to Resident 72 on her in accordance with the facility's policy and protocol. 2. Document the wrong physician order and wrong volume of receiving medication vial on Resident 72's Control Drug Record. These deficient practices had the potential to result in medication errors, which could lead to adverse reactions (any unexpected or dangerous reaction to a drug) for Resident 72, and undetected diversion (illegal distribution or abuse of prescription drugs or their use for unintended purposes) of controlled medication. Cross reference to F755 Findings: 1.During a review of Resident 72's admission Record indicated the facility admitted Resident 72 on 6/30/2023 with diagnoses that included dementia (a general term for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure proper footwear for one of two sampled residents (Resident 76). This deficient practice had the potential to result in Resident 76's discomfort and placed Resident 76 at risk for falls and injuries. Findings: During a review of Resident 76's admission Record indicated the facility originally admitted Resident 76 on 2/26/2024 and readmitted on [DATE] with diagnoses that included diabetes mellitus (a group of diseases that affect how the body uses blood sugar) and cellulitis (a deep infection of the skin caused by bacteria) of right lower limb During a review of Resident 76's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/12/2024, indicated Resident 76 had moderate memory and cognitive (ability to think and reasonably) impairment. The MDS indicated Resident 76 required setup or clean-up assistance with eating, supervision or touching assistance with oral hygiene, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents who were at risk for skin breakdown and pressure injuries (localized damage to the skin and underlying soft tissue, usually occurring over a bony prominence or related to medical devices) received treatment and services to prevent skin breakdown for one of three sampled residents (Resident 21) with pressure injury by failing to ensure the low air loss mattress (LAL Mattress -air filled mattress used to relieve pressure) was set according to resident's weight. Resident 21's LAL mattress was set for 320 pounds (lbs.) body weight instead of 200 lbs. body weight since Resident 21's weigh was 185 lbs. As a result of this deficient practice Resident 21 was at a potential risk for developing pressure injury and/or worsened pressure injury to both heels. Findings: During a review of Resident 21's admission Record (Face Sheet), dated 4/6/2023, the face sheet indicated the facility admitted Resident 4 on 4/6/2023, and readmitted on [DATE] with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide foot care for one of three sampled residents (Resident 45) with long nails and [NAME] infection and was documented by the facility as the resident refused podiatric (a physician specialized in foot treatment) treatment and no alternative services were offered or provided to ensure foot care was provided. Resident 45 stated he was never asked and provided foot and nails care by the facility's staff. This deficient practice resulted in Resident 45's feeling pain and uncomfortable when his feet were being touched and had a potential to result in worsened foot infection. Cross Reference to F656. Findings: During a review of Resident 45's admission Record, indicated Resident 45 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included paraplegia (chronic condition that refers to the loss of muscle function in the lower half of the body, including the legs and sometimes the abdomen), primary…

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 two sampled residents (Resident 28), was administered with the correct feeding formula (nutritional formula) delivered via gastrointestinal tube (GT- a tube surgically inserted into the stomach to deliver liquids and medications) as ordered by the physician. This failure had a potential to result in Resident 28's weight loss, intolerance (not able to absorb formula effectively) to GT feeding formula, such as having increased GT residual, vomiting, diarrhea, and stomach pain/discomfort. Findings: During a review of Resident 28's admission Record, indicated Resident 28 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia [the loss of cognitive functioning (thinking, remembering, and reasoning) to such an extent that it interferes with a person's daily life and activities], gastrostomy (a surgical procedure used to insert a tube, often referred to as a G-tube, through the abdomen…

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 three sample residents (Resident 55) was provided respiratory care was consistent with professional standards of practice and facility's policy and procedure for by failing to ensure Resident 55's nebulizer mask (changes medication from a liquid to a mist so you can inhale it into your lungs) was kept in a plastic bag when not in use. The deficient practice had the potential to spread bacteria and infection to the residents and resulted in contamination of Residents 55's oxygen equipment and can place the resident at risk for infection. Findings: During a review of Resident 55's admission Record (Face Sheet), dated 7/25/2023, the face sheet indicated the facility admitted Resident 55 on 7/25/2023, and readmitted on [DATE] with diagnoses including disorder of the lung and generalized anxiety disorder. During a review of Resident 55's Minimum Data Set (MDS-a federally mandated resident assessment tool.), dated 9/7/2024,…

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 accurately and safely provide pharmaceutical services, in accordance with the facility ' s policy and procedure (P&P) titled Controlled Substances and Discarding and Destroying Medications, by failing to: 1.Properly discard and destroy the remaining Morphine Sulfate (MS, a controlled medication [a drug whose manufacture, possession, or use is regulated by a government] is used to treat moderate to severe pain) for Resident 72. 2. Document the MS administered to Resident 72 on her Control Drug Record on 10/10/2024 in accordance with the facility ' s P&P. 3. Document the correct instruction and the correct volume of the MS to start on Resident 72 ' s Control Drug Record. 4. Maintain a record of the receipts of Resident 72 ' s MS that was delivered by the hospice pharmacy. 5. Ensure the nurses to sign on the facility ' s Narcotic Medications Surveillance when they completed the narcotic count. These deficient practices had placed Resident 72 at risk for medication errors, which could lead to adverse reactions…

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 one out of 23 sampled residents (Residents 62) with meals that accommodated the resident's food preferences. Residents 62 received tomato products and milk with her meals, despite her dislikes for tomato products and allergy to milk. This deficient practice had the potential to result in decreased meal intake and can lead to weight loss and malnutrition. Findings: During a review of Resident 62's admission Record, indicated Resident 62 was admitted to the facility on [DATE] with diagnoses that included Moderate Protein-Calorie Malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat) and Gastro-esophageal reflux disease (GERD-is a chronic condition that occurs when stomach contents flow back up into the esophagus). During a review of Resident 62's Minimum Data Set (MDS-a federally mandated resident assessment tool), 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.

Based on observation, interview, and record review, the facility's Quality Assessment and Assurance committee (QAA, committee established for the purpose of improving the safety and quality of health services) failed to establish and implement written policies and procedures to address noncompliance to the facility's smoking policy for 8 out of 28 residents (Resident 2, 3, 9, 14, 18, 56, 67 and 136) who were smokers, by failing to: 1. Identify quality deficiencies related to noncompliance with the facility's smoking policy. 2. Ensure effective oversight of the facility's smoking area. 3. Ensure effective system to obtain input from the Activity Director (AD) 1 to develop and implement appropriate plan of action to address noncompliance with the facility's smoking policy. This failure resulted in eight residents (Resident 2, 3, 9, 14, 18, 56, 67 and 136) smoking unsupervised during nonscheduled smoking time, which had the potential for the residents to be at risk for accidental burn, fire hazards that could affect the health, safety, wellbeing of residents, staffs, visitors. Cross…

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 and maintain a functioning call light (a device that allows residents to communicate with their care providers when they need assistance) for one of 23 sampled residents (Resident 10). This deficient practice had the potential to result in a delay in meeting the resident's needs for assistance and can lead to falls and accidents. Findings: During a review of the admission record indicated Resident 10 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including but not limited to lack of coordination, chronic obstructive pulmonary disease (COPD, a progressive lung disease that makes it hard to breathe), and cognitive communication deficit. During a review of the Minimum Data Set Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 10/10/2024 indicated Resident 10 had severely impaired cognitive skills for daily decision making and required extensive assistance for bed mobility,…

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 clean and sanitary environment for four of four sampled residents (Residents 58, 60, 66, and 74) by failing to: 1. Ensure Resident 66's oxygen concentrator machine (a medical device that supplies oxygen and it can help people with breathing difficulties breathe more easily) was clean. 2. Ensure the facility maintained an effective pest control in the facility. Three of three residents (Resident 58, 60, and 74) were observed in the dining room with flies while eating their meals. These deficient practices had the potential for Resident 66 to have an allergic reaction from the dust and had a potential to result in Resident 58, 60, and 74's food contamination transfer of disease-causing organism from the flies from one contact area to another that could result in infection. Findings: 1. During a review of Resident 66's admission Record indicated the facility admitted Resident 66 on 7/1/2022 with diagnoses that included anxiety…

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 three of three facility staffs had appropriate competencies and skills sets necessary to provide nursing related services related to residents with wandering behavior (walking or going to places aimlessly) and at risk for elopement (running away or leaving the facility without proper permission) as indicated in the facility's policy and procedure titled Staffing, Sufficient and Competent Nursing. The facility failed to ensure: 1. Licensed Vocational Nurse (LVN) 1 attended in-services for elopement and Code Green (the code used to alert all facility staff that a resident is missing or has eloped). 2. Director of Staffing Development (DSD) evaluate the competencies of staff after in-services and when Resident 1 eloped. 3. DSD did not have specific clear instructions in the in-services provided about Code Green. 4. Registered Nurse (RN) 1 to completed Resident 1's Elopement Evaluation (EE) and not copying the previous form which was incorrect and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1), was appropriately transferred/discharged on 4/11/24 at 9 pm, in accordance with the facility ' s policy and procedure titled Discharging the Resident. As a result, Resident 1 was inappropriately discharged to Law Enforcement and then to home with Family (FAM) 1 on 4/11/24 at 9 pm, without a physician ' s order, discharge medications, and appropriate discharge planning. This deficient practice had resulted to Resident 1 not getting any of the prescribed and routine medications from 4/12/24 to 4/17/24 (6 days). This deficient practice may further result to medical complications due to inability to receive routine medications and the unsafe/unplanned discharge back to home. Findings: A review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included immunodeficiency (the decreased ability of the body to fight infections and other…

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 residents (Resident 1), had a developed comprehensive care plan that addressed refusal to medications, specifically the risperidone (antipsychotic medication). This failure had a potential to result in not meeting the resident ' s needs and could lead to medical complications. Findings: A review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included immunodeficiency (the decreased ability of the body to fight infections and other diseases), schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), and generalized anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness). A review of Resident 1's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 1/29/24, the MDS indicated, Resident 1 was cognitively intact (able to think, remember and reason)…

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 residents (Resident 1), had behavior monitoring related to schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), in accordance with the facility ' s policy and procedure titled Behavior, Mood and Cognition. This failure had a potential to result in a delay in physician ' s notification, interventions, and treatment of the resident ' s psychotropic medications. Findings: A review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included immunodeficiency (the decreased ability of the body to fight infections and other diseases), schizophrenia, and generalized anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness). A review of Resident 1's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 1/29/24, the MDS indicated, Resident 1 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.

Based on interview and record review, the facility failed to supervise one of four sampled residents (Resident 1) who walked out of the facility ' s premises without the facility ' s knowledge on 2/8/24. As a result, Resident 1 was found on the street by the local police and was transferred to a general acute care hospital (GACH) with no injury. This deficient practice placed Resident 1 at risk to cold exposure, dehydration (a dangerous loss of body fluid caused by illness, sweating, or inadequate intake) and other medical complications, and being struck by a motor vehicle. Findings: During a review of Resident 1 ' s face sheet indicated the facility admitted Resident 1 on 12/22/23 with diagnoses that included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and dementia ((a term for a range of conditions that affect the brain's ability to think, remember, and function normally). During a review of Resident 1 ' s History and Physical (H&P), dated 12/23/23, indicated Resident 1 does not have the capacity to understand and make decisions.…

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 sufficient monitoring and supervision for one of three sampled residents (Resident 1) who eloped (the act of leaving a facility premises or a safe area without notifying anyone) or was absent without official leave (AWOL) from the facility. Resident 1 left the faciity on an approved out on pass order from his physician on 11/30/23 at 5:30 am. The resident had not returned and his whereabouts were unknown until he returned to the facility on [DATE]. This deficient practice had the potential for Resident 1 and other residents with out of on pass orders to be at risk to be in danger or harm from the environment and extreme weather conditions, which could lead to accidents, dehydration (when the body doesn't have enough water and other fluids to carry out its normal functions), and injuries. Findings: A review of Resident 1's Face sheet indicated the facility admitted the resident on 9/18/23 with diagnoses that included but not limited to, bipolar…

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 behavioral health care and services to maintain physical, mental and psychosocial wellbeing for one of two sampled residents (Resident 1). Resident 1 is a parolee (a person released from prison) wearing an ankle tracking device (an ankle monitor used to track location and is monitored 24 hours a day around the clock). On 10/2/23, Resident 1 had a decrease in dose of Haloperidol (Haldol) an antipsychotic medication. There was no individualized plan of care developed to address the resident's immediate needs and standard of care to reflect changes in approaches, as needed, that could result in significant changes in the resident's mental and psychosocial condition or needs. This deficient practice had the potential to negatively affect the Resident 1's emotional and psychosocial well-being. Findings: A review of Resident 1's Face sheet indicated the resident was initially admitted to the facility on [DATE] with diagnoses of paranoid schizophrenia…

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 ensure the maintenance of a safe, clean, and home-like environment for twelve of twelve sample residents as evidenced by: 1. Soiled curtains in rooms for Residents 2, 7, 23, 26, 34, 50, 54, 63, 70, and 78. 2. Residents 12 and 60's restrooms had damaged and peeling paint. This deficient practice placed the residents at risk for physical discomfort and had the potential for the spread of infection. Findings: 1a. A review of Resident 70's Facesheet indicated the resident was initially admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (a lung disease characterized by long-term poor airflow) and chronic kidney disease (longstanding disease of the kidneys leading to renal failure). A review of Resident 70's History and Physical Examination (HPE), dated 7/27/2023, indicated Resident 70 ha the capacity to understand and make decisions. A review of Resident 70'S Minimum Data Set (MDS - a standardized 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 the Quarterly Minimum Data Set (MDS-a resident assessment and care-screening tool) was performed timely and transmitted to the Centers for Medicare and Medicaid Services (CMS) system for 5 of 11 sampled residents (Residents 46, 49, 53, 82, 83). This deficient practice had the potential for the residents not to receive the care and services to achieve their highest potential. Findings: 1. A review of Resident 46's Facesheet indicated the facility admitted Resident 46 on 05/25/2022 with diagnoses that included diabetes (a group of diseases that result in too much sugar in the blood), and schizophrenia (a mental disorder that affects a person's ability to think, feel, and behave clearly). A review of Resident 46's MDS, dated [DATE] indicated Resident 46 limited assistance (staff provided guided maneuvering of arms/legs) for bed mobility, toilet use, and personal hygiene. Resident 46's MDS indicated that Resident 46 required extensive assistance…

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 Minimum Data Set (MDS-a resident assessment and care-screening tool) was transmitted (a process of transferring report) Transmittal requirements within 14 days after a facility completes the resident's assessment, into the Centers for Medicare and Medicaid Services (CMS) system information for 7 of 11 sampled residents (Residents 8, 19, 46, 49, 53, 82, 83). This deficient practice had the potential to result in confusion regarding the care and services provided to Residents 8, 19, 46, 49, 53, 82, and 83. It also had a potential to affect the facility's quality of care monitoring system that measures the effective, safe, efficient, patient-centered, equitable (fair), and timely care. Findings: 1. A review of Resident 8's Face Sheet (an admission record) indicated the facility admitted Resident 8 on 4/17/2023 with diagnoses that included depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can…

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 their policy and procedure titled, Arbitration Agreement, for three of three sampled residents (Resident 4, 40 and 86) by not ensuring that they were informed and understood any proposed binding arbitration agreement (resolving disputes with a neutral third party instead of the court) before having them enter into one. This failure resulted in Resident 4,40 and 86 unknowingly giving up their right to resolve any disputes with the facility through a court of law before a jury. Findings: 1. During a review of Resident 4's Facesheet (an admission record) indicated the resident was admitted to the facility on [DATE] with the following diagnoses of schizoaffective disorder (a mental health illness that can affect your thoughts, moods and behavior) and generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities). During a review of Resident 4's History and Physical dated 3/7/23, the History and Physical indicated that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on, observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 63 and Resident 42) had the right to be informed and make treatment decisions. 1. Resident 63 refused care that included diaper change and nail care, had an interdisciplinary (IDT) plan of care to determine the cause of the refusal, in accordance with the facility's policy and procedure on Requesting, Refusing and/or Discontinuing Care or Treatment. 2. Resident 42 was prescribed Lorazepam (medication used to treat anxiety [a mental disorder that result in having the fear of the unknown]) without informed consent. This failure violated Resident 42's and Resident 63's rights to be informed when choosing the type of care or treatment to be received, and make decisions on alternative measures the resident or responsible party preferred. Findings: 1. A review of Resident 63's Facesheet (an admission record) indicated the resident was initially admitted to the facility on [DATE] with diagnoses 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 ensure that the call light (an alerting device for residents to call nurses or other nursing personnel to assist when they are in need) was accessible for one of ten sampled residents (Resident 20). This failure had the potential to result in Resident 20 not being able to call staff for assistance and result in delayed or no emergency care when needed. Findings: A review of Resident 20's Facesheet indicated the resident was initially admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (a lung disease characterized by long-term poor airflow), bilateral osteoarthritis (arthritis that occurs when flexible tissue at the ends of bones wears down) of the hip and morbid obesity (a severe and dangerous level of being overweight that significantly and negatively impacts health and shortens the lifespan). A review of Resident 20's History and Physical Examination, dated 4/5/2023, indicated Resident 20 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 follow their policy and procedure titled, Physician Orders for Life Sustaining Treatment (POLST; a person's treatment wishes during a medical emergency), for one of 18 sampled residents (Resident 23) by not ensuring the revised POLST form showing the resident's code status (the type of emergent treatment a person would or would not receive if their heart or breathing were to stop) as Do Not Resuscitate (DNR; no medical measures to maintain life) was in Resident 23's medical chart. This failure had the potential to result in Resident 23's wishes not being met during a medical emergency. Findings: During a review of Resident 23's Facesheet (an admission record) indicated the resident was admitted on [DATE] with the following diagnoses; malignant neoplasm of brain (a fast-growing cancer that spreads to other areas of the brain and spine) and hypertensive heart disease (a long-term condition that develops over many years in people who have high blood…

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 Skilled Nursing Facility (SNF) Advanced Beneficiary Notice of Non-coverage (SNF ABN, CMS-10055 form to notify beneficiary about potential non-coverage and the option to continue services with the beneficiary accepting financial liability for those services) to one of three sample residents (Resident 62), who was discharged from Medicare skilled service and continued to stay at the facility under custodial care (non-medical care that helps individuals with their activities of daily living, such as eating and bathing). This failure resulted in Resident 62 not knowing about the financial liability for services provided by the facility. Findings: A review of Resident 62 ' s Facesheet (a document that contains a summary of a patient ' s physical and demographic information) indicated the resident was admitted to the facility on [DATE] with diagnoses of urinary tract infection, paraplegia (paralysis of the legs and lower body), lack of coordination,…

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 facility staff prevent abuse by implementing the facility's abuse policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating during the provision of care and services for one of four sampled residents (Resident 63). The facility failed to: 1. Identify an allegation of physical abuse which was reported by Resident 63 to the Social Services Director (SSD) on 10/31/2023, when Certified Nurse Assistant (CNA) 4 allegedly got on top of Resident 63, pulled the resident's right arm down, put CNA 4's knee on the resident, and cut the resident's nails, approximately about two to three weeks ago, as verbalized by the resident. 2. Start the investigation of Resident 63's allegations of abuse to CNA 4 to determine if abuse had occurred on 10/31/2023. 3. Protect Resident 63 from an alleged physical abuse, by not suspending CNA 4 and reporting to the facility's abuse coordinator the resident's allegations of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to report a suspected abuse immediately to the Administrator immediately (within two hours of an allegation involving abuse or result in serious bodily injury) to the administrator and to other officials [state agency, adult protective services (a social services program serving older adults and adults with disabilities)] according to state law and in accordance with the facility's policy and procedure on Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, for one of four sampled residents (Resident 63). The facility did notify the appropriate agencies within two hours when the Social Services Director (SSD) was informed of Resident 63's allegation of abuse towards Certified Nurse Assistant (CNA) 4, on 10/31/2023. Certified Nurse Assistant (CNA) 4 allegedly got on top of Resident 63, pulled the resident's right arm down, put CNA 4's knee on the resident, and cut the resident's nails, approximately about two to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to obtain a Preadmission Screening and Resident Review (PASRR - a federally required screening for mental health; Level I screening identifies suspected mental illness, intellectual/developmental disability or related condition; Level II screening determines if the individual would benefit from specialized mental health services) Level II evaluation for two of three sampled residents (Resident 20 and 78). This failure had the potential to result in Resident 20 and Resident 78 not receiving necessary mental health services. Findings: A review of Resident 20's Facesheet indicated the resident was initially admitted to the facility on [DATE] with diagnoses of bipolar disorder (a mental illness that causes unusual shifts in mood, energy, and concentration), schizoaffective disorder (mental illness that affects mood and has symptoms of hallucinations and/or delusions), suicidal ideations (having thoughts of possibility of ending one's life,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a baseline and comprehensive care plan for one of four sampled residents (Resident 3), who was receiving Eliquis (an anticoagulant or a medication that thins the blood or blood thinner which makes the blood flow through veins and arteries more easily). This deficient practice had the potential for Resident 3's not to receive the assessment and monitoring or other interventions needed to prevent or intervene when complications such as bleeding and bruising occurs while receiving anticoagulant. Findings: A review of Resident 3's Face Sheet (an admission record) indicated the resident was admitted to the facility on [DATE] with diagnoses that including pulmonary embolism (a sudden blockage in your pulmonary arteries, the blood vessels that send blood to your lungs), cirrhosis of liver (liver damage where healthy cells are replaced by scar tissue, and Type II Diabetes (a condition of high blood sugar). A review of Resident 3's History and Physical…

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 revise the plan of care for one of 18 sampled residents (Resident 23) to reflect the new physician's order for Life-Sustaining Treatment (POLST-a person's treatment wishes during a medical emergency) from full code (all medical measures will be taken to maintain life) to Do Not Resuscitate (DNR-no medical measures to maintain life). This failure had the potential for Resident 23 not to receive the emergency treatment and intervention according to the resident's wishes. Findings: During a review of Resident 23's Facesheet (an admission record) indicated the resident was admitted to the facility on [DATE] with the following diagnoses of malignant neoplasm of brain (a fast-growing cancer that spread to other areas of the brain and spine) and hypertensive heart disease with heart failure (a long-term condition that develops over many years in people who have high blood pressure which is a condition in which the force of the blood against the artery walls…

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 collaborate with hospice (a team of health care professionals that focuses of end-of-life pain and symptoms and attend to the emotional and spiritual needs at the end of life) for the development, implementation of, and revision of the coordinated plan of care for two of two residents (Resident 9, 77) reviewed for care plans by failing to ensure Resident 9, 77 had coordinated care plans with the hospice providing end of life care. This deficient practice had the potential to negatively affect the delivery of care and services related to the end-of-life status of Resident 9, 77. Findings: 1. A review of Resident 9's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses of, Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time), and dysphagia (difficulty…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure 1 of 10 sampled residents (Resident 7) environment remained free of exposed electrical wiring. This deficient practice had the potential to result in Resident 7 sustaining an electrocution or burn injury. Findings: A review of Resident 7's admission Record indicated the resident was initially admitted to the facility on [DATE], with diagnoses of schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions), chronic kidney disease (longstanding disease of the kidneys leading to renal failure), and morbid obesity (a severe and dangerous level of being overweight that significantly and negatively impacts health and shortens the lifespan). A review of Resident 7'S Minimum Data Set (MDS - a standardized resident assessment care screening tool), dated 7/31/2023, indicated the resident was cognitively intact (ability to think, remember, and reason), but required extensive…

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 nursing staff to follow physician order to provide correct amount of feeding formula for one of two sampled residents (Resident 78) who was on tube feeding (a therapy where a feeding tube supplies nutrients to people who cannot get enough nutrition through eating) by giving more feeding formula amount than physician ordered. This failure had the potential to result in putting Resident 78 at risk for aspiration (when food, liquid or some other material enters the airway or lungs by accident) and unplanned weight gain. Findings: A review of Resident 78 ' s Facesheet (a document that contains a summary of a patient ' s physical and demographic information) indicated the resident was admitted to the facility on [DATE] with diagnoses including dysphagia (difficulty swallowing), Gastrostomy status (GT - a tube that is surgically inserted into the resident's stomach to allow access for food, fluids and medications), lack of coordination,…

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 implement the facility's policy and procedure related to respiratory care, titled Departmental (Respiratory Therapy) Prevention of Infection by ensuring the oxygen humidifier bottle (a device used to make supplemental oxygen moist) was labeled with the accurate the date of when first used for one of 3 sampled residents (Resident 77). This deficient practice has the potential for Resident 77 and other potential residents to develop an infection associated with unlabeled humidifier bottle. Findings: A review of Resident 77's Face sheet (admission Record) indicated the facility initially admitted Resident 77 to the facility on 7/1/22 with the diagnoses that included, acute respiratory failure(serious condition that happens when lungs cannot get enough oxygen into your blood or remove enough carbon) chronic obstructive pulmonary disease (lung diseases that block airflow and make it difficult to breathe) and paranoid schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly which…

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 arrange dental service for to one of one sample resident (Resident 86) in a timely manner after Resident 86 was re-admitted to the facility. This failure has the potential to put Resident 86 at risk for oral infection and pain. Findings: A review of Resident 86 ' s Facesheet (a document that contains a summary of a patient ' s physical and demographic information) indicated the resident was admitted to the facility on [DATE] with diagnoses of Type 2 diabetes mellitus (condition that results in too much sugar circulating in the blood) with hyperglycemia (high blood sugar), dysphagia (difficulty swallowing), lack of coordination, seizures, generalized anxiety disorder (a group of mental disorders characterized by significant feelings of fear), and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest in life). A review of Resident 86 ' s History of Physical Examination, dated 10/16/2023,…

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 obtain a permit from the Department of Healthcare Access and Information (HCAI - the State agency having jurisdiction that reviews and approves plans for construction, repairs, renovations, and remodeling made to buildings to comply with State codes) for the replacement of the sprinklers throughout the facility. This deficient practice does not ensure that the installation of the sprinklers complies with the appropriate safety codes and regulations and could potentially pose a risk to the residents, staff, and visitors at the facility. Findings: During an interview, on 10/27/2023, at 10:56 a.m., with the Administrator, the Administrator stated that the facility was in the process of changing all of the sprinklers in the facility due to the fact that the sprinklers heads had been tested and the testing agency found that the sample had failed, and it was required to replace them. The Administrator stated that there was not an available HCAI permit for this sprinkler change project. 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 observation, interview, and record review, the facility failed to provide appropriate treatment and services for one of three sampled residents (Resident 1) with diagnosis of dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and wandering (moving from place to place without a fixed plan; roaming; rambling) behavior by entering to other resident ' s room and nursing stations, and episodes of angry outburst (sudden violent and explosive behavior). Resident 1 was not monitored and supervised, and no plan of care developed to address behaviors related to dementia in accordance to the facility's policy and procedure. These deficient practices had resulted in physical altercation (a dispute between individuals in which one or more persons sustain bodily injury arising out of the dispute) with another resident (Resident 2) who sustained facial skin tear. In addition Resident 1 had a potential to be abused (intentionally hurting someone) and/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.