Arbor Glen Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop an individualized person-centered care plan (CP) for one of one sampled resident (Resident 7) that addressed Resident 7's moderate difficulty (speaker has to increase volume and speak distinctly) hearing.This failure had the potential to result in unmet individual needs for Resident 7 and the potential to affect Resident 7's physical and psychosocial well-being.Cross reference with F636Findings:During a review of Resident 7's Face Sheet (admission record, FS), the FS indicated Resident 7 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation (irregular heartbeats), dysphagia (difficulty swallowing), and generalized muscle weakness.During a review of Resident 7's History and Physical (H&P), dated 3/18/2025, the H&P indicated Resident 7 had the capacity to understand and make decisions.During a review of Resident 7's MDS, dated [DATE], the MDS indicated Resident 7's cognitive (the ability to think and process…

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

Based on observation, interview, and record review, the facility failed to ensure a licensed nursing staff informed one of four sampled residents (Resident 79) of the type of medication being administered during medication administration on 3/26/2026 and as indicated in the facility's Policy and Procedure (P&P), titled Med Pass. This deficient practice had the potential to result in medication errors due to Resident 79 not being encouraged to participate during Resident 79's medication administration. Findings:During a review of Resident 79's Face Sheet (admission record, FS), the FS indicated the facility admitted Resident 79 on 3/20/2024 with diagnoses that included type 2 diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in elevated levels of glucose/sugar in the blood and urine), parkinsonism (disease that affects the nerve cells in the brain that produces symptoms that include muscle rigidity, tremors, and changes in speech and gait).During a review of Resident 79's History and Physical (H&P), the H&P…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 95), who spoke a dialect from China, was provided a communication tool or resources to effectively ensure Resident 95 communicated Resident 95's needs.This deficient practice had the potential to result in Resident 95's care needs not effectively conveyed to the facility staff, which could lead to a decline in the resident's physical and psychosocial well-being.Findings:During a review of a Face Sheet (admission record, FS), the FS indicated Resident 95 was re-admitted to the facility on [DATE] with diagnosis that included traumatic subdural hemorrhage (dangerous collection of blood between the brain surface and its outer covering, caused when tiny bridging veins tear, usually due to head trauma), and abnormalities of gait (manner of walking) and mobility (ability to actively move joints through their full range of motion).During a review of Resident 95's history and physical (H&P), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 42), who was unable to carry out activities of daily living (ADL - routine tasks activities such as bathing, dressing, and toileting, a person performs daily to care for themselves) was properly groomed.This deficient practice had the potential to impact Resident 42's overall health and could affect Resident 42's psychosocial well-being.Findings:During a review of Resident 42's Face Sheet (admission record, FS), the FS indicated Resident 42 was admitted to the facility on [DATE] with diagnoses that included heart failure, essential hypertension (high blood pressure), and abnormalities of gait (manner of walking).During a review of Resident 42's Care Plan (CP), initiated 3/8/2026, the CP's focus indicated Resident 42 had an ADL self-care performance deficit. The CP's interventions indicated Resident 42's personal hygiene routine included: preferred to being shaved, and getting hands…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a low air loss (LAL, mattress that operates using a blower-based pump that was designed to circulate a constant flow of air) mattress was set at intermittent pressure mode (alternating pressure, continuous, automatic inflation and deflation of air cells in a cyclical pattern) for one of four sampled residents (Resident 43).This deficient practice had the potential for Resident 43 to develop new pressure injuries (PI, lesion/wound caused by unrelieved pressure usually over a bony prominence that results in damage of underlying tissue) or delayed healing to Resident 43's existing PI.Findings:During a review of Resident 43's Face Sheet (admission record, FS), the FS indicated the facility admitted Resident 43 on 3/2/2026 with diagnoses that included unstageable PI (pressure ulcer with slough [yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture] or eschar [dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to supervise two of two sampled residents (Resident 82 and Resident 106) while smoking in the patio's designated smoking area.This failure had the potential to result in injury, accidental burns, and fire hazards to the resident.Findings:During a review of Resident 82's Face Sheet (FS), the FS indicated Resident 82 was admitted to the facility on [DATE] with diagnoses including but not limited to effusion of right knee (abnormal fluid in the knee), muscle weakness, and schizoaffective bipolar disorder (a mental illness that can affect thoughts, mood, and behavior).During a review of Resident 82's History and Physical (H&P), dated 3/14/2026, the H&P indicated Resident 82 had the capacity to understand and make decisions.During a review of Resident 82's Minimum Data Set (MDS - a resident assessment tool), dated 3/12/2026, the MDS indicated Resident 82 smoked one to two times a day.During a review of Resident 82's Care Plan (CP), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure call lights (a device used by a resident to signal the need for assistance) were within reach for two of two sampled residents (Resident 10 and Resident 41).This deficient practice had the potential to result in unmet needs for Resident 10 and Resident 41 due to the residents being unable to call for assistance from staff or alert staff during an emergency.Findings: a. During a review of Resident 10's Face Sheet (admission record, FS), the FS indicated the facility admitted Resident 10 on 9/10/2024 with diagnoses that included dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) and metabolic encephalopathy (disease that affects the function or structure of the brain). During a review of Resident 10's Minimum Data Set (MDS – a standardized resident assessment tool), dated 3/3/2026, the MDS indicated Resident10's cognitive (the ability to think and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure Certified Nursing Assistant 2 (CNA 2) turned and repositioned one of two sampled residents (Resident 2) with pressure ulcer/injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) in accordance with the resident's plan of care.This deficient practice had the potential for worsening or delaying healing of Resident 2's Stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone).Findings:During a review of Resident 2's admission Record (AR), the AR indicated the facility originally admitted Resident 2 on [DATE] with diagnoses that included muscle weakness and displaced subtrochanteric fracture of the left femur (broken bone of the left leg).During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated [DATE], the MDS indicated Resident 2 had moderately impaired cognitive skills (ability to make daily 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.

Based on observation, interview and record review, the facility failed to provide pain medication to one of two sampled residents (Resident 2) and let the pain medication take effect prior to continuing with Resident 2's wound care to Resident 2's Stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) and prior to providing a bed bath to Resident 2.This deficient practice resulted in Resident 2 experiencing unrelieved pain for 40 minutes on 2/20/2026.Findings:During a review of Resident 2's admission Record (AR), the AR indicated the facility originally admitted Resident 2 on 7/7/2025 with diagnoses that included muscle weakness and displaced subtrochanteric fracture of the left femur (broken bone of the left leg).During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 12/28/2025, the MDS indicated Resident 2 had moderately impaired cognitive skills (ability to make daily decisions) and required substantial/maximal assistance (helper does more than half the effort to complete the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement proper infection control procedures for one of two sampled residents (Resident 4) when Certified Nursing Assistant 3 (CNA 3) did not change protective gown and performed hand hygiene after providing care to Resident 3 and before providing care to Resident 4.This deficient practice had the potential to spread MDRO infection to Resident 4.Findings:a. During a review of Resident 3's admission Record (AR), the AR indicated the facility admitted Resident 3 on 3/3/2021 with diagnoses that included urinary tract infection (UTI- an infection in the bladder/urinary tract) and diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 12/16/2025, the MDS indicated Resident 3 had an active diagnosis of MDRO (multidrug-resistant organism or bacteria that resists many antibiotics, making infections difficult 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 ensure physician assessment and continued management of a high-risk medication (drugs that can cause serious harm, injury, or death if used incorrectly) for one of three sampled residents (Resident 5). Resident 5 was on insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication), a high-risk medication, for management of diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and Resident 5's Hemoglobin A1C (Hgb A1C - a blood test which measures a person's average blood sugar levels over the past 2-3 months) laboratory test results indicated Resident 5's HgB A1C was 13.6 percent (normal range is below 5.7 percent). This deficient practice resulted in Resident 5 not receiving insulin for eight days and placed Resident 5 at risk for diabetic ketoacidosis (DKA, a serious, life-threatening complication of diabetes) and coma (a prolonged…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 promptly respond to call lights (device used by a resident to signal his or her need for assistance from staff) and/or promptly respond to a resident's request for toileting assistance for two of four sampled residents (Residents 6 and 7). This failure had the potential to result in residents (in general) feeling like their concerns were unheard and feeling frustrated.Findings: During a review of Resident 6's admission Record (AR), the AR indicated the facility admitted Resident 6 on [DATE] with diagnoses including peripheral vascular disease (reduced circulation of blood to a body part), sickle-cell disease (an inherited blood disorder), and muscle wasting and atrophy (loss of muscle tissue). During a review of Resident 6's Minimum Data Set (MDS, a resident assessment tool), dated [DATE], the MDS indicated Resident 6 had no impairment in cognitive skills (ability to make daily decisions). The MDS indicated Resident 1 required supervision…

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

Based on interview and record review, the facility failed to ensure the facility created a Plan of Action form for concerns which 2 of 23 residents (unidentified) expressed during resident council (a formal gathering of residents to discuss shared concerns, improve quality of life, and communicate with management) meetings, according to the facility's Policy and Procedure (P&P) titled, Resident Council Meeting, reviewed 01/2025. This failure had the potential for residents' (in general) concerns to be unheard and had the potential for residents' (in general) needs to be unmet. Findings: During a concurrent interview and record review on 12/18/2025 at 9:45 AM, with the Activities Director (AD), the facility's Resident Council Meeting minutes (RCM), dated 7/17/2025 and 10/21/2025, were reviewed. The RCM, dated 7/17/2025, indicated a resident (unidentified) complaint about waiting a long-time during shift change for assistance from staff (in general). The RCM, dated 10/21/2025, indicated another resident (unidentified) complained again of waiting a long-time during shift change 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.

Based on interview and record review, the facility failed to maintain a complete and accurate medical record for one of three sampled residents (Resident 1) when facility staff (in general) failed to document Resident 1's visit to a physician on 9/4/2025 in Resident 1's medical record. This failure resulted in Resident 1's medical record containing incomplete information and had the potential for Resident 1 to receive inappropriate care. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 7/12/2025 and readmitted Resident 1 on 10/5/2025 with diagnoses including urinary tract infection (UTI, an infection in any part of the urinary system, including the kidneys, bladder, or urethra), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and hypertension (high blood pressure). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 11/18/2025, the MDS indicated Resident 1 had no impairment in cognitive skills (ability to make daily…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the dignity of one of four sampled residents (Residents 2) when staff failed to promptly respond to Resident 2 ' s call light. This failure had the potential to result in Resident 2 feeling unimportant and disrespected and for Resident 2 ' s needs not being met. Cross Reference F677 Findings: During a review of Resident 2 ' s admission Record (AR), the AR indicated the facility admitted Resident 2 on 3/4/25, with diagnoses that included end stage renal disease (ESRD- irreversible kidney failure), hypoglycemia (low blood sugar level), muscle weakness, and other abnormalities of gait (pattern of walking) and mobility (ability to move freely). During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 3/8/25, the MDS indicated Resident 2 had intact cognition (ability to think, learn, and remember). The MDS indicated Resident 2 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, showering/bathing self, and upper and lower…

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

Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 2) who required assistance with activities of daily living (ADLs- tasks of everyday life such as bathing, dressing, and toileting) was provided care timely when staff did not answer Resident 2 ' s call light promptly and assist Resident 2 with incontinence (involuntary loss of urine or feces) care. This failure resulted in Resident 2 to not receive timely assistance with ADL as needed and had the potential to result in skin breakdown and affect Resident 2 ' s well-being. Cross Reference F550 Findings: During a review of Resident 2 ' s admission Record (AR), the AR indicated the facility admitted Resident 2 on 3/4/25, with diagnoses that included end stage renal disease (ESRD- irreversible kidney failure), hypoglycemia (low blood sugar level), muscle weakness, and other abnormalities of gait (pattern of walking) and mobility (ability to move freely). During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 3/8/25, the MDS indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 1 of 3 sampled residents (Resident 3) who received enteral feeding (tube feeding, the delivery of nutrients through a feeding tube directly into the stomach) received care and services from staff who were trained and competent in feeding tube management according to the facility ' s policies and procedures (P&P) titled, Gastrostomy Tube. This failure had the potential for Resident 3 and all residents who received tube feeding to not receive appropriate feeding tube nutrition and feeding tube care. Cross reference F726 Findings: During a review of Resident 3 ' s Face Sheet (FS, front page of the chart that contains a summary of basic information about the resident), the FS indicated Resident 3 was admitted to the facility on [DATE] with diagnoses which included dysphagia (difficulty swallowing) and failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure appropriate staff provided proper care and maintenance for one of three sampled residents (Resident 3) who received enteral feeding (tube feeding, the delivery of nutrients through a feeding tube directly into the stomach). This failure had the potential for Resident 3 to not receive appropriate feeding tube nutrition and care by trained and competent staff. Cross reference F693 Findings: During a review of Resident 3's Face Sheet (FS, front page of the chart that contains a summary of basic information about the resident), the FS indicated Resident 3 was admitted to the facility on [DATE] with diagnoses which included 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). The FS indicated Resident 3 had a gastrostomy (a surgical opening fitted with a device to allow feedings to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement Enhanced Barrier Precautions (EBP- an infection control strategy in nursing homes that expands the use of personal protective equipment [PPE], specifically gowns and gloves, during high-contact resident care to prevent the spread of infection) for one of 13 sampled residents (Resident 3). This failure had the potential to spread infections to the residents, staff, and visitors that could lead to hospitalization and/or death. Findings: During a review of Resident 3 ' s Face Sheet (FS, front page of the chart that contains a summary of basic information about the resident), the FS indicated Resident 3 was admitted to the facility on [DATE] with diagnoses which included 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). The FS indicated Resident 3 had a gastrostomy (a surgical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 to provide care and services to prevent and manage pressure ulcers for three of four residents (Resident 32, Resident 62 and Resident 183) by failing to: 1. Ensure Certified Nursing Assistant 1 (CNA 1) turned and repositioned Resident 62 who had a Stage 4 pressure ulcer (ulcer that extends into the muscle and bone and causing extensive damage on the sacrococcyx (the fused sacrum and coccyx. Sacrum is the large, triangular bone at the base of the spine. Coccyx is the triangular arrangement of bone that makes up the very bottom portion of the spine below the sacrum). 2. Ensure Certified Nursing Assistant 2 (CNA 2) turned and repositioned Resident 183, Resident 183 was assessed as high risk for the development of pressure ulcer. 3. Ensure the low air loss mattress (LAL - tiny laser made air holes in the mattress top surface continually blow out air causing the patient to float) pump was turned on for Resident 32 who had a Stage 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 have sufficient staff to ensure timely incontinence care and dignity was provided for two of two sampled residents (Resident 233 and Resident 39). This failure had the potential for Resident 233 and Resident 39 to experience skin breakdown and loss of dignity. a decline in psychosocial well-being. Cross reference F550 Findings: During a review of Resident 233's admission Record, the AR indicated Resident 233 was admitted to the facility on [DATE] with multiple diagnoses including heart failure (condition that develops when one's heart does not pump enough blood to meet the body's needs) and type 2 diabetes (-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 233's Minimum Data Set (MDS - a resident assessment tool) dated 1/31/2025, the MDS indicated Resident 233 had intact cognition (ability to reason, think, plan) and required substantial or maximum assistance (helper does…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (P&P) titled, Infection Prevention and Control Program (IPCP) Standard and Transmission-Based Precautions, for nine of nine sampled residents (Residents 42, 235, 236, 234, 23, 61, 237, 40 and 46) by failing to: a. Ensure unlabeled personal toiletries were not stored inside Residents 42, 235, 236 and 234's [NAME] n' [NAME] restroom (a restroom that has two doors and is sandwiched between two bedrooms and is accessible by both bedrooms). b. Ensure staff was wearing and/or changed personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environment) during care for Residents 61 and 237 who were in contact isolation (a set of precautions that help prevent the spread of germs from a resident to others by separation of residents with an infection from residents without an infection). c. Ensure Certified Nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its antibiotic (ABX, medication used to treat infections) stewardship program (efforts that ensure antibiotics are used only when necessary and appropriate) for three of seven sampled residents (Resident 10, Resident 72, and Resident 134) sampled residents. Residents 10, 72, and 134 did not meet McGreer's criteria (infection surveillance checklist to help determine appropriate antibiotic) for antibiotic use. These deficient practices had the potential for unnecessary administration of antibiotics and lead to resistance (when the antibiotic can no longer kill the bacteria [living organism that can cause an infection]) to antibiotics for Residents 10, 72, and 134. Findings: A. During a review of Resident 10's admission Record (AR), indicated Resident 10 was re-admitted to the facility on [DATE] with diagnosis that included sepsis (life-threatening complication of an infection), dementia (a group of conditions, decline in mental ability 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.

Based on observation, interview, and record review, the facility failed to ensure the call light was within reach for one of one sampled resident (Resident 283). This deficient practice had the potential to result in a delay or the inability for Resident 283 to obtain necessary care and services. Findings: During a review of Resident 283's admission Record (AR), the AR indicated the facility admitted Resident 283 on 1/19/2025, with diagnoses including unspecified head injury, muscle weakness, and epilepsy (a brain disorder that causes seizures, which are abnormal electrical activity in the brain). During a review of Resident 283's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 1/23/2025, the MDS indicated Resident 283 cognition (the ability to think and process information) was moderately impaired. The MDS indicated Resident 283 required substantial/maximal assistance (helper does more than half the effort) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and required substantial/maximal 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 treat one of one sampled resident (Resident 39) with respect and dignity when Certified Nursing Assistant 4 (CNA 4) was observed saying, not right now, I am busy now to Resident 39 when Resident 39 asked CNA 4 for assistance on 2/6/2025. This deficient practice had the potential to compromise Resident 39's dignity and individuality and result in psychosocial decline to Resident 39. Findings: During a review of Resident 39's an admission Record (AR), the AR indicated Resident 39 was admitted to the facility on [DATE] with diagnosis that included Alzheimer's disease (disease causing memory loss and other mental functions), generalized muscle weakness, and abnormal posture. During a review of Resident 39's History and Physical Reports (H&P), dated 11/4/2024, the H&P indicated Resident 39 did not have the capacity to understand and make decisions. During a review of a Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 8/23/2024,…

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 provide reasonable accommodation to meet the resident's needs by failing to ensure the resident's call light system was accessible and functional for one of six sampled residents (Resident 53). This deficient practice had the potential to negatively impact the psychosocial well-being of Resident 53 or result in delayed provision of services. Findings: During a review of Resident 53's admission Record (AR), the AR indicated the facility admitted Resident 53 on 3/19/2024, and re-admitted the resident 4/4/2024, with diagnoses including metabolic encephalopathy (a change in how your brain works due to an underlying condition) Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) without dyskinesia (involuntary muscle movements that can feel like tremors, spasms, or writhing), and muscle weakness. During a review of Resident 53's History and Physical (H&P), dated 4/9/2024, the H&P indicated Resident 53 did not have the capacity to…

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

Based on interview and record review, the facility failed to ensure an accurate assessment was completed to reflect the history of falls within the past 3 months of the assessment for one of one sampled resident (Resident 59). This deficient practice had the potential to negatively affect Resident 59's plan of care and delivery of necessary care and services. Findings: During a review of Resident 59's admission Record (AR), the AR indicated the facility admitted Resident 59 on 5/21/2024, and re-admitted the resident on 10/18/2024, with diagnoses including psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), muscle weakness, abnormalities of gait (the way a person walks or moves, including the pattern of foot movements and arm swing) and mobility, and dementia (a progressive state of decline in mental abilities). During a review of Resident 59's History and Physical (H&P), dated 10/19/2024, the H&P indicated Resident 59 did not have the capacity to understand and make decisions. During a review of Resident 59's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 45), who was a newly admitted resident was pre-screened for PASARR (Preadmission Screening and Resident Review - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) prior to admission to the facility and a record of the PASARR was retained in Resident 45's medical record. These deficient practices had the potential for Resident 45's mental disorder was not identified and could result in Resident 45 not receiving specialized care and/or rehabilitative services as needed. Findings: During a review of Resident 45's admission Record (AR), the AR indicated Resident 45 was admitted to the facility on [DATE] with multiple diagnoses including unspecified dementia (a progressive state of decline in mental abilities), unspecified severity, without behavioral disturbance,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a care plan (CP) for two of two sampled residents (Resident 59 and 183), by failing to: A. Revise a CP for Resident 59 after the resident sustained a fall on 12/31/2024 and was at risk for recurrent falls. B. Revise a CP for Resident 183 after the resident developed a pressure injury [PI, localized injury to the skin and or underlying tissue usually over a bony prominence as result of pressure or pressure in combination with shear (mechanical force that cause the skin to break off) and/or friction) and when Resident 183 refused to turn and be repositioned. This deficient practice had the potential to result in unmet individualized needs for Residents 59 and 183 and the potential to affect the resident's physical well-being. Findings: A. During a review of Resident 59's admission Record (AR), the AR indicated the facility admitted Resident 59 5/21/2024, and re-admitted the resident 10/18/2024, with diagnoses including psychosis (a severe mental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 activities was provided to one of two residents (Resident 62). This deficient practice had the potential to affect Resident 62's psychosocial wellbeing. Findings: During an observation on 2/5/2025 from 8:30 AM to 12:07 PM and from 12:30 PM to 3 PM, Resident 62 was in bed, lying on her back. During an interview on 2/6/2025 at 1:59 PM with the Activities Director, the Activities Director (AD) stated the facility provides one to one (1:1) activities to residents who stay inside their room and would not join group activities. The Activities Director (AD) stated the Activities Staff (AS) would conduct 1:1 room visits between 8:30-9 AM and 1:30-2 PM. The Activities Director was unable to provide proof or documentation of activities provided to Resident 62. The Activities Director stated the AS do not document activities provided to residents (in general). During the same interview, the AD stated the documentation of 1:1 room visits would…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 42), was provided care in accordance with professional standards of practice by failing to: 1. Notify Resident 42's physician when Resident 42 had multiples bowl movements and refused to take Milk of Magnesia suspension (MOM, a laxative, medication used to relieve occasional constipation) when the resident had constipation. 2. Follow Resident 42's physician's orders for Dulcolax suppository (a medication that stimulates bowel movements [bm] designed to be inserted into the anus). These deficient practices resulted in Resident 42 having multiple bm and Resident 42 feeling anxious and miserable. Resident 42 was transferred to the General Acute Care Hospital (GACH) for further evaluation. Findings: During a review of Resident 42's admission Record (AR), the AR indicated, Resident 42 was admitted to the facility on [DATE] with multiple diagnoses including unspecified intracapsular fracture (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 two of two sampled residents' (Resident 233 and Resident 59) environment remained free of accident (refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident) hazards to prevent a falls (refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force) by failing to: A. Ensure Resident 233's bed always remained in a low position. B. Ensure Resident 59 received staff assistance on 1/31/2025 to prevent Resident 59 from falling. These deficient practices had the potential for Resident 233 who was a risk for fall to sustain a fall and result in injury and resulted in Resident 59 sustaining a fall on 1/31/2025. Findings: A. During a review of Resident 233's admission Record (AR), the AR indicated, Resident 233 was admitted to the facility on [DATE] with multiple diagnoses including 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to post oxygen (02 - a colorless, odorless, tasteless gas that's essential for life) signage per facility's policy and procedure (P&P) for one of three sampled residents (Resident 233) when Resident 233 was receiving supplemental continuous oxygen. This deficient practice had the potential for an unsafe environment for Resident 233, other residents, staff and visitors due to the risk of fire related to the use of supplemental 02. Findings: During a review of Resident 233's admission Record (AR), the AR indicated, Resident 233 was admitted to the facility on [DATE] with multiple diagnoses including respiratory failure (a serious condition that makes it difficult to breathe on your own), unspecified, unspecified whether with hypoxia (low levels of oxygen in your body tissues) or hypercapnia (when you have too much carbon dioxide in your blood), shortness of breath and heart failure, unspecified. During a review of Resident 233's History and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of two sanitation buckets (bucket 1) in the kitchen had adequate amount of quaternary sanitizing solution (an ammonium solution used for sanitizing surfaces) for the disinfection of key areas in the kitchen utilized to prepare resident's food. This deficient practice placed the residents at increased risk of infections and could have impacted the health and safety of residents. Findings: During an observation on 2/3/2025 at 8:57 AM, the [NAME] (CK) checked the quaternary sanitizing solution and used a quaternary test strip for two sanitation buckets located in the kitchen. The CK placed the test strip in bucket 1 for 10 seconds. The strip indicated 100 ppm (ppm-parts per million, unit of measurements). The CK placed the quaternary test strip in bucket 2 for 10 seconds, the strip indicated 300 ppm. During an interview and record review on 2/3/2025 at 9:05 AM, with the CK, the CK stated the quaternary test strip was used to check…

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

Based on interview and record review, the facility failed to ensure a Director of Nursing (DON) attended the Quality Assurance Performance Improvement quarterly meeting. This deficient practice had the potential to affect residents' physical, mental and psychosocial well-being. Findings: During a concurrent record review of the QAPI Sign in Sheet and interview on 2/6/2025 at 5:30 PM, there was no Director of Nursing among the attendees. The Administrator stated there was no DON during the QAPI meeting om 1/24/2025. During an interview on 2/6/20255 at 5:40 PM, the Administrator stated the DON needed to be in all the QAPI meetings. The DON is the head of the nursing department, so she needs to be in the planning and monitoring nursing related services. The Administrator stated he needed to have an acting DON attend the QAPI meeting when the previous DON left. During a review of the facility's 2025 Quality Assurance and Performance Improvement Plan (QAPI), the plan indicated the department heads who had been named to the QAPI leadership team and indicated what their individual roles…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one out of 34 rooms had no more than 4 residents (room [ROOM NUMBER]) in the room. This failure had the potential to result in lack of space and privacy for the residents residing in that room. Findings: During an observation and interview on 2/6/2025 at 10:46 AM with Treatment Nurse (TN) 1, TN 1 stated there were six residents inside room [ROOM NUMBER]. During an interview on 2/6/2025 at 2:56 PM with the Administrator (ADM), the ADM stated when the ADM was first hired at the facility 8/2024, room [ROOM NUMBER] had five beds and five residents. The ADM stated the facility added the sixth bed on 1/20/2025 and admitted the sixth resident to occupy the bed on 1/21/2025. During an interview on 2/6/2025 at 4:42 PM with the ADM, the ADM stated the facility did not have a policy that indicated how many residents could be accommodated in a single room.

Based on observation, interview, and record review, the facility failed to follow the facility's policy and procedure (P&P) titled, Medication Administration: Controlled Medications, for five of five sampled residents (Resident 2, Resident 3, Resident 4, Resident 5, Resident 6) by failing to: 1. Ensure the facility's controlled medication (refers to a substance [narcotics] that is regulated by the government due to its potential for abuse and addiction) count sheets were signed after Licensed Vocational Nurse 1 (LVN 1) administered the controlled medications for Resident 2, Resident 3, Resident 4, Resident 5, and Resident 6. 2. Ensure LVN 1 signed the Medication Administration Record (MAR) after the controlled medications were administered for Resident 4 and Resident 6. These deficient practices had the potential for controlled medications to not be properly accounted for. Findings: During a concurrent observation and interview on 1/29/2025 at 1:15 pm, LVN 1 and LVN 3 were observed counting the controlled medications that were in one of the facility's medication carts (Cart 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.

Based on observation, interview, and record review, the facility failed to implement a care plan for the use of an abdominal binder (a wide band of elastic or cotton material that fits around the abdomen) for one of eight sampled residents (Resident 1). This deficient practice had the potential for Resident 1 to receive inconsistent care and services. Findings: During an observation on 1/28/2025 at 11:03 am, in the presence of Licensed Vocational Nurse 2 (LVN 2), Resident 1 was observed with an abdominal binder around Resident 1's abdomen. During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 3/13/2021 and recently admitted the resident on 12/29/2023 with diagnoses that included cerebral infarction due to thrombosis of right carotid artery (a stroke caused by a blood clot that blocks or disrupts blood flow to the brain), malignant neoplasm of colon (cancer of the large intestine), and gastrostomy status (having the presence of a gastrostomy tube [a flexible tube that delivers food, liquids, and medicine directly into…

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

Based on observation, interview, and record review, the facility failed to provide a sanitary (clean) environment to prevent the spread of infections for 3 of 13 sampled residents (Resident 5, Resident 12, and Resident 13) by failing to ensure Certified Nursing Assistant 3 (CNA 3) and Licensed Vocational Nurse 1 (LVN 1) performed hand hygiene (cleaning hands by either washing them with soap and water, or by using an alcohol-based hand sanitizer) according to the facility's Hand Washing policy and procedure (P&P). These failures had the potential to spread infection to all residents, staff, and visitors in the facility. Findings: During an observation on 12/13/24 at 12:16 pm, LVN 1 fist bumped (greeting someone by lightly tapping each other's clenched fist) with a male resident (Resident 12) in the dining room while passing out lunch trays to the residents. After LVN 1 fist bumped with the resident, LVN 1 started touching residents' trays inside the meal cart while checking residents' trays, without washing hands or using hand sanitizer first. During an interview on 12/13/24 at 12:20…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1 of 13 sampled residents (Resident 2) was provided peripherally inserted central catheter (PICC - a thin, flexible tube that's inserted into a vein in the arm and threaded into a large vein near the heart. It is used to administer intravenous (IV) fluids, blood transfusions, chemotherapy, and other drugs, and to draw blood samples) care according to the physician's order and the facility's policy and procedure. This failure had the potential for Resident 2 to develop an infection on Resident 2's PICC site and/or develop sepsis (a life-threatening blood infection). Findings: During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE] with multiple diagnoses which included cellulitis (a skin infection that causes swelling and redness) of the right lower limb and Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reduce the risk of a fall and injury hazard for Resident 1 (who had a fall with a skin tear at the facility on 7/17/24), by not providing Resident 1 with bilateral floor mats as indicated in Resdient 1's care plan and physician order. This deficient practice had the potential to placed Resident 1 at risk for recurrent falls and injury. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 4/7/24 with diagnoses including metabolic encephalopathy (a group of conditions that cause brain dysfunction), muscle weakness (a lack of muscle strength), multiple sclerosis (MS - a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of right and left knees, and abnormal posture (a chronic, involuntary, or rigid body position or movement that can indicate a severe brain or spinal cord injury). 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 interview and record review, Certified Nursing Assistant (CNA) 2 and CNA 3 failed to treat one of six sampled residents (Resident 2) with consideration, respect, and full recognition of Resident 2's dignity and individuality according to the facility's policy and procedure (P&P) titled, Resident Rights, by failing to listen and respect Resident 2's request to be turned a certain way in bed during patient care. This failure caused Resident 2 to feel degraded and feel that Resident 2 had no say about her care in the facility. Findings: During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included multiple sclerosis (long standing disease that affects the brain, spinal cord, optic nerves, and blocks messages between the brain and body), hydronephrosis (condition where one or both kidneys become stretched and swollen as a result of build-up of urine), and cerebral palsy (disorder of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to promptly (quickly/with little or no delay; immediately) notify the physician for one of six sampled residents (Resident 2) who experienced a change of condition (COC- a sudden clinically important deviation from a resident/patient's baseline in physical, behavioral, or functional domains) as indicated in the facility's policy and procedure (PP) titled, Change of Condition Reporting, by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 1 notified Resident 2's Primary Care Provider/Medical Doctor (MD) 1 promptly when LVN 1 noted a lump (growth, swelling, or mass that can appear anywhere on the body) in Resident 2's left breast on 4/17/2024 at 12:15 pm. 2. Ensure LVNs 1, 4, 5, 6, 8, 9, 10, and 11 communicated with MD 1 and clarified MD 1's recommendation to order a mammogram (X-ray [pictures of the inside of the body] examination of the breast to help detect breast cancer [a disease caused by an uncontrolled division of abnormal cells in a part of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a care plan (CP) upon a significant change of condition for one of six sampled residents (Resident 2) according to the facility's policy and procedure (P&P) titled, Care Planning, revised 1/2024, by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 1 and/or assigned licensed nurses (LVNs or Registered Nurses [RNs]) developed and implemented a CP when LVN 1 noted a lump (growth, swelling, or mass that can appear anywhere on the body) in Resident 2's left breast on 4/17/2024. 2. Ensure licensed nurses (LVNs or RNs) developed and implemented a CP when Resident 2 was found to have a suspicious for malignancy (cancer [a disease in which abnormal cells divide without control and can invade nearby tissues] breast lesion on Resident 2's left breast on 7/1/2024 and was diagnosed with infiltrating ductal carcinoma (breast cancer [disease that occurs when cells grow and divide uncontrollably, potentially invading other parts of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow the facility's policy and procedure (P&P) titled, Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment, when the facility failed to report an allegation of abuse to the California Department of Public Health (the Department) for one of three sampled residents (Resident 1). This failure violated Resident 1's rights, had the potential to compromise Resident 1's safety, and could subject Resident 1 to potential further abuse. Findings: During a review of Resident 1's admission Record (AR), the AR indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses that included other cervical disc degeneration (a condition affecting the neck's spinal discs which can lead to neck pain, headaches, and other symptoms) unspecified cervical region (made up of the cervical spine, which is the first seven vertebrae in the spine), dysphagia (difficulty swallowing), oropharyngeal phase (swallowing problems occurring in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide sufficient nursing staffing for one of three shifts (the nocturnal shift [NOC- night shift, 11 pm to 7 am]) on 08/24/2024, from 3 am to 7 am, to provide safe and timely nursing care to four of eight sampled residents (Residents 1, 3, 4, and 5). This failure resulted in Residents 1, 3, 4, and 5 to feel unsafe during the NOC shift on 08/24/2024 from 3 am to 7 am, and had the potential to delay the provision of care for the residents. Findings: 1. During a review of Resident 1's admission Record (AR), the AR indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses including peripheral vascular disease (narrowed blood vessels reduce blood flow to the arms or legs)) and muscle wasting (a weakening, shrinking, and loss of muscle caused by disease or lack of use) and atrophy (wasting away of a body part or tissue). During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and screening 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the indwelling Foley catheter (thin, sterile tube inserted into the bladder to drain urine into a bag outside the body) tubing was free from urine sediments (bacteria and white blood cells are shed into the urine) for one of one sampled resident (Resident 6). This failure had the potential for Resident 6 to receive delay in care and treatment and placed the resident at risk for urinary tract infection (UTI- infection in the urinary system). Findings: During a review of Resident 6's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (chemical imbalance in the brain caused by illness or organ dysfunction), UTI and sepsis (life-threatening complication of an infection). During a review of Resident 6's Physician Orders (PO) dated 4/8/24, the PO indicated for staff to monitor signs or symptoms of infection due to indwelling catheter use:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 1 of 10 sampled residents (Resident 7) had the call light within reach. This deficient practice had the potential to result in Resident 7 being unable to summon health care workers for assistance for care and services as needed. Findings: During a review of the admission Record (AR), the AR indicated Resident 7 was admitted to the facility on [DATE] with diagnoses included but not limited to cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), hypertension (when the pressure in your blood vessels is to high), and gastro esophageal reflux disease (stomach acid repeatedly flows back into the tube connecting your mouth and stomach). During a review of the History and Physical Examination (H&P- the most formal and complete assessment of the patient and the problem), dated 10/23/2023, the H&P indicated Resident 7 has 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.

Based on interview and record review, the facility failed to provide a dignified existence and self-determination to one of five sampled residents (Resident 1) by failing to: Ensure facility staff showered or provided a full bath (an all-over washing, as given to a person confided to bed, done with a wet sponge or washcloth rather than in a bathtub or shower than includes the washing of hair and or shaving) or sponge bath (an all-over washing, as given to a person confided to bed, done with a wet sponge or washcloth rather than in a bathtub or shower) to Resident 1 on 2/12/2024 which was a designated shower day for Resident 1. This deficient practice had the potential for Resident 1 to develop infection, skin breakdown, and suffer psychosocial (mental, emotional, social, and spiritual effects) harm. Findings: During a review of Resident 1's admission Record (AR), the AR indicated, the facility admitted Resident 1 to the facility on 2/5/2024 with diagnoses that included end-stage renal disease (ESRD- condition in which the kidneys cease functioning on a permanent basis leading 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 interview and record review, the facility failed to maintain the dignity of five of seven sampled residents (Residents 1, 20, 25, 281, and 283): a. For Resident 1, 20, and 25, facility staff failed to promptly respond to call lights (a device used by a resident to signal his or her need for assistance from staff). b. For Resident 281, facility staff failed to promptly respond to Resident 281's call light during the night, to assist Resident 281 to the toilet. c. For Resident 283, the facility failed to assist Resident 283 in getting dressed for the day, in a timely manner. These failures resulted with Resident 281 to feel miserable and like crying and for Resident 283 to feel afraid. The failures had the potential to result in Residents 1, 20, 25, 281, and 283 to feel like their concerns were unheard and feel disrespected. Findings: a. During a review of Resident 1's admission Record (AR) the AR indicated Resident 1 was admitted to the facility on [DATE] with multiple diagnoses including muscle…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medication error rate was less than 5% (percents) for one of four sampled residents (Resident 26). The medication error rate was 11.76 % due to four medication errors in a total of 34 opportunities observed during the medication administration. The facility failed to: A. Ensure Resident 26's insulin glargine (long-acting insulin [hormone that regulates blood sugar] that keeps blood sugar levels stable during periods of fasting) was properly labeled and available for administration as ordered by the physician. B. Ensure Resident 26's insulin aspart (rapid-acting insulin taken before meals that works quickly to prevent blood sugar from going too high after carbohydrates intake) was available for administration per the physician's insulin sliding scale order. C. Ensure Resident 26's Zinc sulfate (mineral that promotes skin health) was available for administration as ordered by the physician. D. Ensure Resident 26's Hydroxyzine (antiallergy medication to alleviate itching) for itching was available 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, interviews, and record review, the facility failed to ensure three of three sampled residents (Resident 26, 38, and 183) had their blood sugar (BG) levels checked and were adminitered insulin (medication used to control sugar in the blood) as indicated in the physician's orders. a. For Resident 26, during medication administration observation on 1/24/2024, insulin glargine (long-acting insulin [hormone that regulates blood sugar] that keeps blood sugar levels stable during periods of fasting) and insulin aspart (rapid-acting insulin taken before meals that works quickly to prevent blood sugar from going too high after carbohydrates intake) were not available for administration. b. For Resident 38, on 1/24/2024, the BG level was not checked prior to meals. c.For Resident 183, the BG level was not checked prior to meals and on 1/22/24, insulin aspart was administered late to Resident 183. These failures placed Residents 26, Resident 38, and Resident 183 at risk for untreated, high, or low…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 all medications were properly labeled and stored as indicated in the facility's policies and procedures (P&P): a. The facility did not properly label Resident 26's insulin glargine pen (long-acting insulin [hormone that regulates blood sugar] that keeps blood sugar levels stable during periods of fasting) in one of three medication carts (Med Cart 3). b. The facility staff did not dispose of expired Epi-Pen (life-saving medication to treat a severe allergic reactions) in one of three medication carts (Med Cart 1). c. The facility did not properly label and store in a designated locked area the discontinued medications or medications of discharged residents. These failures had the potential to lead to medication administration errors and/or drug diversion (transfer of a resident's prescribed controlled medication to another individual). Cross Reference with F759 Findings: a.During a review of Resident 26's admission Record (AR), the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure accurate documention for three of three sampled residents (Resident 38, 183, and 26) by failing to document the insulin (medication used to lower blood sugar levels) administration as soon as it was administered. This failure had to the potential result in staff and health care providers to use inacurate and insufficient resident information during care planning and a changing status, in addtion, there was a potential to show inaccurate trends in Residents 38, 183, and 26's blood sugar management. Findings: a.A review of Resident 38's admission Record indicated the facility admitted the resident on 12/11/2023, with diagnoses including type 2 diabetes mellitus (a disease that occurs when your blood sugar is too high). A review of Resident 38's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 12/15/2023, indicated the resident had intact cognition (able to make decisions of daily living). A review of Resident 38's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow infection control practices to maintain a safe, sanitary environment for three of three sampled residents (Resident 25, 1, and 181) in accordance with the facility's policies and procedures (P&P) when, a-b.the facility failed to store resident care equipment properly. On 1/22/24, there was an unlabeled bedpan stored on the floor in Resident 1 and Resident 25's shared restroom and the facility did not know which resident the bedpan belonged to. c.For Resident 181, on 1/22/24 the Director of Rehabilitation (DR) exited Resident 181's room without performing hand hygiene. These failures had the potential to result in cross contamination (process by which bacteria can be transferred from one area to another) and/or the development and transmission of disease and infection to Residents 25, 1 and Resident 181. Findings: a.During a review of Resident 25's admission Record (AR), the AR indicated Resident 25 was originally admitted 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 interview and record review, the facility failed to ensure one of three sampled residents (Resident 284), was provided with a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN, a document that informs the resident they may need to pay out of pocket for their care). This failure had the potential to result in Resident 284 to not be able to make an informed decision about Resident 284's care. Findings: During a review of Resident 284's admission Record (AR), the AR indicated Resident 284 was admitted to the facility on [DATE] with multiple diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), heart failure (condition in which the heart cannot pump enough blood to all parts of the body), and dysphagia (difficulty swallowing foods or liquids). The AR indicated Resident 284 was discharged from the facility on 11/16/23. During a review of Resident 284's Minimum Data Set (MDS, a standardized assessment and care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a comfortable environment and failed to protect resident (in general) property for two of two sampled residents (Resident 131 and Resident 26) as indicated in the facility policy and procedures (P&P), titled, Hot Water Temperatures, Controlling and Personal Belonging, Inventory of, when, a. For Resident 131, the facility staff gave Resident 131 a bed bath (an all-over wash given to a person in bed) with water that was not hot enough or comfortable for Resident 131. b. For Resident 26, Resident 26's personalized blanket went missing and the blanket was not added to Resident 26's inventory list. These failures resulted in Resident 131 to experience an uncomfortable environment and had the potential to affect Resident 131's health and safety. In addition, the failure had the potential to result in a decline in Resident 26's psychological-psychosocial well- being. Findings: a.During a review of Resident 131's admission Record (AR), the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to conduct a comprehensive and accurate assessment, for two of two sampled residents (Resident 181 and 61) when, a. For Resident 181's admission Minimum Data Set (MDS, an assessment and screening tool), dated 1/2/24, indicated Resident 181 had minimal difficulty hearing (when a person speaks softly, or a setting is noisy) when Resident 181 had difficulty hearing and was hard of hearing. b.For Resident 61, the MDS was not completed accurately. This failure resulted in inaccurate assessments of Resident 181's hearing and Resident 61 and had the potential to result in physical and psychosocial declines to Resident 181 and could potentially result in Resident 181 and 61 to not receive appropriate care and services based on the resident's preferences, goals of care, functional-health status, strengths, and needs. Cross Reference F656 Findings: a.During a review of Resident 181's admission Record (AR), the AR indicated Resident 181 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.

Based on interviews and record review, the facility failed to develop and implement a baseline care plan within 48 hours of admission for the physician's orders for medications used to treat anxiety disorder (anxiety, persistent or excessive worry about activities or events, including routine and ordinary issues), psychosis (mental condition wherein one loses some contact with reality), and major depressive disorder (depression, persistently low or depressed mood and loss of interest in activities that brought joy previously, interfering with daily life) for one of one sampled resident (Resident 131). This failure had the potential to lead to inaccurate or inconsistent provision of treatments and services to Resident 131. Findings: During a review of Resident 131's admission Record (AR), the AR indicated the facility initially admitted Resident 131 on 1/9/2024 with multiple diagnoses including fracture (partial or complete break in the bone) of the right upper arm, chronic kidney disease, cirrhosis of the liver (scarring of liver, causing permanent damage), psychosis, major…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a comprehensive plan of care for one of one sampled resident (Resident 181) when: 1. Resident 181 was hard of hearing and there were no alternative communication tools like a communication board at Resident 181's bedside as indicated in Resident 181's care plan (CP). This failure resulted in no individualized care to Resident 181 and did not maintain Resident 181's highest practical physical and mental well-being. Findings: 1.During a review of Resident 181's admission Record (AR), the AR indicated Resident 181 was readmitted to the facility on [DATE] with diagnoses that included pneumonia (infection that inflames one or both air sacs in the lungs), hypo-osmolality and hyponatremia (the metabolic consequence of excess fluid retention), and dysphagia (difficulty swallowing). During a review of Resident 181's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 1/2/24, indicated Resident 181 had moderate cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of one sampled resident's (Resident 59) care plan (CP, provides direction on the type of nursing care an individual needs that include goals of treatment, specific nursing interventions [actions, treatments, procedures, or activities designed to meet an objective] and an evaluation plan) was revised in accordance with the facility's policies and procedures (P&P) titled, Comprehensive Person-Centered Care Planning. This failure had the potential to result in Resident 59, who had a change in condition, to receive inadequate care and services. Findings: During a review of Resident 59's admission Record (AR), the AR indicated, Resident 59 was admitted on [DATE] with multiple diagnoses including muscle weakness (generalized), other abnormalities of gait and mobility, essential (primary) hypertension (a type of high blood pressure that has no clearly identifiable cause) and history of falling. During a review of Resident 59'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.

Based on observation, interview, and record review, the facility failed to ensure one of 20 sampled residents (Resident 26) was provided with activities that met the resident's interests and supported the resident's physical, mental, and psychosocial well-being. This failure had the potential to cause a decline in Resident 26's physical, mental, social, and emotional well-being. Findings: During a review of Resident 26's admission Record (AR), the AR indicated the facility initially admitted Resident 26 on 3/13/2021 with multiple diagnoses including stroke (brain damage due to blocked blood flow to the brain) with hemiplegia (paralysis of one side of the body) and muscle atrophy (reduced muscle mass due to lack of muscle use), type 2 diabetes mellitus (chronic condition wherein body does not produce enough or resists insulin [hormone that regulates blood sugar]) with long-term use of insulin, and colon cancer (growth of malignant cells in the lower end of the digestive tract). During a review of Resident 26's Minimum Data Set (MDS, a standardized resident assessment 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 observations, interviews and record review, the facility failed to provide care and services to meet the residents' physical, mental, and psychosocial needs for two of two sampled residents (Residents 181 and 185) by failing to ensure: a. Resident 181 who was hard of hearing was provided audiology (hearing) services. b. Resident 185's order for urine sample for culture and analysis was carried out as ordered by the physician. These failures had the potential to result in the delay of necessary care and services for Residents 181 and 185. Findings: During a review of Resident 181's admission Record (AR), the AR indicated Resident 181 was admitted to the facility on [DATE] with diagnoses that included pneumonia (infection in the lungs), muscle weakness, and dysphagia (difficulty swallowing). During a review of Resident 181's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 1/2/24, the MDS indicated Resident 181 had moderately impaired cognition (ability to process thoughts and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure two of two sampled residents (Resident 70 and Resident 59) were provided proper treatment to promote the prevention of pressure ulcer/injury (PU/PI, refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) development by failing to ensure the low air loss mattress (LAL, special type of mattress used for both the prevention and treatment of PU/PI) was set correctly. This failure could result in the development of PU/PI for Resident 70 and Resident 59 due to incorrect LAL setting. Findings: a.During a review of Resident 70's admission Record (AR), the AR indicated, Resident 70 was admitted on [DATE] with multiple diagnoses including type 2 diabetes mellitus (adult on-set disease characterized by high levels of sugar in the blood) and essential (primary) hypertension (a type of high blood pressure that has no clearly identifiable cause). 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 ensure, for one of two sampled residents (Resident 59), was free of accident (any unexpected or unintentional incident, which results or may result in injury or illness to a resident) hazards by failing to ensure Resident 59's bed remained in a low position when Resident 59 had a history of falls (refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force e.g., resident pushes another resident). This failure could potentially result in Resident 59 falling and sustaining injuries. Findings: During a review of Resident 59's admission Record (AR), the AR indicated, Resident 59 was admitted to the facility on [DATE] with multiple diagnoses including muscle weakness (generalized), other abnormalities of gait (how a person walks) and mobility (the ability to move or be moved freely and easily), essential (primary) hypertension (a type of high blood pressure that has…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 manage pain and follow its policy and procedure to consult physician for pain not relieved by current pain medication orders for one of two residents (Resident 185). As a result, Resident 185's pain was unrelieved. These failures caused Resident 185 physical and emotional distress and failed to maintain Resident 185's highest practical physical, mental, and psychosocial well-being. Findings: A review of Resident 185's Face Sheet indicated she was admitted on [DATE] with diagnoses that included fracture of left acetabulum (a painful injury usually caused by a high impact incident or weakened bones), enterocolitis due to Clostridium difficile (bacteria that causes inflammation of the colon), polyneuropathy (simultaneous malfunction of many peripheral nerves), and cirrhosis of the liver (chronic liver damage). A review of Resident 185's History & Physical (H&P), dated 1/13/24, indicated Resident 185 is status post (s/p) fall and has the…

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

Based on interviews and record review, the facility failed to ensure, one of one sampled resident (Resident 40), who received hemodialysis (dialysis, process of filtering the blood of an individual whose kidneys are impaired) received care and services consistent with Resident 40's care plans and the facility's policy and procedures (P&P). This failure had the potential to cause a decline in Resident 40's physiological and psychosocial well-being. Findings: During a review of Resident 40's admission Record (AR), the AR indicated the facility initially admitted Resident 40 on 3/13/2021 with multiple diagnoses including end-stage renal disease (final, permanent stage of chronic [long standing] kidney disease) with dependence on renal dialysis, hypertension (high BP, high pressure of blood pushing against the walls of arteries with normal values being less than 120/80 millimeters of mercury [mm Hg, unit of measurement of pressure]), rheumatic tricuspid valve disease (defect in the heart valve, restricting blood flow), peripheral vascular disease (narrowing of blood vessels, causing…

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

Based on observation, interview, and record review, the facility failed to ensure a system of accurate acquisition, receipt, dispensing of all routine drugs for one of 4 sampled residents (Resident 26) was in place with documentation readily available for review. This failure had the potential to lead to a decline in Resident 26's well-being due to missed medications and possible drug diversion (transfer of a resident's prescribed medication to another individual) related to unaccounted medications. Cross Reference with F759, F760, and F761. Findings: During a review of Resident 26's admission Record (AR), the AR indicated the facility initially admitted Resident 26 on 3/13/2021 with multiple diagnoses including stroke (brain damage due to blocked blood flow to the brain) with hemiplegia (paralysis of one side of the body) and muscle atrophy (reduced muscle mass due to lack of muscle use), type 2 diabetes mellitus (chronic condition wherein body does not produce enough or resists insulin [hormone that regulates blood sugar]) with long-term use of insulin, and colon cancer (growth of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 282), who received a psychotropic drug (any drug that affects brain activities associated with mental processes and behavior), was monitored for adverse consequences (unwanted, uncomfortable, or dangerous effects) as indicated in the facility's Policy and Procedure (P&P), titled, Psychotropic Drug Use. This failure had the potential to result in Resident 282 to experience adverse consequences from administration of psychotropic drugs and the potential to result in a physical decline to Resident 282. Findings: During a review of Resident 282's admission Record (AR), the AR indicated Resident 282 was admitted to the facility on [DATE] with multiple diagnoses including Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), unspecified psychosis (a mental disorder characterized by a disconnection 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, for one of three sampled residents (Resident 38), provide the Agreement To Arbitrate Disputes Related To Medical Malpractice Binding Arbitration Agreement (Binding Arbitration Agreement), in a language Resident 38 understood when the facility asked Resident 38 to enter into an agreement for binding arbitration (involves the submission of a dispute to a neutral party who hears the ca12se and makes a decision). This failure had the potential to result in Resident 38 to not be able to make an informed decision and/or his rights to be denied. Findings: During a review of Resident 38's admission Record (AR), the AR indicated Resident 38 was admitted to the facility on [DATE] with multiple diagnoses including fracture (broken bone) of unspecified lumbar vertebra (back bone), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and dysphagia (difficulty swallowing foods or liquids). 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 suspend three of eight staff (Certified Nursing Assistant 1 [CNA 1], CNA 2, and CNA 4) pending the investigation of an abuse allegation as indicated in the facility's Policy and Procedure (P&P) titled, Resident Rights - Abuse: Prevention of and Prohibition Against. This failure had the potential to result in compromised safety for all residents residing at the facility. Findings: During a review of the admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included spinal stenosis (narrowing of the spinal cord causing back or neck pain), heart failure (heart cannot pump enough blood to meet the body's needs), chronic obstructive pulmonary diseases (COPD, lung airways narrow and cause difficulty or discomfort in breathing), and abnormality of gait (walk). During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/16/2023, the MDS…

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

Based on observation, interview, and record review, the facility failed to maintain two out of two swamp coolers (a device that cools air through the evaporation of water) used to supply the kitchen with cool air in operable condition. This failure resulted in an increase of temperature in the kitchen relative to the rest of the facility potentially affecting equipment functionality (refrigeration units, etc.) and staff ' s ability to safely prepare food for residents. Findings: During an interview on 8/19/2023, at 3:20 p.m., with the Housekeeper/Maintenance (HM), the HM stated that the two swamp coolers located on the roof were not fully operational because the chillers (the portion of the unit that uses cold water to cool the air) are leaking. During an interview on 8/19/2023, at 3:33 p.m., with the Administrator, the Administrator stated that the facility was in the process of replacing the two broken swamp coolers on the roof because the two units are not operational. During an observation on 8/19/2023, at 3:57 p.m., in the Kitchen with the HM, the ambient temperature of the…

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

Based on interview and record review, the facility failed to administer medication to one of seven sampled residents (Resident 1) according to its policy and procedure by failing to ensure: 1. Morphine (controlled medication [regulated by the government] for pain) was administered to Resident 1 on 8/6/2023 at 2 pm and at 10 pm, and on 8/7/2023 at 6 am and at 2 pm. 2. The pharmacy delivered Resident 1's Morphine before the supply ran out. 3. The pharmacy replaced the Emergency Drug Supply (E-kit) as soon as the last Morphine dose was removed from the E-kit. These failures resulted in Resident 1 did not get the Morphine as prescribed by the physician and had the potential for Resident 1 to have unrelieved pain. These failure also resulted in inaccurate Medication Administration Record (MAR) for Resident 1 and had the potential for unsafe medication administration. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 5/25/2023 with diagnoses which included lung and bone cancer. During a review of Resident 1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three newly admitted sampled residents (Resident 1) was administered antibiotic medication that was started at the acute hospital before admission to the skilled nursing facility. Resident 1 was started Meropenem (an antibiotic used for the treatment of bacterial infections) 1000 milligrams (mg) thru intravenous (IV) injection every 12 hours at the acute hospital. Resident 1 was transferred to the facility on 8/3/2023, for continuation of the IV antibiotic Meropenem. Resident 1 was not administered the IV antibiotic Meropenem until 8/4/2023. This had the potential risk for the resident's bacterial infection to get worse. Findings: During a review of Resident 1's, Discharge Summary, from the acute hospital, dated 8/3/2023, indicated Resident 1 was admitted on [DATE] with left foot cellulitis (a potentially serious bacterial skin infection) with osteomyelitis (an infection in a bone) and had a transmetatarsal amputation (TMA, surgical…

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