Mesa Glen Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to keep the dumpster area free from litter and securely cover four of four large facility trash bins, as indicated in the facility's Policy and Procedure (P&P) on garbage and rubbish disposal. These deficient practices had the potential to attract vermin (animals that are harmful and carry diseases) and pests (any living thing that has a negative effect on humans) that could potentially enter the facility, affect the resident care areas, and expose the residents and staff to diseases. Findings: During a review of Resident 23's admission Record (AR), the AR indicated Resident 23 was admitted to the facility on [DATE] with diagnoses including anxiety disorder (mental health condition with persistent, excessive, and uncontrollable fear or worry that interferes with daily functioning), and major depressive disorder (a mental disorder with persistent, severe low mood, sadness, or a loss of interest in activities). During a review of Resident 23'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 promote and treat one of one sampled resident (Resident 5) with respect, privacy and dignity in accordance with facility's policy titled Dignity and Respect. This deficient practice had the potential to cause psychosocial (mental and emotional well-being) decline and low self-esteem for Resident 5.Findings: During a review of Resident 5's admission Record (AR), the AR indicated the facility admitted Resident 5 on 3/21/2026 and readmitted on [DATE] with diagnoses that included dysphagia (difficulty swallowing) and gastrostomy (GT, tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) status. During a review of Resident 5's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 3/26/2026, the MDS indicated, Resident 5 had severely impaired cognition (mental action or process of acquiring knowledge and understanding). 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 the resident's bathroom sink was repaired for one of four sampled residents (Resident 23) when Resident 23's bathroom sink did not produce freely flowing hot water.This failure had the potential to increase Resident 23's risk of physical and emotional discomfort and distress due to a lack of access to hot water. Findings: During a review of Resident 23's admission Record (face sheet), dated 5/7/2026, the face sheet indicated Resident 23 was admitted to the facility on [DATE] with diagnoses including but not limited to cervical disc disorder (the breakdown of the cushion-like pads separating the bones in the neck), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (a mental health condition that causes intense and constant feelings of worry and fear). During a review of Resident 23's History and Physical (H&P), dated 3/5/2026, the H&P indicated Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 46) was free from restraints. Resident 46 had a Wanderguard (a wearable security device used to manage and monitor residents prone to wandering or at risk of leaving the facility) without a physician's order. This failure placed Resident 46 at risk for psychological distress (an experience of emotional, mental, suffering that occurs when individuals are overwhelmed) related to the use of the Wanderguard alarm.Findings: During a review of Resident 46's admission Record (AR), the AR indicated Resident 46 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (a type of stroke that happens when blood, which carries oxygen, gets blocked from reaching a part of the brain), schizophrenia (mental illness) and dementia (a decline in mental ability severe enough to interfere with daily life). During a review of Resident 46's Minimum Data Sheet (MDS, a resident assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to revise the care plan for one of three sampled residents (Resident 64) when her care plan indicated to provide her with two conflicting diets (meals that meet daily and special dietary needs of each resident).This failure had the potential to result in Resident 64 not receiving the appropriate diet, leading to malnutrition (a condition where the body does not get the right balance of nutrients to function correctly). Findings: During a review of Resident 64's admission Record (face sheet), dated 5/7/2026, the face sheet indicated Resident 64 was admitted to the facility on [DATE] with diagnoses including but not limited to type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), cerebral infarction (stroke, loss of blood flow to a part of the brain), and hypertensive chronic kidney disease (a condition where long-term high blood pressure damages the blood vessels of the kidneys). 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.

Based on observation, interview, and record review, the facility failed to ensure non-English speaking (refers to individuals who cannot speak or understand or have difficulty speaking or understanding the English language) residents were provided with a communication device in a language that the resident understood for one of one sampled resident (Resident 105). This failure had the potential to affect Resident 105's communication with staff and had the potential for delay in the provision of care, treatment and service to the resident.Findings: During a review of Resident 105's admission Record (AR), the AR indicated the facility admitted Resident 105 on 5/1/2026 with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), dementia (a progressive state of decline in mental abilities), and anxiety (a feeling of fear, dread, or unease). During a concurrent observation inside Resident 105's room and interview on 5/5/2026 at 9:47 am with Licensed Vocational Nurse 1 (LVN 1), Resident 105 was in bed. Resident 105…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 64) was provided with bilateral quarter side rails on her bed for mobility and repositioning as ordered.This failure had the potential to cause a decline in Resident 64's mobility and independence.Findings: During a review of Resident 64's admission Record (face sheet), dated 5/7/2026, the face sheet indicated Resident 64 was admitted to the facility on [DATE] with diagnoses including but not limited to type 2 diabetes mellitus (disorder characterized by difficulty in blood sugar control and poor wound healing), cerebral infarction (stroke, loss of blood flow to a part of the brain), and hypertensive chronic kidney disease (a condition where long-term high blood pressure damages the blood vessels of the kidneys). During a review of Resident 64's History and Physical (H&P), dated 8/14/2025, the H&P indicated Resident 64 has the capacity to make her needs known. During a review of Resident 64'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 address the significant weight loss (the resident lost a large amount of weight in a short time) for one of five sampled residents (Resident 65) who had significant weight loss of 6.52 percentage (%) from 3/20/2026 to 3/29/2026. This deficient practice placed Resident 65 at risk for further weight loss. Findings: During a review of Resident 65's admission Record (AR), the AR indicated the facility admitted Resident 65 on 1/12/2026 and readmitted on [DATE] with diagnoses including acute respiratory failure with hypoxia (the resident suddenly had trouble breathing and did not get enough oxygen) and major depressive disorder (a mood disorder that caused a persistent feeling of sadness and loss of interest). During a review of Resident 65's History and Physical (H&P) dated 3/26/2026, the H&P indicated Resident 65 did not have the capacity to understand and make decisions. During a review of Resident 65's Minimum Data Set (MDS, a resident assessment tool)…

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

Based on observation, interview, and record review, the facility failed to provide residents on hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) an emergency kit (E-kit, contains the main items needed in an emergency) at the bedside for one of one sampled resident (Resident 2). This failure had the potential for Resident 2 not to receive emergency treatment from complications caused by unexpected bleeding from the hemodialysis access site. Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 3/3/2026 with diagnoses including end stage renal disease (ESRD, irreversible kidney failure) and dependence on renal dialysis (treatment for kidney failure that removes unwanted toxins, waste products and excess fluids by filtering the blood). During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool) dated 4/28/2026, the MDS indicated Resident 2 had moderately impaired cognition (ability to understand 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 implement its Policy and Procedure (P&P) on the use of bed rails/siderails (adjustable metal or rigid plastic bars attached to the bed) for one of one sampled resident (Resident 106). This failure placed Resident 106 at risk of entrapment and injury from the use of bed rails.Findings: During a review of Resident 106's admission Record (AR), the AR indicated the facility admitted Resident 106 on 5/4/2026 with diagnoses including diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), depression (a mood disorder that causes a persistent feeling of sadness, emptiness, and a loss of interest in activities), and peripheral vascular disease (PVD, a slow progressive narrowing of the blood flow to the arms and legs). During a review of Resident 106's Minimum Data Set (MDS- a resident assessment tool) dated 5/8/2026, the MDS indicated Resident 106 had intact cognition (ability to understand and process information). The MDS indicated Resident 106 required…

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

Based on interview and record review, the facility failed to conduct skills competencies upon hire for one of five sampled staff (Certified Nurse Assistant 2 [CNA 2]). This failure had the potential for the residents in the facility not to receive appropriate/safe nursing care and services from CNA 2. Findings: During a concurrent record review and interview on 5/7/2026 at 10:20 am with the Assistant Director of Staff Development (ADSD), CNA 2's employee file was reviewed. The ADSD stated CNA 2 was a full-time employee in the facility since 1/13/2026. The ADSD stated CNA 2 did not complete a skills competence upon hire. The ADSD stated skills competency should be done and completed upon hire and yearly by the Director of Staff Development (DSD). During a concurrent record review and interview on 5/7/2026 at 10:25 am with the Director of Nursing (DON), CNA 2's employee file was reviewed. The DON stated CNA 2's skills competency upon hire was not completed and validated by the DSD. The DON stated orientation skill competency should have been completed and validated by the DSD upon…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pharmacist's recommendation for Protonix (medication used to treat excessive stomach acid) oral tablet delayed release 40 milligrams (mg- unit of measurement) was acted upon for one of one sampled resident (Resident 69). This deficient practice had the potential for Resident 69 to receive unnecessary medication that could lead to adverse side effects.Findings: During a review of Resident 69's admission Record (AR), the AR indicated the facility admitted Resident 69 on 6/30/25 with diagnoses including protein/caloric malnutrition (reduced nutrients leading to changes in body composition and function), chronic kidney disease (the kidneys are damaged and gradually lose their ability to filter blood and remove waste) and gastro-esophageal reflux disease (GERD- stomach acid frequently flows back into the esophagus [ the tube that carried food from the mouth to the stomach]) without esophagitis (inflammation of the esophagus). During a review of Resident 69's History and Physical (H&P) dated 9/25/25. the H&P indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prevent two medication errors out of 28 observed opportunities, yielding a facility medication error rate of 7.14 percent. The Licensed Vocational Nurse (LVN) crushed and administered two medications that should not be crushed for one out of eight sampled residents (Resident 9). These failures increased the risk for the medications to not work as intended, potentially leading to Resident 9 having uncontrolled seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). Findings: During a review of Resident 9's admission Record (face sheet), dated 5/7/2026, the face sheet indicated Resident 9 was initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including but not limited to epilepsy (a brain condition that causes recurring seizures), chronic obstructive pulmonary disease (a chronic lung disease causing difficulty in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prevent significant medication errors for one of eight sampled residents (Resident 9) when lamotrigine (a medication used to prevent seizures (a sudden, uncontrolled disturbance in the brain which can cause jerking, blank stares, and loss of consciousness)) extended release (ER) tablets were crushed prior to administration. These failures increased the risk for the medication to not work as intended, potentially leading to Resident 9 having uncontrolled seizures.Findings: During a review of Resident 9's admission Record (face sheet), dated 5/7/2026, the face sheet indicated Resident 9 was initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including but not limited to epilepsy (a brain condition that causes recurring seizures), chronic obstructive pulmonary disease (a chronic lung disease causing difficulty in breathing), and parkinsonism (a group of movement disorders with symptoms such as tremors, slow…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 clinical records in accordance with acceptable professional standards of practice for one of one sampled resident (Resident 5) by failing to accurately assess Resident 5's Fall Risk Evaluation (FRE- method of assessing a patient's likelihood of falling) upon admission. This deficient practice had the potential to negatively impact on Resident 5's delivery of services. Findings: During a review of Resident 5's admission Record (AR), the AR indicated the facility admitted Resident 5 on 3/21/2026 and readmitted on [DATE] with diagnoses that included dysphagia (difficulty swallowing) and gastrostomy (GT, tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) status. During a review of Resident 5's FRE dated 3/21/2026, the FRE indicated Resident 5 was assessed as low risk for falls due to intermittent confusion and being bedbound. Resident 5's FRE was not assessed 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 observation, interview, and record review, the facility failed to maintain a safe and secure handrail located in one of one facility hallways at the North Station of the facility building. This deficient practice placed the residents at risk of injury. Findings: During an observation of the facility's handrail located in the hallway at the North Station on 5/6/26 at 8:14 AM, the handrail was not firmly secured to the corridor wall. During an observation and interview with the Director of Nursing (DON) on 5/6/2026 at 10:43 AM, the DON stated the handrail along the wall located in the hallway of the North Station was not secured to the wall. The DON stated if the handrail was not secured, and if a resident was using it, it could cause the resident to lose balance causing a fall. The DON stated the handrail should be secured to keep the residents safe and prevent harm. The DON stated the Maintenance Supervisor (MS) was responsible for maintaining the facility in good condition and safe for the residents. During an observation and interview with the MS on 5/7/2026 at 8:12 AM,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents' room was free from pests (any living organism such as bugs or rodents that can transmit disease) for two of four sampled residents (Resident 23 and 64) when a bug was found in Resident 23 and 64's shared room. This failure had the potential to increase Resident 23 and 64's risk of infection and emotional distress.Findings: During a review of Resident 23's admission Record (face sheet), dated 5/7/2026, the face sheet indicated Resident 23 was admitted to the facility on [DATE] with diagnoses including but not limited to cervical disc disorder (the breakdown of the cushion-like pads separating the bones in the neck), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (a mental health condition that causes intense and constant feelings of worry and fear). During a review of Resident 23's History and Physical (H&P), dated 3/5/2026, 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 interview, and record review, the facility failed to ensure one of three sampled residents' (Resident 5's) medical record was complete when documentation regarding assisting Resident 5 with dinner and providing oral hygiene to Resident 5 on 2/2/2026 evening shift (3 PM to 11 PM) and providing Resident 5 oral hygiene on 2/3/2026 night shift (11 PM to 7 am) was not found in Resident 5's medical record.This failure resulted in incomplete documentation in Resident 5's medical record and had the potential for Resident 5 not to receive necessary services and adequate care.During a review of Resident 5's admission Record (AR), the AR indicated the facility originally admitted Resident 5 on 10/4/2022 and readmitted on [DATE] with diagnoses which included primary arthritis (a degenerative joint disease, mainly affects joints in hands, knees, hips and spine), dementia (a progressive state of decline in mental abilities), and gastro-esophageal reflux disease (a condition when stomach acid flows back into 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 ensure infection control practices were followed to prevent the transmission of disease and infection for two of three sampled residents (Residents 1 and 2) when: a. Residents 1 and 2 took a shower in the shower room next to the facility's dining room while the shower drain was clogged.b. Facility staff failed to empty Resident 1's 3 full urinals hanging on the foot of Resident 1's bed. These failures had the potential to result in the spread of infections among the residents (in general) residing at the facility.(Cross reference F584)a1. During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 11/5/2025 with diagnoses including anorexia nervosa (an eating disorder defined by restriction of energy intake relative to requirements), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and anxiety disorder (mental health disorder characterized by…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 be adequately equipped to allow residents (in general) to call for staff assistance, when:One of three sampled residents (Resident 2) did not have a functioning call light (a device used by a resident to signal the need for assistance) when taking a shower in the shower room next to the facility's dining room.One of three of the facility's shower room (across from the South Nurses' Station) call light pull cord did not reach down to the ground.These failures had the potential for residents to experience harm if residents were unable to alert staff during an emergency. During a review of Resident 2's AR, the AR indicated the facility admitted Resident 2 on 10/14/2020 and readmitted Resident 2 on 1/25/2026 with diagnoses including cellulitis (a spreading skin infection) of both legs, lack of coordination, and hypertension (high blood pressure).During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 was moderately…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure infection control practices were followed to prevent the transmission of disease and infection for two of three sampled residents (Residents 1 and 2) when: Residents 1 and 2 took a shower in the shower room next to the facility's dining room while the shower drain was clogged. Facility staff failed to empty Resident 1's 3 full urinals hanging on the foot of Resident 1's bed.These failures had the potential to result in the spread of infections among the residents (in general) residing at the facility.(Cross reference F584)a. During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 11/5/2025 with diagnoses including anorexia nervosa (an eating disorder defined by restriction of energy intake relative to requirements), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and anxiety disorder (mental health disorder characterized by feelings…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 administer physician ordered medication to one of three sampled residents (Resident 1) on 3/13/2026 and 3/14/2026. This failure had the potential to result in Resident 1 experiencing itching and dryness to the face. During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 11/5/2025 with diagnoses including anorexia nervosa (an eating disorder defined by restriction of energy intake relative to requirements), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities).During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 2/6/2026, the MDS indicated Resident had no impairment in cognitive skills (ability to make daily decisions). The MDS indicated Resident 1 was dependent (helper does all the effort) on staff for putting on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure five of 35 sampled staff (Licensed Vocational Nurse [LVN] 1, LVN 3, Care Coordinator [CC] 1, Treatment Nurse [TN] 2, and the Hairdresser [HD]) followed state regulations by failing to wear identification name badges while on duty.This failure had the potential for residents (in general) not to know who was providing care for the residents (in general). a. During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 11/5/2025 with diagnoses including anorexia nervosa (an eating disorder defined by restriction of energy intake relative to requirements), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities).During a review of Resident 1's Minimum Data Set (MDS, a resident assessment…

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

Based on observation, interview, and record review, the facility failed to ensure that hot foods were maintained at a temperature greater than 140 Fahrenheit (Fahrenheit [F], a unit of temperature) during meal service for four of four food items that the residents receiving during mealtime at the facility. This deficient practice had the potential to result in rapid growth of bacteria that can cause foodborne illness and can lead to insufficient meal intake and wight loss due to cold or improperly heated food.Findings: During a test tray observation on 3/16/2026 at 12:25 PM with the Dietary Supervisor (DS), the following food temperatures were recorded: pasta at 105 F, turkey and sauce at 105 F, and green beans at 120 F. During a test tray observation on 3/16/2026 at 12:35 PM in the presence of the DS, temperatures were rechecked and recorded as follows: pasta at 105 F, turkey at 105 F, and green beans at 110 F. During a concurrent observation and interview on 3/16/2026 at 12:35 PM, the DS stated that the facility has been experiencing issues with a malfunctioning plate warmer. 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 provide supervision to prevent accidents for two of two sampled residents (Resident 1 and 2) by failing to:a. Follow the physician's order for one to one (1:1 - an intervention where a dedicated staff member provides continuous direct monitoring of a resident) supervision for Residents 1 and 2.b. Not leave Residents 1 and 2 unattended in accordance with the residents' care plan. These deficient practices had the potential to result in harm that could lead to serious accidents/injury for Residents 1 and 2. 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 including hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following cerebral infarction (type of ischemic [deficient supply of blood] stroke [sudden death of brain cells in a localized area due to inadequate blood flow] resulting 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 observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) was free from physical restraints (any manual method, physical or mechanical device, equipment, or material attached or adjacent to the resident's body that cannot be removed easily by the resident and restricts the resident's freedom of movement or normal access to his/her body). Resident 1's bed was placed against the wall on the left side and a geriatric chair (Geri Chair, a large, padded and mobile reclining chair that prevents a resident from rising) was placed on the right side of Resident 1's bed. The facility did not have a physician's order for the use of Geri Chair for Resident 1. This deficient practice limited Resident 1's mobility, violated Resident 1's right and had the potential to cause physical and/or psychological (mental) harm to Resident 1.Cross Reference: F689 Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted 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 interviews and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) in accordance with the facility's Policy and Procedure (P&P) titled, Abuse Prevention/Prohibition, and Resident Rights for one of four sampled residents (Resident 4) when Resident 3 hit Resident 4 on the back of the head on 1/19/2026. This failure resulted in Resident 4 being subjected to physical abuse by Resident 3 while under the care of the facility. Findings: Cross Reference: F656 During a review of Resident 3's admission Record (AR), the AR indicated the facility admitted Resident 3 on 4/27/2025 and re-admitted on [DATE] with diagnoses including paranoid schizophrenia (a mental illness that is characterized by disturbances in thought) and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 3's Situation Background Assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to implement timely and individualize the care plan interventions to address a resident's known history of aggressive behaviors for one of four sampled residents (Resident 3). This deficient practice placed the residents at risk for physical harm, psychological distress, and/or a decline in overall well-being.Findings: During a review of Resident 3's admission Record (AR), the AR indicated the facility admitted Resident 3 on 4/27/2025 and re-admitted on [DATE] with diagnoses including paranoid schizophrenia (a mental illness that is characterized by disturbances in thought) and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 3's Situation Background Assessment Recommendation (SBAR-a standardized communication tool used in healthcare to convey resident's status, especially during emergencies or handoffs) Communication Form dated 8/8/2025, the SBAR indicated that…

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

Based on observation, interview and record review, the facility failed to ensure current staffing information was posted in a prominent place readily accessible to residents, staff, and visitors on a daily basis at the beginning of each shift. This deficient practice resulted in posting inaccurate staffing information.During an observation on 1/2/26 at 12:08 PM, there was a posting titled Census and Direct Service Hours Per Patient Day in front of Nursing Station 1 near entrance lobby. The date on the posting was 12/31/25. During an interview on 1/2/26 at 12:10 PM, the Director of Nursing (DON) stated the posting was not current because the facility's Director of Staff Development had resigned and the facility staff who was responsible for posting the staffing information did not come to work due to personal circumstances. During an interview on 1/2/26 at 1 PM, Certified Nursing Assistant (CNA) 1 stated CNA 1 had been responsible for making the posting. CNA 1 stated there is a computer program where CNA 1 would enter the hours for the licensed nurses and CNA's and the program 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 reevaluate and update care plan interventions to address resident's hoarding and the potential for accident hazards for one of five sampled residents (Resident 2).This deficient practice had the potential to place Resident 2 at increased risk for tripping and falling hazards, unsanitary environmental conditions, and fire safety violations. Cross Reference: F689Findings:During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was initially admitted to the facility on [DATE] and then readmitted on [DATE] with diagnoses that included bilateral primary osteoarthritis of knee (a condition where both knees experience inflammation and degeneration of the cartilage, the protective layer that cushions the joints), COPD (Chronic Obstructive Pulmonary Disease, a chronic lung disease causing difficulty in breathing), anxiety disorder (a group of mental health conditions characterized by excessive and persistent worry, fear,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of five sampled resident's (Resident 2) environment/room remained free of accident hazards and clutter. This deficient practice placed Resident 2 at risk for falls, and injury due to excessive clutter surrounding Resident 2's bed. Cross Reference: F656Findings:During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was initially admitted to the facility on [DATE] and then readmitted on [DATE] with diagnoses that included bilateral primary osteoarthritis of knee (a condition where both knees experience inflammation and degeneration of the cartilage, the protective layer that cushions the joints), COPD (Chronic Obstructive Pulmonary Disease, a chronic lung disease causing difficulty in breathing), anxiety disorder (a group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can interfere with daily functioning), and personality disorder (a 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 maintain a safe and sanitary ice and water handling practices to prevent contamination and the potential for waterborne illness for one of one ice machine serving the facility. This deficient practice had the potential to expose residents to unfiltered ice and water, which can harbor bacteria (Listeria, a bacterium), mold, and other contaminants, posing serious health risks and the potential for illness. During an observation on [DATE] at 1:05 p.m. in the facility kitchen with the Dietary Manager (DM), an expired water filter, dated [DATE], was observed connected to the icemaker. During an observation and concurrent interview with the Dietary Manager (DM) on [DATE] at 1:14 p.m. in the kitchen, DM stated he was new and was unsure when the water filter needed to be changed for the icemaker. Reviewed a log sheet on the side of the icemaker with DM. Observed the log was dated December, but no year was indicated. During an observation with 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 to develop and implement a care plan for one of three sampled residents (Resident 2) regarding the use of rollator walker (an assistive device designed to aid individual with walking difficulties that requires proper training and instruction for safe use to prevent falls and injuries). This deficient practice placed resident at risk for fall and injuries. On 11/27/2025, Resident 2 fell while attempting to get up from the rollator walker and sustained a left acute humeral neck fracture (a break in the humerus [the long bone in the upper arm, running from the shoulder to elbow] bone of the left arm). During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis that included end-stage renal disease (ESRD, permanent stage of kidney disease when kidneys can no longer support body's needs) with hemodialysis (HD, a life-sustaining medical treatment that filters waste, toxins,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 adequate supervision to one of three sampled residents (Resident 1) when Resident 1 exited the building without the facility's knowledge on 10/22/2025.This failure placed Resident 1 at risk of an accidental injury while outside the facility's premises without staff supervision.Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 4/3/2025, with diagnoses including seizures (a sudden, uncontrolled electrical disturbance in the brain) and depression (a mental health condition characterized with persistent feelings of sadness, loss of interest in activities, and a decrease in energy that affects a person's daily functioning). During a review of Resident 1's provider's Progress Note, dated 4/16/2025, the provider's Progress Note indicated Resident 1 had fluctuating capacity to make medical decisions. During a review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 10/7/2025, the MDS indicated the cognitive (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 promptly respond to call lights (a 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 three of five sampled residents (Residents 1, 4, and 6) according to the facility's Policy and Procedure (P&P) titled, Dignity, revised February 2021.This failure had the potential to result in residents (in general) feeling like their concerns were unheard and to feel frustrated.(Cross Reference F552)a. During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 10/4/2022 with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and hypertension (high blood pressure). 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, the facility failed to ensure an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) was obtained by the ordering healthcare provider for one of five sampled resident (Resident 1). This failure had the potential to result in Resident 1 receiving medication against Resident 1's wishes. (Cross Reference F550)Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 10/4/2022 with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and hypertension (high blood pressure). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 10/20/2025, the MDS indicated Resident 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 1) when on 9/2/2025, Registered Nurse 1 (RN1) threw a cup of juice on Resident 1's face.This failure resulted in Resident 1 being subjected to physical abuse by RN 1 while under the care of the facility. Resident 1 cried and did not answer how Resident 1 felt when RN 1 threw water on Resident 1's face. Findings: During a record review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted on [DATE] with diagnoses including intellectual disability (term used to describe a person with certain limitations in cognition [process of acquiring knowledge] and other skills including communication and self-care), Schizoaffective Disorder Bipolar Type (a mental condition that causes both a loss of contact with reality and mood problems) and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an incident of physical abuse for one of three sampled residents (Resident 1) within two hours to the California Department of Public Health in accordance with the facility's Policy and Procedure (P&P) titled, Abuse Reporting and Investigation.This failure violated Resident 1's right and had the potential for delay in abuse investigation and continued to expose Resident 1 to further physical abuse.Findings: During a record review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted on [DATE] with diagnoses including intellectual disability (term used to describe a person with certain limitations in cognition [process of acquiring knowledge] and other skills including communication and self-care), Schizoaffective Disorder Bipolar Type (a mental condition that causes both a loss of contact with reality and mood problems) and Unspecified Anxiety Disorder (excessive and persistent worry and fear that significantly…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 treat two of four sampled residents (Residents 8 and 14) with dignity by failing to:a. Ensure Staff did not stand over Resident 8 while assisting the resident to eat.b. Ensure Activity Assistant (AA) 1 did not refer to Resident 14 as a Feeder.These failures had the potential to result in Residents 8 and 14 to feel disrespected which could result in impairing Residents 8 and 14's sense of wellbeing and feelings of self-esteem.(Cross Reference F580, F689, and F755). Findings: a. During a review of Resident 14's admission Record (AR), the AR indicated the facility admitted Resident 14 on 7/31/2024 with diagnoses including adult failure to thrive (a decline in older adults that manifests as a downward spiral of health and ability), hypertensive (high blood pressure) heart disease with heart failure (condition in which the heart cannot pump enough blood to all parts of the body), and dementia (a group of thinking and social symptoms that interferes with daily functioning). During a review of Resident 14's “Minimum…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 environment remained free of accident hazards and/or provided adequate supervision for three of 11 sampled residents (Residents 6, 9, and 15) by failing to: a. Ensure Resident 15's assigned 1:1 sitter (S1) (1:1 Sitter, facility staff who provides constant, one-to-one observation for a resident who is at risk of falls, self-harm, or other dangers due to a medical or cognitive condition) S1 was not looking at S1's personal phone for four minutes instead of watching Resident 15. S1 was sitting inside the facility while Resident 15 was sitting outside in the facility patio. b. Ensure to have an interdisciplinary team meeting (IDT- brings together professionals from various disciplines to develop a shared, comprehensive understanding and plan for a patient's needs, ensuring coordinated care across different areas like physical, emotional, social, and clinical aspects) post fall for two of eleven sampled residents (Resident 6 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 the nurse staff followed the facility's Administering Medications policy and procedure (P&P) by failing to:a. Administer medications in a timely manner for one of three sampled residents (Resident 6).b. Initial the resident's Medication Administration Record (MAR) after giving each medication and before administering the next ones for one of three sample residents (Resident 5).c. Ensure LVN 2 and LVN 5 documented that they administered Resident 4's medications before administering medications to another resident. Resident 4 did not receive Resident 4's scheduled medications on the evening of 8/12/2025. These deficient practices had the potential to place Resident 6 at risk of not receiving the optimal therapeutic effect (desirable and beneficial effects resulting from a medical treatment) of the medication, which had potential to impair Resident 6's wellbeing and delayed medication administration documentation for Resident 5.(Cross…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the doorknob and door of residents' room for three of three sampled residents (Residents 11, 16, and 17) was cleaned daily. This failure had the potential for residents to become sick by contacting germs (microscopic bacteria, viruses, fungi, and protozoa that can cause disease) from the dirty doorknob.Findings:During a review of the facility's, Midnight Census Report (Census), dated 8/29/2025. The Census indicated Residents 11, 16, and 17 resided in Room (RM) A. During a review of Resident 11's admission Record (AR), the AR indicated the facility admitted Resident 11 on 3/13/2025 and readmitted Resident 11 on 5/16/2025 with diagnoses including metabolic encephalopathy (brain disease that alters brain function or structure), chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), and bipolar disorder (a mental illness that causes unusual shifts in a person's mood).During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their Change in a Resident's Condition or Status policy and procedure to notify one of three sampled residents (Resident 7's) doctor of Resident 7's weight loss on 7/1/2025.These failures had the potential to result in Resident 7 to not receive treatment to address Resident 7's weight loss which could negatively affect Resident 7's health and wellbeing. (Cross Reference F550, F689, and F755)Findings:During a review of Resident 7's admission Record (AR), the AR indicated Resident 7 was admitted to the facility on [DATE] with diagnoses including multiple fractures (broken bone) of ribs, hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time), urinary tract infection (UTI- an infection in the bladder/urinary tract), and protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function).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.

Based on observation, interview and record review, the facility failed to honor the privacy (a resident's right to be free from observation including the resident's private space) and confidentiality (safeguarding the content of information including video, audio, or other computer stored information from unauthorized disclosure) of one of one sampled resident (Resident 13) when a video recording (Video 1) of Resident 13's room was posted to TikTok (a social media app where people create and share short videos).This failure resulted in the violation of Resident 13's right to privacy and confidentiality and had the potential to result in Resident 13 experiencing emotional distress and feelings of decreased self-worth.Findings:During a review of Resident 13's admission Record (AR), the AR indicated the facility originally admitted Resident 13 on 3/4/2025 and readmitted Resident 13 on 6/27/2025 with diagnoses including hereditary (a disease passed down from a person's parents) and idiopathic (a disease of unknown cause) neuropathy (nerve damage or disease leading to pain, numbness,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of four Residents, Resident 22, was provided an accurate comprehensive admission assessment. This deficient practice resulted in delayed interventions for pain from a red and swollen right hand and forearm and services accommodating to Resident 22's cognitive state and blindness. Findings:During a review of Resident 22's admission Record (AR), the AR indicated that Resident 22 was admitted to the facility on [DATE], with multiple diagnoses including Unspecified dementia and legal Blindness.During a review of Resident 22's Care Plan Report (CP), dated 8/25/2025, the CP indicated that Resident 1 was to have a wanderguard placed on the left wrist for safety, with an initiated date one day after admission on [DATE].During a review of Resident 22's N ADV Clinical admission Note (NACAN), dated 8/25/2025, the NACAN indicated Resident 4 is confused, and did not require any special care and had no safety concerns.During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide one of one sampled resident (Resident 1) with behavioral health care and services for the treatment of Resident 1's emotional, mental, and drug abuse (a disease that affects a person's brain and behavior and leads to an inability to control the use of a legal or illegal drug or medication) by failing to: Identify goals and nursing interventions when Resident 1 had cannabis (marijuana, a mind-altering drug) abuse, anxiety (nervousness), and depression (persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities) would leave the facility on out on pass (OOP, temporary permission of a resident to leave the facility in a specified time) unsupervised, without OOP orders from Resident 1's Physician (MD 1). This deficient practice resulted in Resident 1 continuing to go OOP unsupervised and without MD 1's orders and had the potential to result in serious injury or harm to Resident…

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

Based on interview and record review, the facility failed to promptly (quickly/timely) notify one of four sampled residents (Resident 1) Primary Care Physician/Medical Doctor (MD) 1 of Resident 1's unwitnessed fall (move downward, typically rapidly and freely without control, from a higher to a lower level) that occurred in Resident 1's in Resident 1's bathroom on 7/16/2025 at 11 pm, and of Resident 1's complaint of back pain after the fall, in accordance with the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, by failing to ensure:1. Licensed Vocational Nurse (LVN) 1 notified MD 1 on 7/16/2025, when Certified Nurse Assistant (CNA) 1 notified LVN 1 of Resident 1's unwitnessed fall in the bathroom on 7/16/2025 at 11 pm.2. Registered Nurse (RN) 1 notified MD 1 on 7/17/2025, when LVN 1 notified RN 1 of Resident 1's unwitnessed fall in Resident 1's bathroom on 7/16/2025 at 11 pm and Resident 1's complaint of back pain after the fall.3. RN 2 notified MD 1 on 7/17/2025, after RN 2 received information regarding Resident 1's unwitnessed fall on…

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

Based on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Signing Residents Out, for one of four sampled residents (Resident 4) when Resident 4, who did not have a physician's order to leave the facility was allowed to leave the facility with Resident 4's responsible party (RP, a person who is responsible for guiding, informing, and assisting the resident regarding their care) on 6/15/2025 without Resident 4's medications.This failure had the potential to put Resident 4 at risk for serious injury, harm, and/or death due to not receiving diabetic medication (medication used to treat diabetes mellitus [disease that results in too much sugar in the blood due to the body's inability to process carbohydrates [one of the basic food groups]) and seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) medication.During a review of Resident 4's admission Record (AR), the AR indicated the facility admitted Resident 4 on 12/19/2024 with diagnoses which…

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

Based on interview and record review the facility failed to administer pain medication to one of four sampled residents (Resident 1) when Licensed Vocational Nurse (LVN) 1 did not administer any pain medication to Resident 1 on 7/17/2025 at 12:30 am, after Resident 1 complained of back pain after Resident 1 fell on 7/16/2025.This failure had the potential for Resident 1 to have unrelieved pain which could affect Resident 1's overall health and quality of life. During a review of Resident 1's Face Sheet (FS), the FS indicated, the facility admitted Resident 1 on 7/15/2024, with diagnoses which included arthritis (a condition characterized by joint pain, stiffness, and inflammation) on multiple areas of the body.During a review of Resident 1's History and Physical (H&P, physician clinical evaluation and examination of resident), dated 7/16/2024 the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 6/15/2025, the MDS indicated Resident 1 was dependent (helper does all the…

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

Based on interview and record review, the facility failed to promptly identify signs and symptoms (S/S, ways the body lets a person know that a person is sick) of a urinary tract infection (UTI- an infection in the bladder/urinary tract) for one (1) of three (3) sampled residents (Resident 1) when the facility did not monitor Resident 1's vital signs (VS, measurements of the body's basic functions, such as heart rate, breathing rate, blood pressure, and temperature) every shift according to Resident 1's care plan (CP) for UTI, dated 1/23/2025.This failure resulted in Resident 1 being transferred to General Acute Hospital (GACH) 1 and being admitted to GACH 1 with UTI and sepsis (a life-threatening blood infection).During a review of Resident 1's admission Record (AR), the AR indicated facility admitted Resident 1 on 12/23/2024 with diagnoses including encephalopathy (any disease or disorder that affects the function or structure of the brain), dementia (a general term for a decline in mental ability severe enough to interfere withs daily life), and anxiety (a group of mental health…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents have the right to be free from verbal and mental abuse for one of three sample residents (Resident 8). These deficient practices resulted in residents being subject to neglect, verbal, mental and physical abuse. Findings: During a review of Resident 8's admission Record (Face Sheet), the facility admitted Resident 8 on 6/10/2025 with diagnoses including hyperlipidemia (a condition in which there are high levels of fat particles in the blood), and mood disorder. During a review of Resident 8's History and Physical (H&P), dated 6/12/2025 indicated, Resident 8 does not have the mental capacity to make medical decisions. During an observation on 6/20/2025 at 2:00 PM in Resident 8 room, Resident 8 was calm, cooperative, and appropriately groomed. No visible injuries were noted. No signs of distress or behavioral changes were observed. During an interview on 6/20/2025 at 2:00 PM with Resident 8, Resident 8 was alert and oriented to person, place, and time. Resident 8 acknowledged there had been…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview and record review, the facility failed to report the resident- to- resident altercation to the State Survey Agency (SSA), the state Ombudsman (advocates for residents of nursing homes, board and care homes and assisted living facilities), within two (2) hours after the allegation of verbal abuse (the harmful use of language to control, intimidate or hurt someone. It can include behavior such as name-calling, belittling, or using controlling or threatening language) for one of three sampled residents (Resident 1) in accordance with the facility's policy and procedure [NAME], Abuse Reporting and Investigation. This deficient practice placed violated Resident 1's right and had the potential for delayed in abuse investigation and actual physical abuse (intentional bodily injury to a person, for example slapping, pinching, choking, kicking, shoving). Findings: a. During a review of Resident 1's admission Record (AR), the AD indicated the resident 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 to provide an environment free from abuse for one of four sampled residents (Resident 2). This failure resulted in Resident 2 being subjected to physical abuse by Resident 1. Resident 2 sustained a laceration (a torn or jagged wound, a break in the skin or other tissue, often caused by blunt force or sharp objects) on the left eyebrow that required examination and cleaning at the General Acute Care Hospital (GACH 1). Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility readmitted Resident 1 on 2/1/25 with diagnoses including Huntington's disease (inherited condition when nerve cells in the brain break down over time), unspecified dementia with psychotic disturbance (a chronic condition that causes a gradual decline in cognitive abilities, such as thinking, remembering, and reasoning with some loss of contact with reality,) and schizophrenia (a serious mental disorder in which people interpret reality abnormally, may…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 allow communication with persons outside the facility when Receptionist 1 did not notify Resident 1of incoming phone calls. This failure had the potential for Resident 1 to not receive important communication and worsen Resident 1's depression (a persistent mood disorder characterized by a pervasive feeling of sadness, loss of interest in activities, and difficulty with thinking, memory, and sleep). 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 of hypertensive heart disease without heart failure (refers to heart problems caused by high blood pressure, where the heart is working harder but not necessarily experiencing the symptoms of heart failure) and depression (a mental health disorder characterized by sadness, loss of interest, and other symptoms that impact daily life). The AR indicated Family Member (FM) 1 was Resident 1 ' s responsible party.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a care plan was developed and implemented for one of two sampled residents (Resident 1) who had a diagnosis of hypertensive heart disease without heart failure (refers to heart problems caused by high blood pressure, where the heart is working harder but not necessarily experiencing the symptoms of heart failure). This failure had the potential for Resident 1 to experience orthostatic hypotension (a condition where blood pressure drops significantly when a person stands up from a sitting or lying position) from not being monitoring for blood pressure (BP-the force exerted by blood against the walls of the arteries as it circulates throughout the body) as ordered by Resident 1's physician. Cross Reference: F684, F726, and F842 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 of hypertensive heart disease without heart failure (refers to heart…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one of two sampled residents (Resident 1) was monitored for blood pressure (BP- the force exerted by blood against the walls of the arteries as it circulates throughout the body) on 3/8/2025 as ordered by Resident 1' s primary physician. This failure had the potential for Resident 1's BP to be low (hypotension [HTN]- a condition where the force of blood pushing against artery walls is too low). Cross Reference: F656, F726, and F842 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 of hypertensive heart disease without heart failure (refers to heart problems caused by high blood pressure, where the heart is working harder but not necessarily experiencing the symptoms of heart failure) and depression (a mental health disorder characterized by sadness, loss of interest, and other symptoms that impact daily life). During a review of Resident 1 ' s 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 interview and record review the facility failed to ensure Licensed Vocational Nurse (LVN) 4 and Registered Nurse (RNs) had the competency (the capability to apply or use the knowledge, skills, and abilities required to successfully perform tasks in the work setting) to follow through with one of two sampled residents (Resident 1) physician orders blood pressure assessment. This failure had the potential for Resident 1 BP to be low (hypotension [HTN]- a condition where the force of blood pushing against artery walls is too low). Cross Reference: F656, F684, and F842 Findings: During a review of Resident 1 ' s admission Record (AR), dated 4/15/2025, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including toxic encephalopathy (brain dysfunction caused by exposure to harmful substances) and depression (a mental health disorder characterized by sadness, loss of interest, and other symptoms that impact daily life). The AR indicated Family Member (FM) 1 was 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 the residents and/or responsible parties (RP) were provided information regarding the resident's right to formulate an Advance Directive (AD, a written instruction, such as a living will or durable power of attorney for health care, recognized under State law relating to the provision of health care when the individual is incapacitated) and the resident's Physician Orders for Life-Sustaining Treatment (POLST- medical form that documents a patient's wishes regarding end-of-life care) was accurate and complete for seven of seven sampled residents (Residents 5, 6, 11, 35, 37, 41, and 75). This deficient practice had the potential to result in Residents 5, 6, 11, 35, 37, 41, 75 receiving unwanted care and treatment and/or unnecessary life-sustaining treatment. Findings: a. During a review of Resident 6's admission Record (AR), the AR indicated Resident 6 was readmitted to the facility on [DATE], with diagnoses that included fracture (crack or break…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a safe, clean, homelike environment for three of three sampled residents (Residents 11, 63, and 68) by failing to: a. Ensure Resident 11's personal wheelchair was reported as missing to the Social Services Director (SSD). b. Ensure Resident 63's toilet seat was fully attached to the toilet bowl. c. Ensure Resident 68's patio door was able to fully close. These failures had the potential to result in negatively impacting Resident 11, 63 and 68's quality of life and had the potential for an unsafe environment for the residents Findings: a. During a review of Resident 11's admission Record (AR), the admission Record indicated Resident 11 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder (MDD, persistent feelings of sadness, loss of interest in activities, and difficulty functioning in daily activities for at least two weeks). During a review of Resident 11's Resident's Clothing and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a comprehensive plan of care for four of four sampled residents (Resident 5, Resident 47, Resident 68, and Resident 196). These failures resulted in Residents 5, 47, 68, and 196 not receiving individualized care and had the potential for Residents 5,47, 68, and 196 not able to maintain the residents' highest practical physical and mental well-being. Findings: a. During a review of Resident 5's admission Record (AR), the AR indicated Resident 5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included end stage renal disease (kidneys lose the ability to remove waste and balance fluids), Type 1 diabetes mellitus (pancreas makes little or no insulin\ leading to high sugar levels), and non-ST elevation myocardial infarction (partial blockage of coronary [heart] artery). During a review of Resident 5's Minimum Data Set (MDS, a resident assessment tool), dated 12/24/24, the MDS indicated Resident 5 was cognitively…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care in accordance with professional standards of practice for two of three sampled residents (Residents 27 and 49) by failing to: a. Ensure Resident 27's Peripherally Inserted Central Catheter (PICC, thin flexible tube that is inserted into a view in the upper arm to give fluids and other medications) line and Midline (long, thin, flexible tube that is inserted into a large vein in the upper arm) were flushed (to fill with normal saline [NS, mixture of salt and water concentration] solution to prevent clotting when not in use) per the Medical Doctor (MD) order. b. Ensure Treatment Nurse (TN) 1 assessed Resident 49's skin condition. These failures had the potential to result in Residents 27 and 49 to develop complications from a delay in care and services. Findings: a. During a review of Resident 27's admission Record (AR) the AR indicated Resident 27 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide treatments to prevent the development of pressure ulcer (PU- an injury that breaks down the skin and underlying tissue when an area of skin is placed under pressure) and promote healing for four of six sampled residents (Residents 1, 16, 20 and 36) by failing to: a. Ensure the low air loss mattress (LALM - a specialty bed that alternates pressure to help heal and prevent pressure injuries) for Resident 36 was set to alternating pressure. b. Ensure the low air loss mattress for Resident 20 was set to alternating pressure. c. Ensure Resident 1's heel boots for offloading purposes were applied. d. Ensure Resident 16's LALM was set at the correct weight setting. These failures had the potential to cause pressure ulcers, worsen and prevent healing for residents with skin and pressure injuries. Findings: a. During a review of Resident 36's admission Record (AR), the AR indicated Resident 36 was readmitted to the facility on [DATE] with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement the facility's policy titled, Pain Assessment and Management for two of two sampled residents (Resident 5 and 25) by failing to: a. Communicate the Pain Specialist (PS) recommendations to the Medical Doctor (MD) for Resident 25 on 1/28/2025 and 2/25/2025. b. Notify Resident 5's Physician when the current pain management was not working for Resident 5's pain. These failures had the potential to result in Resident 5 and 25 to experience unnecessary pain affecting their quality of life and well being Findings: a. During a review of Resident 25's admission Record (AR), the AR indicated Resident 25 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder (MDD, mood disorder characterized by at least two weeks of persistent feelings of sadness and loss of interest). During a review of Resident 25's Order Details (OD) dated 1/29/2025 timed at 8:23 AM, the OD indicated an order for Gabapentin (medication used 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 sufficient nursing staff to provide care and services to meet the needs for three of four sampled residents (Resident 5, Resident 6, and Resident 41). These deficient practices had the potential to result in Residents 5, 6 and 41 did not receive adequate care to meet the residents' needs. Findings: a. During a review of Resident 5's admission Record (AR), the AR indicated Resident 5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included end stage renal disease (kidneys lose the ability to remove waste and balance fluids), Type 1 diabetes mellitus (pancreas makes little or no insulin leading to high sugar levels), and non-ST elevation myocardial infarction (partial blockage of coronary [heart] artery). During a review of Resident 5's Minimum Data Set (MDS, a resident assessment tool), dated 12/24/24, the MDS indicated Resident 5 was cognitively intact (ability to understand and process thoughts), and required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Zosyn (type of antibiotic) Intravenous (IV, route of administration that is directly inserted into the vein) and Daptomycin (type of antibiotic) IV were given per the physician's order for one of one sampled resident (Resident 27). These failures had the potential for Resident 27 to develop severe infections and complications from antibiotic use. Findings: During a review of Resident 27's admission Record (AR), the admission Record indicated Resident 27 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included acute osteomyelitis (bone infection caused by bacteria) of the left foot and ankle and cellulitis (serious bacterial skin infection). During a review of Resident 27's Minimum Data Set (MDS, a standardized comprehensive assessment of each resident's functional capabilities and identifies health problems) dated 1/10/2025, the MDS indicated Resident 27's cognitive abilities (ability to think, learn, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its policy titled, Psychotropic (medication that affects behavior, mood, thoughts, or perception) Medication Use for two of two sampled residents (Resident 5 and 197) by failing to: a. Ensure Resident 197's order for Ativan (medication used to treat anxiety) 0.5 milligrams (mg, unit of measurement) tablets every six hours as needed (PRN) for anxiety had an end date of 14 days. b. Obtain a signed informed consent for the use of Olanzapine (mediation used to treat schizophrenia [serious mental disorder in which people interpret reality abnormally] and bipolar disorder [mental illness that causes extreme mood swings]) and Lorazepam (medication used to treat anxiety) for Resident 5. These failures had the potential to result in unnecessary psychotropic medication use for Resident 5 and 197. Findings: a. During a review of Resident 197's admission Record, the admission Record indicated Resident 197 was admitted to the facility on [DATE] with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure they had a medication error rate of five (5) percent (%) or lower for two of two sampled residents (Resident 13 and 26) during the medication administration on 3/6/2025. This failure resulted in three (3) medication errors out of 25 opportunities for errors, which resulted in a Medication Administration Error Rate of 12%. Findings: a. During a review of Resident 13's admission Record (AR), the AR indicated Resident 13 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday tasks) and schizophrenia (serious mental disorder in which people interpret reality abnormally). During a review of Resident 13's History and Physical (H&P) dated 10/11/2024, the H&P indicated Resident 13 lacked capacity to make medical decisions. During a review of Resident 13's Order Summary Report (OSR) dated 11/2/2024, 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 ensure significant medication error were prevented for two of two sampled resident (Resident 24 and 27) by failing to: a. Check the heart rate (HR) prior to administration of Metoprolol (medication used to lower blood pressure) and Amlodipine (medication used to lower blood pressure) to Resident 24. b. Administer Zosyn (type of antibiotic) intravenous (IV, route of administration that was directly inserted into the vein) and Daptomycin (type of antibiotic) IV as ordered by the Medical Doctor (MD) for Resident 27. These failures had the potential to result in discomfort or jeopardize the residents' health and safety. Findings: a. During a review of Resident 27's admission Record (AR), the AR indicated Resident 27 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included acute osteomyelitis (bone infection caused by bacteria) of the left foot and ankle and cellulitis (serious bacterial skin infection).…

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

Based on interview and record review, the facility failed to ensure one of one sampled nutrition services staff member (Dishwasher 1 [DW 1]) was in-serviced monthly. These failures had the potential to result in resident injuries related to dietary needs. Findings: During a concurrent observation and interview on 3/4/2025 at 9:49 AM with the Dietary Supervisor (DS) while in the kitchen, the chlorine parts per millions (ppm, unit of a concentration of chlorine in water that is used for sanitation) was checked. The DS stated the strip indicated the ppm was at zero and it should be at 100 ppm. During an interview on 3/4/2025 at 10:05 AM with DW 1, DW 1 stated DW 1 did not check the chlorine ppm in the morning prior to washing the dishes. DW 1 stated DW 1 does not check the chlorine ppm and does not know what the chlorine is used for in the dishwashing machine. DW 1 stated DW 1 never checks the chlorine ppm in the morning and has been working mornings in the kitchen for the last three months. During an interview on 3/7/2025 at 9:30 AM with the DS, the DS stated there were no in-services…

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

Based on observation, interview, and record review, the facility failed to ensure food was stored in a sanitary manner by failing to: a. Date apple sauces, mandarin oranges, fruit cocktail, and boxes of milk with the received date. b. Remove the vanilla extract from the dry storage when it was opened on 11/22/2024 and remove the chicken pozole from refrigerator 1 (Ref 1) when the use by date of 2/27/2025 had past. c. Ensure an opened date was listed on an opened muffin mix, powdered sugar, baking soda, peanut butter, cottage cheese, cream cheese, pepperoni, salad dressing, and liter of milk. d. Ensure the peanut butter was stored in a sanitary manner when the peanut butter canister was observed with crusted peanut butter and jelly on the outside of the canister and stored in the dry storage. e. Date a bag of grilled cheese sandwiches in Ref 1. f. Report out of range chlorine PPM results to the Dietary Supervisor for 3/2025. g. Ensure the dishwater's chlorine parts per million (ppm, unit of a concentration of chlorine in water that is used for sanitation) was tested when the chlorine…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 its infection prevention and control program for 58 out of 91 sampled residents (Resident 1, 5, 7, 9, 11, 12, 13, 15, 16, 17, 18, 21, 24, 25, 26, 27, 28, 30, 31, 32, 33, 34, 36, 37, 39, 40, 42, 44, 46, 47, 49, 50, 52, 53, 54, 55, 56, 57, 59, 62, 63, 64, 65, 67, 68, 69, 71, 72, 74, 77, 78, 80, 88, 89, 294, 295, 296, 298) by failing to: a. Initiate a line listing, contact tracing, monitoring, and isolation measures after Certified Nursing Assistant (CNA) 12 notified the facility that CNA 12 was diagnosed with scabies (a contagious skin infestation caused by the microscopic mite, Sarcoptes scabie) on 2/28/2025. b. Ensure that proper personal protective equipment (PPE-clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) was worn while providing direct care to Resident 5. c. Ensure that signage was posted, and appropriate PPE was provided for enhanced based precautions…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 treat one of 19 sampled residents (Resident 16) with respect and dignity by failing to ensure facility staff placed Resident 16's indwelling catheter (medical device that helps drain urine from your bladder) inside a privacy bag (a discreet cover designed to conceal a urine drainage bag) as indicated in the facility's policy and procedure titled, Quality of Life-Dignity. This failure resulted in a breach of the facility's standard protocol designed to preserve the resident's privacy and dignity. Findings: During a review of Resident 16's admission Record (AR), the AR indicated the facility admitted Resident 16 on 10/22/2024, and readmitted Resident 16 on 1/21/2025, with diagnoses including, metabolic encephalopathy (a change in how your brain works due to an underlying condition), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and pressure ulcer (damage to the skin and underlying tissue caused by prolonged pressure on the skin, often over bony…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 its policy and procedure (P&P) titled, Psychoactive Medication Informed Consent, for the use of for Olanzapine (Zyprexa- antipsychotic medication that used to treat mental disorders) and Lorazepam (Ativan- medication to treat anxiety) for one of one sampled resident (Resident 5). This failure violated Resident 5's right and placed Resident 5 at risk for psychological distress due to unnecessary medication. Cross reference: F758 Findings: During a review of Resident 5's admission Record (AR), the AR indicated Resident 5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included end stage renal disease (kidneys lose the ability to remove waste and balance fluids), Type 1 diabetes mellitus (pancreas makes little or no insulin\ leading to high sugar levels), and non-ST elevation myocardial infarction (partial blockage of coronary [heart] artery). During a review of Resident 5's Minimum Data Set (MDS,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide for one of one sampled resident (Resident 20) reasonable accommodation to meet the resident's needs by failing to ensure the call light was within reach. This deficient practice had the potential to negatively impact the psychosocial well-being of the resident and result in delayed provision of care and services. Findings: During a review of Resident 20's admission Record (AR), the AR indicated Resident 20 was readmitted to the facility on [DATE] with diagnoses that included epilepsy (a brain disorder that causes recurring, unprovoked seizures) and osteoporosis (weak and brittle bones). During a review of Resident 20's History and Physical (H&P), dated 3/4/2024, the H&P indicated Resident 20 had a fluctuating capacity to understand and make decisions. During a review of Resident 20's Minimum Data Set (MDS - a federally mandated resident assessment tool) assessment, dated 1/22/2025, the MDS indicated Resident 20 had intact…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report alleged abuse within two hours to the California Department of Public Health (CDPH) on 1/22/2025 for one of one sampled resident (Resident 51). This failure had the potential to expose Resident 10 to further abuse from Resident 51. Findings: a. During a review of Resident 51's admission Record (AR), the admission Record indicated Resident 51 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease (brain disorder that gradually destroys memory and thinking skills). During a review of Resident 51's Minimum Data Set (MDS, a standardized comprehensive assessment of each resident's functional capabilities and identifies health problems) dated12/20/2024, the MDS indicated Resident 51's cognitive abilities (ability to think, learn, and process information) were moderately impaired and indicated Resident 51 used a wheelchair. During a review of Resident 51's Change of Conditions (COC) dated 1/22/2025 at 3:09 PM, the COC…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 transmit the Minimum Data Set (MDS, a standardized comprehensive assessment of each resident's functional capabilities and identifies health problems) for one of one sampled resident (Resident 2) within 14 days of Resident 2's death. This failure had the potential to result in inaccurate resident information. Findings: During a review of Resident 2's admission Record (AR), the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm (cancerous growth of cells) of the stomach and prostate (small gland in male reproductive system). During a review of Resident 2's Health Status Note (HSN) dated [DATE] at 10:08 PM, the HSN indicated Resident 2 expired on [DATE] at 11:08 PM. During a review of the MDS 3.0 NH Final Validation Report (FVR) dated [DATE], the FVR indicated Resident 2's MDS was submitted on [DATE] and indicated it was submitted past 14 days after Resident 2's death. During an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 titled Catheter (thin flexible tube used to drain fluids from the body or deliver fluids into it) Care, Urinary for one of one sampled resident (Resident 27) by failing to perform foley catheter (FC, thin, flexible tube inserted into the bladder through the urethra to drain urine) care every shift per the physician's order for Resident 27. This failure had the potential to result in Resident 27 to experience complications from indwelling catheter use. Findings: During a review of Resident 27's admission Record (AR), the AR indicated Resident 27 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included neuromuscular dysfunction of the bladder (unable to control the bladder due to injury to the spinal cord). During a review of Resident 27's untitled care plan (CP) dated 10/9/2024, the CP indicated for staff to check the indwelling catheter tubing for kink every shift. During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the Medical Doctor and create a Change of Condition (COC) for one of one sampled resident (Resident 28), when Resident 28 lost 17 pounds (lbs., unit of measurement for weight) on 1/9/2025. This failure had the potential to result in Resident 28 to experience further weight loss. Findings: During a review of Resident 28's admission Record (AR), the admission Record indicated Resident 28 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday tasks) and dysphagia (difficulty swallowing). During a review of Resident 28's History and Physical (H&P) dated 11/28/2024, the H&P indicated Resident 28 was alert and oriented to self. During a review of Resident 28's Minimum Data Set (MDS, a standardized comprehensive assessment of each resident's functional capabilities and identifies health problems) dated 11/29/2024,…

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 ensure that a precautionary signage indicating No Smoking/Oxygen in Use was placed on the door of the room and there was a physician's order for oxygen therapy for one of two sampled residents (Resident 293) who was on oxygen therapy. This deficient practice had the potential for unnecessary oxygen therapy use for Resident 293 and increased risk of harm to residents, staff, and visitors in the facility. Findings: During a review of Resident 293's admission Record (AR), the AR indicated the facility admitted Resident 293 on 1/28/2025, with diagnoses including, end stage renal disease (End Stage Renal Disease-irreversible kidney failure), chronic obstructive pulmonary disease (COPD-a chronic lung disease that makes it hard to breathe), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) with foot ulcer (a sore or break in the skin or lining of an organ). During a review of Resident 293's Minimum Data Set (MDS, a resident assessment tool), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Hemodialysis (HD, use of machine to remove waste and extra fluids from the blood) Catheters (soft, flexible tube that is inserted into a large vein)-Access and Care of for one of one sampled resident (Resident 62) when the post dialysis (treatment to remove waste and excess fluid in the body) process assessment form was not completed on 3/1/2025. This failure had the potential to result in Resident 62 to experience complications after dialysis. Findings: During a review of Resident 62's admission Record (AR), the AR indicated Resident 62 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included end stage renal disease (ESRD, occurs when kidney function has declined to the point the kidneys can no longer function on own) and dependence on dialysis. During a review of Resident 62's History and Physical (H&P) dated 11/14/2024, the H&P indicated Resident 62 had the capacity…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 trauma-informed care for one of one sampled resident (Resident 47) by not ensuring that Resident 47 received adequate care and services to address Resident 47's Post-Traumatic Stress Disorder (PTSD- a mental health condition that can develop after someone has experienced a deeply disturbing or frightening event). This deficient practice had the potential to result in inadequate attention to Resident 47's specific trauma-related needs. Cross Reference F656 and F726 Findings: During a review of Resident 47's admission Record (AR), the AR indicated the facility admitted Resident 47 on 12/31/2024, and readmitted Resident 47 on 2/13/2025, with diagnoses including, sickle-cell disease (a genetic disorder that causes abnormal red blood cells), bipolar disorder (a mental illness that causes extreme mood swings, from mania [a state of intense, often euphoric or irritable, energy and activity, characterized by racing thoughts, rapid speech, and a decreased need for sleep, often accompanied by impulsive or risky behaviors] 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 provide in-service training (a type of professional training or staff development that is given to staff while they are employed) on Post-Traumatic Stress Disorder (PTSD- a mental health condition that can develop after someone has experienced a deeply disturbing or frightening event) for 106 of 106 nursing staff to adequately care for one of one sampled resident (Resident 47) with diagnosis of PTSD. This deficient practice had the potential to result in inadequate attention to Resident 47's specific trauma-related needs that could affect Resident 47's well-being. Cross Reference F656 and F699 Findings: During a review of Resident 47's admission Record (AR), the AR indicated the facility admitted Resident 47 on 12/31/2024, and readmitted Resident 47 on 2/13/2025, with diagnoses including, sickle-cell disease (a genetic disorder that causes abnormal red blood cells), bipolar disorder (a mental illness that causes extreme mood swings, from mania [a state of intense, often euphoric or irritable, energy and activity,…

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

Based on interview and record review, the facility failed to provide care and serves to prevent elopement for one of three sampled residents (Resident 1) as indicated in the facility's policy and procedure (P&P) titled, Wandering (to walk around from place to place without any clear purpose) & Elopement, revised 1/11/2016, by failing to: a. Develop and implement a plan of care to address elopement risk for Resident 1, who was assessed as being at risk for elopement on 10/24/2024. b. Ensure Licensed Vocational Nurse (LVN) 4 and the Social Services Director (SSD) notified all staff caring for Resident 1 of Resident 1's history of elopement. c. Ensure facility staff provided Resident 1 with a wanderguard (monitoring device or system that helps keep residents at risk of wandering safe) as requested by Resident 1's responsible party (RP 1) on 11/8/2024. d. Ensure LVN 3 accurately assessed Resident 1's elopement risk after Resident 1 eloped from the facility on 1/19/2025. These failures resulted in Resident 1 leaving the facility unsupervised and had the potential to result in injuries…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement the care plan to provide a sitter for monitoring for one of five sampled residents (Resident 1), who had a history of suicidal/homicidal ideations. This failure had the potential to result in serious injury and harm to Resident 1 and other residents. Cross reference F689 Findings: During a review of Resident 1 ' s admission Record (AR), the AR indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included schizoaffective disorder (mental disorder that is characterized by abnormal thought processes and an unstable mood), generalized anxiety disorder, and bipolar disorder (mental illness that causes extreme mood swings). During a review of Resident 1 ' s Minimum Data Set (MDS, a standardized comprehensive assessment of each resident's functional capabilities and identifies health problems) dated 10/31/2024 indicated Resident 1 ' s cognitive abilities (ability to think, learn, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a Situation Background Assessment Recommendation Communication Form (SBAR) for one of five sampled residents (Resident 1) when Resident 1 engaged in a verbal altercation with Resident 5 on 12/31/2024. This failure had the potential to result in the delay of care for Resident 1. Cross reference F689 Findings: a. During a review of Resident 1 ' s admission Record (AR), the AR indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included schizoaffective disorder (mental disorder that is characterized by abnormal thought processes and an unstable mood), generalized anxiety disorder, and bipolar disorder (mental illness that causes extreme mood swings). During a review of Resident 1 ' s Minimum Data Set (MDS, a standardized comprehensive assessment of each resident's functional capabilities and identifies health problems) dated 10/31/2024, the MDS indicated Resident 1 ' s 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 implement the facility ' s policy titled Safety and Supervision of Residents and supervise one of five sampled residents (Resident 1) when Resident 1 verbalized having feelings of hurting Resident 5 on 12/31/2024 at 5 PM. This failure resulted in Resident 1 entering Resident 5 ' s room without permission, engaging in a verbal altercation with Resident 5, and attempting to throw items towards Resident 5 on 12/31/2024. Cross reference F656 and F684 Findings: a. During a review of Resident 1 ' s admission Record (AR), the AR indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included schizoaffective disorder (mental disorder that is characterized by abnormal thought processes and an unstable mood), generalized anxiety disorder, and bipolar disorder (mental illness that causes extreme mood swings). During a review of Resident 1 ' s Minimum Data Set (MDS,a standardized comprehensive assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Abuse Reporting and Investigation, by failing to report an alleged physical abuse to the facility's Abuse Coordinator, California Department of Public Health (CDPH), the Ombudsman (an official appointed to investigate individual's complaints and assists in resolution of concerns), and the local law enforcement immediately and within 2 hours on 12/3/2024 for one of three sampled residents (Residents 2) when Resident 1 allegedly threw water at Resident 2. This failure had the potential to subject Resident 2 to potential further abuse from Resident 1. Findings: 1. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included bipolar disorder (mental health condition that causes extreme mood swings) and generalized anxiety. During a review of Resident 1's Minimum Data Set (MDS, a…

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

Based on interview and record review, the facility failed to apply Permethrin External Cream (a topical medication used to treat scabies [infestation of the skin caused by the human itch mite]) to one of six sampled residents (Resident 5) skin rash as ordered by Resident 5's physician on 11/23/2024. This failure had the potential for Resident 5 to not receive the necessary treatment for Resident 5's rash, which had the potential to result in Resident 5 experiencing pain and discomfort. (Cross Reference F755) Findings: During a review of Resident 5's admission Record (AR), the AR indicated the facility admitted Resident 5 on 8/16/2024 with diagnoses that included type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), dysphagia (difficulty swallowing foods or liquids), and epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures). During a review of Resident 5's Minimum Data Set (MDS, a resident assessment tool), dated 8/22/2024, the MDS indicated Resident 5 was moderately impaired in cognitive skills…

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

Based on interview and record review, the facility failed to supply ordered medication in a timely manner for one of six sampled residents (Resident 5), per the facility's policy and procedure (P&P), Ordering and Receiving Medications from Alliance Pharmacy, Inc, dated 04/2021. This failure had the potential to result in Resident 5 not receiving the necessary treatment for Resident 5's rash, which had the potential for Resident 5 to experience pain and discomfort. (Cross Reference F684) Findings: During a review of Resident 5's admission Record (AR), the AR indicated the facility admitted Resident 5 on 8/16/2024 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), dysphagia (difficulty swallowing foods or liquids), and epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures). During a review of Resident 5's Minimum Data Set (MDS, a resident assessment tool), dated 8/22/2024, the MDS indicated Resident 5 was moderately impaired 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a safe and orderly discharge for two of three sampled residents (Resident 1 and Resident 2) as indicated in the facility's policies and procedures (P&P) by failing to: 1. Ensure Resident 1 and Resident 2 were discharged to an appropriate facility that was able to provide the level of care Resident 1 and Resident 2 needed such as assistance with activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) and medications, blood sugar checks, insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) administration, and wound care. Resident 1 and Resident 2 were discharged to an Independent Living Facility (ILF- housing arrangement which does not provide care, supervision, or assistance with daily activities). 2. Ensure Resident 1 was discharged to ILF 3 as indicated in the physician's order and Notice of Transfer/Discharge.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement the discharge plan for two of three sampled residents (Resident 1 and Resident 2) by failing to: 1. Ensure Resident 1 and Resident 2 were discharged to an appropriate facility that was able to provide the level of care Resident 1 and Resident 2 needed such as assistance with activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) and medications, blood sugar checks, insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) administration, and wound care. Resident 1 and Resident 2 were discharged to an Independent Living Facility (ILF- housing arrangement which does not provide care, supervision, or assistance with daily activities). 2. Ensure Resident 1 was discharged to ILF 3 as indicated in the physician's order and Notice of Transfer/Discharge. Resident 1 was discharged to ILF 1 instead of ILF 3. 3. Ensure Resident 1's…

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

Based on interview and record review, the facility failed to conduct daily skin checks for one of two sampled residents (Resident 2) who was at risk for skin breakdown as indicated in Resident 2's care plan titled, At Risk for Skin Breakdown. This failure had the potential for Resident 2 to experience skin breakdown and to not receive timely treatment for the skin breakdown. (Cross Reference F622, F623, and F842) Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 10/11/2024 with diagnoses including Huntington's disease (a genetic, incurable brain disorder that causes nerve cells to break down and die), paranoid schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). During a review of Resident 2's care plan titled, At Risk for Skin Breakdown ., dated 10/12/2024, the care plan indicated Resident 2 was at risk for skin…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and implement its Infection Control Program to prevent the transmission of disease and infection by not assisting two of three sampled residents (Resident 1 and 6) in washing residents' hands before meals and after using the bathroom. This failure had the potential to result in the spread of infection to residents in the facility. Findings: a. During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 7/15/2024, with diagnoses including major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), and lack of coordination. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 7/22/2024, the MDS indicated Resident 1 was moderately impaired in cognitive skills (decisions poor; cue/supervision required). 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 interview and record review, the facility failed to ensure appropriate information and specific resident needs were communicated to the receiving health care facility for one of one sampled resident (Resident 2), who was transferred to General Acute Care Hospital (GACH) 1 on 10/26/2024. This failure had the potential for Resident 2 to not receive the needed care and treatment at GACH 1 which could negatively impact Resident 2's health and well-being. (Cross Reference F623, F656, and F842) Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 10/11/2024, with diagnoses including Huntington's disease (a genetic, incurable brain disorder that causes nerve cells to break down and die), paranoid schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). During a review of Resident 2's Minimum Data Set (MDS, a resident…

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

Based on interview and record review, the facility failed to send a copy of the notice of discharge/transfer for one of one sampled resident (Resident 2) to the Ombudsman (an official appointed to investigate individuals' complaints against maladministration) in a timely manner. This failure had the potential for the Ombudsman to not know of Resident 2's transfer/discharge from the facility and could violate Resident 2's right to be informed by the Ombudsman of Resident 2's options and transfer/discharge rights. (Cross Reference F622, F656, and F842) Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 10/11/2024, with diagnoses including Huntington's disease (a genetic, incurable brain disorder that causes nerve cells to break down and die), paranoid schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). During a…

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

Based on interview and record review, the facility failed to maintain a complete and accurate medical record for one of one sampled resident (Resident 2) by failing to accurately document in Resident 2's medical record the correct date of treatment provided to Resident 2 and the correct date of Resident 2's discharge from the facility. These failures resulted in Resident 2's medical records to contain inaccurate information. (Cross Reference F622, F623, and F656) Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 10/11/2024 with diagnoses including Huntington's disease (a genetic, incurable brain disorder that causes nerve cells to break down and die), paranoid schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 10/17/2024,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide care and services for a change of condition to two of eight sampled residents (Resident 1 and Resident 2) in accordance with the facility's policies and procedures (P&P) titled, Change in a Resident's Condition or Status, and Charting and Documentation, by failing to ensure: 1. Resident 1's physician and Resident 2's physician was notified of Resident 1's and Resident 2's change of condition. 2. Resident 1's physician was not notified Resident 1 was transferred to the General Acute Care Hospital (GACH) 1. 3. Resident 1 and Resident 2 were monitored for any physical and/or psychosocial changes every shift for 72 hours after their altercation (a loud argument or disagreement) on 8/6/24. 4. An altercation between Resident 1 and Resident 2 which occurred on 8/6/24 was documented in Resident 2's medical record. 5. A Situation Background, Appearance, Review (SBAR, a standardized communication tool between healthcare providers) Communication Form was…

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

Based on interview and record review, the facility failed to ensure the facility had a Registered Nurse (RN) for at least 8 consecutive hours a day for 7 days a week for one (1) out of 18 days reviewed for nursing staffing assignments. This failure had the potential to result in a decline in residents' physical and/or psychosocial well-being due to insufficient monitoring and coordination of care and services by an RN. Findings: During a review of the Nursing Staffing Assignment and Sign-in Sheets (NSASS) for 7/19/24 to 8/5/24, the NSASS indicated, there was no RN who worked in the facility for 8 consecutive hours on 7/21/24. During a concurrent interview and record review on 8/9/24 at 11:15 am with the Director of Staff Development Assistant (DSDA), the facility's Nursing Staffing Assignment and Sign-in Sheets for 7/19/24 to 8/5/24 were reviewed. The DSDA stated the timecard (card used to record an employee's working hours) for the RNs had to be reviewed because the NSASS did not always show who worked. During a concurrent interview and record review on 8/9/24 at 2:53 pm with…

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

Based on observation, interview, and record review, the facility failed to maintain a clean, stain free, and homelike environment for the residents in one of two nursing stations (South Station). This failure had the potential to result in an unsanitary and non-homelike environment for the residents. Findings: During an observation in the South Station on 7/31/24 at 2:56 p.m., brown drip marks and small, dark red circles were observed on the right side of hand sanitizer dispenser and on the wall located outside of the residents ' room. During an interview on 7/31/24 at 2:57 p.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated the brown drip marks was chocolate milk because LVN 2 saw a small puddle of chocolate milk on the floor from a resident, under the hand sanitizer dispenser. LVN 2 stated LVN 2 did not see the brown drip marks on the hand sanitizer dispenser when LVN 2 cleaned the chocolate milk from the floor. During a concurrent observation and interview on 7/31/24 at 3:13 p.m., with Maintenance Supervisor 1 (MS 1) and MS 2, MS 1 and MS 2 observed the dried, brown…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 adequate supervision and assistance during ambulation for one of two sampled residents (Resident 1) as indicated in Resident 1's care plan titled, Patient Care Plan: Fall Risk. As a result, on 7/10/24 at 11:30 pm, Resident 1 walked backwards and fell to the floor. Resident 1 sustained right inferior (lower in position) pubic ramus (a group of bones in the lower pelvis [area of the body below the abdomen that contains the hip bones, bladder, and rectum]) fracture (a complete or partial break in a bone) and right sacral ala (fan-shaped bone located on the base of the sacrum [triangle-shaped bone in the lower spine]) fracture. Resident 1 was transferred and admitted to General Acute Care Hospital (GACH) 1 on 7/10/24 for further evaluation. Findings: During a review of Resident 1's Face Sheet (FS - admission record), the FS indicated, the facility admitted Resident 1 on 6/26/24, with diagnoses that included cognitive communication deficit (a group of disorders that affect a person's ability 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 notify the physician for one of eight sampled residents (Resident 1) who was being discharged from the facility for a scheduled admission to General Acute Care Hospital (GACH) 3 on 4/22/2024 by failing to: 1. Ensure Social Services Assistant (SSA), Registered Nurse Supervisor (RNS) 1, and/or Licensed Vocational Nurse (LVN) 2 notified Resident 1's primary physician, Medical Doctor (MD) 1, and Nurse Practitioner (NP) 1 on 4/19/2024 when the SSA requested transportation to GACH 3 indicating a discharge order was needed for 4/22/2024, and on 4/22/2024, when RNS 1 and LVN 2 were caring for Resident 1, and NP 1 was in the facility to see Resident 1. 2. Ensure facility staff notified Resident 1's Representative (RP) 1 on 4/22/2024 when Resident 1 left the facility to go to his scheduled admission at GACH 3 in a private ride-share vehicle instead of the medical transportation setup by SSA. As a result, Resident 1 left the facility in a private ride-share…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect one of eight sampled residents (Resident 3) from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) as indicated in the facility's policies and procedures (P&P) titled, Resident Rights, and Abuse Prevention Program, when on 4/24/2024, Resident 4 punched (hit) Resident 3 in the face during a board game. As a result, Resident 3 was subjected to physical abuse by Resident 4. Resident 3 sustained blunt trauma (injury of the body by forceful impact, falls, or physical attack) to the face with edema (swelling) and ecchymosis (discoloration of the skin because of ruptured blood vessels below the skin surface) to the left eye. Resident 3 was transferred to General Acute Care Hospital (GACH) 2 on 4/24/2024 at 7:30 pm for further evaluation. Resident 3 experienced 8 out of 10 pain (numerical Rating for pain that graded pain levels from 0 = no pain, 1, to 3 = mild pain, 4, to 6 = moderate pain, 7 to 9 = severe…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident-centered comprehensive care plan to prevent a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) for one of eight sampled residents (Resident 5) by failing to: Ensure facility staff placed bilateral (both sides) floor mats (padding placed on flooring intended to help prevent injury from falls) on each side of Resident 5's bed as indicated in Resident 5's Care Plan (CP) titled, Fall Risk. As a result of this failure, on 4/13/2024 at 5:20 pm, Resident 5 fell and sustained four (4) centimeter (cm- unit of measurement) hematoma (bruise- mark on the skin caused by blood trapped under the surface as a result of injury to small blood vessels but no break on the skin) on the right forehead, three (3) cm laceration (deep cut or tear in the skin or flesh) on the right eyebrow, and ecchymosis (discoloration of the skin as a result of ruptured blood vessels below the skin surface) on the right eye and upper lip. Resident 5 was transferred to General…

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

Based on interview and record review the facility failed to ensure one of nine sampled residents (Resident 3) who was a high elopement (when a person who has been deemed too ill or impaired to make a reasoned decision leaves) risk was monitored as per the interventions outlined in Resident 3's 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]) for elopement. This deficient practice had the potential to result in harm and injury to Resident 3. Findings: During a review of Resident 3's admission Record (AR), dated 4/9/2024, the AR indicated Resident 3 was admitted to the facility 3/22/2024 with multiple diagnoses including schizophrenia (mental disorder characterized by loss of contact with the environment) and generalized anxiety disorder (a mental disorder that produces fear, worry, and a constant feeling of being overwhelmed.) During a review of Resident 3's Elopement Risk Assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure readmission to the facility, for one of one sampled resident (Resident 1), after hospitalization. This deficient practice resulted in Resident 1 waiting for placement at the General Acute Care Hospital 1 (GACH 1) from 11/15/2024 to 11/23/2024 and had the potential to result in a decline in psychosocial well-being to Resident 1. Findings: During a review of Resident 1's Facesheet (admission record) indicated the facility admitted Resident 1 on 7/5/2023, with diagnoses that included chronic obstructive pulmonary disease (COPD - long standing inflammatory lung disease that causes obstructed airflow from the lungs,) obstructive sleep apnea (a disorder that causes repeated breathing interruptions during sleep.) During a review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 12/21/2023, the MDS indicated Resident 1 had no cognitive (ability to understand and process information) impairment. The MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY During an interview and record review, the facility failed to ensure Psychiatric Progress Notes were readily accessible on the resident's chart for two of two residents (Resident 1 and Resident 2). This deficient practice had the potential for inadequate, incomplete information among the interdisciplinary team for Resident 1 and Resident 2. Findings: During a review of Resident 1's Facesheet, the Face sheet indicated the facility admitted the resident on 2/9/2024, 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), atherosclerotic heart disease (when plaque builds up in the arteries and can cause heart attacks, strokes, and other complications). During a review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 2/15/2024, the MDS indicated Resident 1 was rarely able to express ideas and wants and was rarely able to understand verbal content. 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 implement its policies and procedures titled, Investigating Injuries, Abuse Investigation and Reporting, and investigate an injury of unknown origin for one of two sampled residents (Resident 1). This deficient practice had the potential for Resident 1 to sustain more injuries of unknown origin. Findings: During a review of Resident 1's Facesheet, the Facesheet indicated the facility admitted the resident on 2/9/2024, 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 atherosclerotic heart disease (when plaque builds up in the arteries and can cause heart attacks, strokes, and other complications.) During a review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 2/15/2024, indicated Resident 1 was rarely able to express ideas and wants and was rarely able to understand verbal content. The MDS indicated Resident 1 required moderate assistance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accommodate residents' physical limitations and ensure the call light was within reach for three of 22 sampled residents (Resident 7, 19, and 63) as indicated in the facility's policy and procedure (P&P) titled, Answering the Call Lights, and plan of care. This deficient practice had the potential for Resident 7, Resident 19, and Resident 63 to not be able to call the staff for assistance when needed and receive assistance in a timely manner. Findings: a. During a review of Resident 7's admission Record (AR), the AR indicated, the facility initially admitted Resident 7 on 12/2/2023 and readmitted Resident 7 on 12/29/2023 with diagnoses that included history of falling, and unspecified atrial fibrillation (when the atria or the upper chambers of the heart contract at an excessively high rate and in an irregular way). During a review of Resident 7's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 12/12/2023,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow its policy and procedure titled Advance Directive (a written statement of a person's wishes regarding medical treatment), for two of three sampled residents (Resident 7 and Resident 89). For Resident 89, the facility failed to offer Resident 89 to formulate an advance directive at the time when Resident 89 admitted to the facility. For Resident 7, the facility failed to obtain a copy of Resident 7's existing advance directive and placed the advance directive in Resident 7's medical record. These deficient practices had the potential for the staff to violate Resident 7 and Resident 89's right to refuse treatment and implement the resident's preferred medical treatment. Findings: a. During a review of Resident 89's admission Record, the record indicated the resident was admitted on [DATE], with diagnoses that included diabetes mellitus (a medical condition characterized by the body's inability to regulate blood sugar levels) and acute…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, Residents 28 and 86's notice of Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) of non-coverage did not have documented evidence of informed decision from the residents or resident representatives to pay for non-covered services after they were discharged from Medicare Part A for two of two sampled residents (Residents 28 and 86). These deficient practices placed Residents 28 and 86 at risk for payment of out-of-pocket costs from non-coverage services while in the facility. Findings: a. During a review of Resident 28's admission Record (AR), the AR indicated the facility admitted Resident 28 on 1/11/24, with diagnoses that included Alzheimer's disease (type of dementia that affects memory, thinking and behavior) and generalized muscle weakness. During a review of Resident 28's signed notice of SNF ABN of non-coverage dated 2/14/24, the SNF ABN form indicated Resident 28 skilled nursing services under Medicare Part A would end on 2/15/24. The SNF ABN form indicated Resident 28 did not make an informed decision about financial…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure a timely comprehensive (annual) assessment was completed for two of 5 sampled residents (Resident 20 and Resident 25). These deficient practices had the potential to result in inappropriate care for Residents 20 and 25. Findings: a. During a review of Resident 20's admission Record (AR, face sheet) the AR indicated Resident 20 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included epilepsy (seizure disorder, is a brain condition that causes recurring seizures), secondary parkinsonism (a brain conditions that cause slowed movements, rigidity or stiffness and tremors, which occurs as a result of an underlying process or factor, such as a drug, head trauma, toxins, brain infection, or stroke), neuromuscular dysfunction of the bladder (lack of bladder [stores urine from the kidneys before disposal by urination] control due to brain, spinal cord or nerve problems), and psoriasis (a chronic skin disease…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure a timely quarterly assessment was completed for two (Resident 31 and Resident 54) of 5 sampled residents. These deficient practices had the potential to result to an inappropriate care for these residents. Findings: a. During a review of Resident 31's admission Record (AR, face sheet), the AR indicated Resident 31 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included Parkinsonism (a brain conditions that cause slowed movements, rigidity or stiffness and tremors, which occurs as a result of an underlying process or factor, such as a drug, head trauma, toxins, brain infection, or stroke), Paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease), and Osteoporosis (when the creation of new bone doesn't keep up with the loss of old bone). During a review of a minimum data set (MDS, a standardized assessment and care screening tool) for Resident 31, dated 1/26/2024,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop and implement an individualized person-centered plan of care for two of 22 sampled residents (Resident 7 and 45) as indicated in the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive. a. For Resident 7, the facility failed to develop and implement a care plan to address Resident 7's diagnosis of atrial fibrillation (Afib- an irregular and often very rapid heart rhythm) and use of Xarelto (a medication used to prevent blood clots). b. For Resident 45, the facility failed to develop and implement a care plan for Resident 45's suprapubic catheter (a hollow flexible tube inserted into the bladder used to drain urine from the bladder). These deficient practices had the potential for Resident 7 and Resident 45 to not receive consistent and appropriate care, treatment, and/or services. Findings: a. During a review of Resident 7's admission Record (AR), the AR indicated, the facility initially admitted Resident 7 to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: A. Provide care and services to prevent the development of Deep Tissue Injury (DTI- intact skin with localized area of persistent non-blanchable deep red maroon, purple discoloration due to damage of underlying soft tissue)/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) for two of four sampled residents (Residents 31 and 49 ), who were assessed as high risk for developing pressure ulcers and to prevent worsening of pressure ulcer for one of four sampled residents (Resident 40), by failing to : 1. Assess Residents 31 and 49's skin condition on the buttocks (bottom), coccyx (tail bone), sacral (a triangular shape bone at the bottom of the spine) area, for redness or open sores (injuries that involve a break in the skin and leave the internal tissue exposed) during resident care as indicated in Resident 31 and 49's…

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

Based on interview and record review, the facility failed to ensure that all nursing staff possessed the competencies (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needed to perform work roles or occupational functions successfully) and skill sets necessary to meet the residents' needs safely by failing to: a. Perform a performance evaluation and skills competency evaluation for one of four sampled facility staff. b. Ensure the current competency skills evaluation included staff communication/reporting regarding changes in resident condition. c. Ensure the training schedule and in-services training included staff communication/reporting regarding changes in resident condition. Findings: a. During a concurrent interview and record review on 3/4/2024 at 3:23 pm to 4:48 pm with the Director of Staff Development, four sampled employee files were reviewed. Certified Nursing Assistant (CNA) 4's employee file indicated CNA 4 was hired on 10/20/2022. CNA 4's employee file indicated, CNA 4's Employee Performance Review was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent unnecessary use of medication for two of five sampled residents (Resident 7 and Resident 13). Resident 7 and Resident 13 were not assessed and monitored for complications related to anticoagulant (commonly known as a blood thinner, medication that decrease the blood's ability to clot) therapy such as bleeding and bruising as indicated in the facility's policy and procedure (P&P) titled, Anticoagulation - Clinical Protocol, and Resident 13's plan of care. This deficient practice placed Resident 7 and Resident 13 at risk for undetected bruising and bleeding which could result in blood loss and bleeding in the brain and other major organs without immediate interventions and had the potential to cause a decline in Resident 7's and Resident 13's well-being. Findings: a. During a review of Resident 7's admission Record (AR), the AR indicated, the facility initially admitted Resident 7 to the facility on [DATE], and readmitted Resident 7 on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of five sampled residents (Resident 53 and 70) on psychotropic drugs (any drug capable of affecting mood, emotions, and behavior) were free from unnecessary medication. a. For Resident 70, licensed staff failed to monitor Resident 70's target behavior related to the use of Effexor (medication used to treat depression [a feeling of severe sadness or hopelessness]) as indicated in the facility's policy and procedure (P&P) titled, Psychotropic Medication Use, and Resident 70's care plan. b. For Resident 53, the facility failed to attempt a gradual dose reduction (GDR- the stepwise tapering of a dose to determine if symptoms, conditions, or risks could be managed by a lower dose or if the dose or medication can be discontinued) of Resident 53's Escitalopram (medication used to treat depression) 20 mg since it was ordered on 3/3/2021 and Quetiapine (medication used to treat psychosis [mental disordered characterized by a disconnection form…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 its policies and procedures titled, Acute Condition Changes, Prevention of Pressure Injuries (PU/PI- refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence,) Prevention of Pressure Ulcers, and the Care Plans titled, Risk for Skin Breakdown, and High Risk for Pressure Ulcer Secondary to Hypertension, for two of four sampled residents (Residents 31 and 49), who were assessed as at risk for developing pressure ulcers, by failing to ensure: 1. Certified Nurse Assistant 1 (CNA 1) completed the Stop and Watch Form (a written documentation of any changes of condition observed by the CNA's reported to the licensed nurses) when CNA 1 saw Resident 31 had a change in Resident 31's skin condition on the resident's sacral (a triangular shape bone at the bottom of the spine) coccyx (tail bone) area on 2/25/2024 so the Treatment Nurses (TNs 1 and 2) would notify Resident 31's Primary Care Physician…

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

Based on interview and record review, the facility failed to implement written policies and procedures (P&P) that indicated prohibition and prevention of abuse, neglect, and exploitation of residents for one of eight sampled resident (Resident 87). On 1/11/2024, the facility failed to investigate and report Resident 87's purple discoloration located on the right orbital (space within the skull that contains the eye including its nerves and muscles). This failure had the potential to result in compromised safety and psychosocial decline to Resident 87. Cross Reference F609 Findings: During a review of Resident 87's Face sheet (FS, admission record). The FS indicated the facility admitted Resident 87 on 11/6/2023, with diagnoses that included nontraumatic intracerebral (within the brain) hemorrhage (bleed), hemiplegia (paralysis of one side of the body.) During a review of Resident 87's History and Physical (H&P) dated 11/9/2023, the H&P indicated Resident 87 had the capacity to understand and make decisions. During a review of Resident 87's Minimum Data Set (MDS - a standardized…

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

Based on interview and record review, the facility failed to report an injury of unknown origin for one of eight sampled resident (Resident 87). On 1/11/2024, the facility failed to report Resident 87's purple discoloration located on the right orbital (space within the skull that contains the eye including its nerves and muscles) as indicated in the facility's Policy and Procedure (P&P) titled, Abuse Investigation and Reporting. This failure resulted in a delayed investigation of an injury of unknown origin and had the potential to result in compromised safety and psychosocial declines to Resident 87 and the residents residing at the facility. Cross Reference F607 Findings: During a review of Resident 87's Face sheet (FS, admission record). The FS indicated the facility admitted Resident 87 on 11/6/2023, with diagnoses that included nontraumatic intracerebral (within the brain) hemorrhage (bleed), hemiplegia (paralysis of one side of the body.) During a review of Resident 87's History and Physical (H&P) dated 11/9/2023, the H&P indicated Resident 87 had the capacity to understand…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 written notice of transfer and discharge to the responsible party (RP 1) of one of three sampled residents (Resident 34) in accordance with the facility's policy and procedure (P&P) titled, Transfer or Discharge, Facility Initiated. This deficient practice placed Resident 34 and RP 1 at risk to not be fully informed of their appeal rights and options, which had the potential to result in inappropriate discharge/transfer from the facility. Findings: During a review of Resident 34's admission Record (AR), the AR indicated, the facility admitted Resident 34 on 11/14/2023 with diagnoses that included history of falling and essential hypertension (high blood pressure). During a review of Resident 34's History and Physical (H&P), dated 11/16/2023, the H&P indicated, Resident 34 was able to make her needs known but did not have the capacity to make medical decisions. During a review of Resident 34's Order Summary Report (OSR) dated 1/22/2024, the OSR indicated, to discharge Resident 34 to a lower level of care. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide in-room activities based on the resident's activity assessment for one of two sampled residents (Resident 45). This deficient practice had the potential to lead to low stimulation, boredom, or loneliness which could affect the physical, emotional, and psychosocial well-being of Resident 45. Findings: During a review of Resident 45's admission Record (AR), the AR indicated, the facility initially admitted Resident 45 on 5/11/2021, and readmitted Resident 45 on 12/8/2023, with diagnoses that included hemiplegia (paralysis on one side of the body) and dysphagia (difficulty swallowing). During a review of Resident 45's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 12/14/2023, the MDS indicated, Resident 45 was usually able to express ideas and wants and understood verbal content. The MDS indicated, Resident 45 was dependent on staff for rolling left and right, required supervision with eating, and…

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

Based on observation, interview and record review, the facility failed to provide appropriate care to prevent urinary tract infection ([UTI] an infection in any part of the urinary system [kidneys, bladder, ureters, and urethra]) for one of two residents (Resident 1) while Resident 1 was having an indwelling catheter (collects urine by attaching to a drainage bag) by failing to: Ensure Certified Nurse Assistant (CNA) 2 positioned Resident 1's urine bag below the level of resident's bladder while Resident 1 was lying in bed. This deficient practice placed Resident 1 at risk for UTI when the urine flows back into the resident's bladder from the tubing and urine bag. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 12/21/21, with diagnoses that included paraplegia (paralysis of the legs and lower part of the body) and neurogenic bladder (a person lacks bladder control due to brain, spinal cord, or nerve problems). During an observation and concurrent interview on 2/27/24 at 9:27 a.m., Resident 1 was lying on his back…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 label the enteral (a method of delivering nutrition through a tube into the stomach) tube feeding bag with the start date and start time for one of one sampled resident (Resident 45) on tube feeding. This deficient practice had the potential to result in inconsistencies and errors in calculating the volume of the tube feeding administered hourly to Resident 45. Findings: During a review of Resident 45's admission Record (AR), the AR indicated, the facility initially admitted Resident 45 to the facility on 5/11/2021, and readmitted Resident 45 on 12/8/2023, with diagnoses that included hemiplegia (paralysis on one side of the body) and dysphagia (difficulty swallowing). During a review of Resident 45's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 12/14/2023, the MDS indicated, Resident 45 was usually able to express ideas and wants and understood verbal content. The MDS indicated, Resident 45 was dependent on staff for rolling left and right and required supervision with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the nasal cannula tubing (a device that delivers extra oxygen through a tube and into the nose) was stored in a plastic bag when not in use for one of 22 sampled residents (Resident 13) in accordance with the facility's policy and procedure (P&P) titled, Departmental (Respiratory Therapy) - Prevention of Infection. This deficient practice placed Resident 13 at risk for respiratory infection and had the potential to spread infection to other residents, staff, and visitors in the facility. Findings: During a review of Resident 13's admission Record, the AR indicated, the facility initially admitted Resident 13 to the facility on 4/4/2023, and readmitted Resident 13 on 1/18/2024, with diagnoses that included history of falling and unspecified atrial fibrillation (an irregular heart rate that commonly causes poor blood flow). During a review of Resident 13's MDS dated [DATE], the MDS indicated, Resident 13's cognition (mental action or…

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

Based on observation, interview and record review, the facility failed to post accurate nurse staffing information of actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift daily. The staffing information included the actual worked hours of the Minimum Data Set (MDS) nurse that was not directly responsible for resident care was not posted in a prominent location readily accessible to residents and visitors for viewing for one of one day (first day of the survey). This deficient practice mislead the residents and visitors and had the potential to affect the quality of nursing care provided to the residents. Findings: During an observation on 2/27/24 at 11 a.m. and 2/28/24 at 8:07 a.m., the facility's staffing information was not posted in the South Station and only posted in the North station of the facility. During a concurrent interview and record review on 2/28/24 at 3:50 p.m., the Director of Staff Development (DSD) stated the staffing information was projected worked hours for the licensed and unlicensed nursing staff.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 11 sampled residents (Resident 2) was free from verbal abuse as indicated on the facility ' s Policy and Procedure (P&P) titled, Abuse Prevention Program. This failure resulted in verbal abuse to Resident 2 and Resident 2 feeling bad and worthless. In addition, the failure had the potential to result in psychosocial decline to Resident 2. Cross Reference F609 Findings: During a review of Resident 2 ' s Face Sheet (admission Record, AR), the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), lack of coordination, and hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long period of time). During a review of Resident 2 ' s Minimum Data Set (MDS, an 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 observation, interview, and record review, the facility failed to report a verbal abuse incident for one of 11 sampled residents (Resident 2) within two hours of occurrence and as indicated in the facility ' s Policy and Procedure (P&P) titled, Abuse Investigation and Reporting. This failure resulted in compromised safety to Resident 2 and had the potential to result in a psychosocial decline to Resident 2. Cross Reference F600 Findings: During a review of Resident 2 ' s Face Sheet (admission Record, AR), the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy) and lack of coordination. During a review of Resident 2 ' s Minimum Data Set (MDS, an assessment and screening tool), dated 7/7/2023, indicated Resident 2 had moderate impaired cognition (ability to understand and process information) and was able…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 palatable food was served for three of 11 sampled residents (Residents 5, 3, and 11). This failure had the potential to result in a physical decline and unmet nutritional needs for the residents. Findings: During a review of the Face Sheet (admission Record, AR), the AR indicated Resident 5 was readmitted to the facility on [DATE] with diagnoses that included hemiplegia (paralysis to one side of the body) following cerebral infarction (area of the brain tissue that dies due to disrupted blood flow). During an concurrent observation and interview on 10/7/2023 at 1:21 pm., Resident 5 wheeled herself down the hallway and stopped surveyor to talk. Resident 5 stated the food was very bad at the facility and did not taste good. During a review of Resident 3's AR, the AR indicated Resident 3 was readmitted to the facility on [DATE] with diagnoses that included hemiplegia following cerebral infarction. During a concurrent observation and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and and record review, the facility failed to ensure two staff assisted one of 11 sampled resident (Resident 3) with the use of the hoyer lift (mobility tool to assist staff with transfers of residents that have mobility challenges) during transfers, as indicated by the physician ' s order. This deficient practice had the potential to result in injury to Resident 3. Findings: During a review of the Face Sheet (admission Record, AR), the AR indicated Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia (paralysis to one side of the body) following cerebral infarction (area of the brain tissue that dies due to disrupted blood flow), and epilepsy (a disorder in which nerve cell activity in the brain is disturbed and causes seizures). During a review of Resident 3 ' s Physician Orders (active orders for October 2023), included an order dated 4/15/2021, indicated, no weight bearing on the left leg especially on the left ankle. The order…

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