Rinaldi Convalescent Hospital

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that a call light (a device used by a patient to signal his or her need for assistance) within reach for one of three residents reviewed under the environment task (Resident 11). This deficient practice had the potential to result in Resident 11 not being able to call for facility staff assistance and delay in the provision of necessary care and services that can negatively affect the residents' comfort and well-being. Findings: During a review of Resident 11's admission Record, the admission Record indicated the facility admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (a temporary, reversible brain dysfunction caused by chemical imbalances in the body), muscle weakness, dysphagia (difficulty swallowing), failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity). During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure one of eight sampled residents (Resident 12) was provided written information regarding their rights to refuse or accept medical or surgical treatment and to formulate an Advanced Directive (AD- a written instruction, recognized under State law, relating to the provision of health care when an individual is unable to make decisions for themselves).This deficient practice had the potential to result in the facility not honoring the residents' medical decisions regarding end-of-life care. Findings:During a review of Resident 12's admission Record (face sheet), the admission Record indicated that the facility originally admitted the resident on 12/3/2025, and readmitted on [DATE], with diagnoses including unspecified dementia (a progressive state of decline in mental abilities), nondisplaced fracture of base of neck of femur (a hip fracture where the thigh bone is broken at its lowest point near the hip joint, but the bone pieces remain in their…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 homelike environment for two of two residents (Resident 15 and 82) by failing to ensure the window screen was in good repair and did not have a tear which created an opening measuring approximately 24 inches from top to bottom. This deficient practice had the potential to allow insects, dirt, and outside debris to enter the room, placing the residents at increased risk for infection and compromising their safety.Findings: a. During a review of Resident 15's admission Record, the admission Record indicated the facility originally admitted the resident on 7/01/2025 and readmitted the resident on 12/17/2025 with diagnosis including, muscle weakness and hypertension (high-blood pressure). During a review of Resident 15's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 3/02/2026, the MDS indicated the resident had the ability to make self-understood and the ability to understand others. 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 Based on interview, and record review, the facility failed to review, and update a care plan (a document outlining a detailed approach to care customized to an individual resident's need) after a resident`s Change of Condition (COC- an improvement or worsening of a resident`s condition which was not anticipated) for one of 19 sampled residents (Resident 12 ) by failing to review and revise the resident`s CP after his fall on 1/29/2026.This deficient practice had the potential to result in Resident 12 receiving inadequate care and supervision at the facility and an increased risk of recurrent falls. Findings: During a review of Resident 12's admission Record (face sheet), the admission Record indicated that the facility originally admitted the resident on 12/3/2025, and readmitted on [DATE], with diagnoses including unspecified dementia (a progressive state of decline in mental abilities), nondisplaced fracture of base of neck of femur (a hip fracture where the thigh bone is broken at its lowest point near 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 the necessary services to maintain good grooming and personal hygiene for one of one two residents (Resident 65) reviewed under the Activities of Daily Living care area by failing to ensure Resident 65's nails were trimmed.This deficient practice placed the resident at risk for skin injury and breakdown and infection. Findings: During a review of Resident 65's admission Record, the admission Record indicated the facility admitted the resident to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included severe protein-calorie malnutrition (a life-threatening condition caused by an extreme lack of protein and total calories, leading to severe weight loss, muscle wasting, and fat depletion), lack of coordination, and muscle weakness. During a review of Resident 65's Minimum Date Set (MDS- a standardized assessment and care screening tool) dated 2/11/2026, the MDS indicated Resident 65's cognition (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 services that promote the prevention of pressure ulcer injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) by failing to ensure that one of four sampled residents (Resident 36) had heel protectors (a specialized medical device or wearable cushion designed to prevent or treat pressure ulcers on the heel) in place as ordered by the physician.This deficient practice placed Resident 36 at risk for developing a new pressure injury.Findings:During a review of Resident 36's admission Record (face sheet), the admission Record indicated that the facility originally admitted the resident on 6/26/2025, and readmitted on [DATE], with diagnoses including encounter for attention to gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), pressure ulcer of right buttock stage three (full-thickness loss of…

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

Based on observation, interview, and record review, the facility failed to provide services and treatments to maintain joint range of motion (ROM- full movement potential of a joint) for one of three sampled residents (Resident 10) by failing to follow physician's orders for a Restorative Nursing program (a nursing-driven service in long-term care settings that helps residents maintain or improve their functional abilities to their highest possible level) treatment to apply an inflatable therapy orthosis carrot (a soft, cone-shaped, inflatable hand splint used to treat severe finger contractures [clenched fists]). This deficient practice had the potential to cause further decline in functional mobility, ROM, and quality of life for Resident 10. Findings: During a review of Resident 10's admission Record, the admission Record indicated the facility admitted the resident to the facility on 6/29/2024 with diagnoses that included dementia (a progressive state of decline in mental abilities), lack of coordination, and contracture (a permanent tightening or shortening of muscles, tendons,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 an environment that was free from accidents and hazards for two of four sampled residents investigated under accidents (Resident 12 and Resident 20) by failing to: 1.Apply landing pads (a floor pad designed to help prevent injury should a person fall) at Resident 12`s bedside as ordered by the physician. This deficient practice had the potential to place Resident 12 at risk for injuries in the event of a fall. 2. Check for placement and functionality of Resident 20`s wander management system (WMS - a wearable bracelet security technology designed to keep residents with memory issues from wandering away from safe areas) every shift from 3/5/2026 - 3/29/2026. This deficient practice placed Resident 20 at an increased risk for injuries and elopement (when a resident who is incapable of adequately protecting himself, and who departs the health care facility unsupervised and undetected)). 2. During a review of Resident 20's admission…

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

Based on observation, interview, and record review the facility failed to: a. Ensure a resident who had a diagnosis of obstructive and reflux uropathy (a blockage in the urinary system that prevents urine from flowing freely, causing it to back up and potentially damage the kidneys. Reflux uropathy is the backward flow of urine from the bladder to the kidneys) receives appropriate treatment and services to prevent recurring urinary tract infections (UTI, common infections that happen when bacteria infect the urinary tract) by failing to keep urinary catheter (a tube that is inserted into the bladder, allowing urine to drain) tubing from forming a dependent loop (a urinary catheter dependent loop is a U-shaped sag in the drainage tubing that falls below the collection bag, creating a low point that disrupts gravity drainage. It causes urine to pool, leading to bacteria growth, reduced bladder drainage, and a high risk of catheter-associated urinary tract infections) and allowing the contents to flow freely into the urinary catheter bag (container that connects to a urinary catheter…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 enteral feeding (delivers liquid nutrition directly to the stomach or small intestine via a tube for individuals unable to meet nutrient needs orally) rate was transcribed (written) on the enteral feeding formula bottle for one of one sampled resident (Resident 43). This deficient practice had the potential to place Resident 43 at risk for not receiving the correct amount of feeding formula per physician's order which could result in unintended weight loss.Findings: During a review of Resident 43's admission Record, the admission Record indicated that the facility admitted the resident on 9/29/2025 with diagnoses including muscle weakness and encounter for attention to gastrostomy (G-tube, a tube inserted through the belly that brings nutrition directly to the stomach). During a review of Resident 43's Minimum Data Set (MDS-a resident assessment tool) dated 12/23/2025, the MDS indicated the resident had the ability to make self-understood and the ability to understand others. The MDS 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: 1. Obtain a physician's order prior to administering oxygen for one of two sampled residents (Resident 99). 2. Ensure a resident's nasal canula (NC- a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) oxygen tubing was labeled with the date and time it was last changed for one of two sampled residents (Resident 99). These deficient practices had the potential to place Resident 99 at increased risk of infection, and cause complications associated with oxygen therapy. 3. Ensure a resident received continuous oxygen as ordered by the physician for one of two sampled residents (Resident 11). This deficient practice had the potential to cause Resident 11 to have shortness of breath that could lead to hypoxemia (a low level of oxygen in the blood).Findings: a. During a review of Resident 99's admission Record, the admission Record indicated that the facility admitted the resident on 3/25/2026, with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic…

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

Based on interview, and record review, the facility failed to ensure a resident's drug regimen was free from unnecessary medications (any medication in excessive dose, excessive duration, without adequate monitoring) for one of one sampled residents (Resident 99) by failing to monitor Resident 99 for sign and symptoms of bleeding for the use of enoxaparin sodium (an anticoagulant [blood thinner] used to prevent and treat harmful blood clots) in accordance with the facility's policy and procedure on Anticoagulation-Clinical Protocol. This deficient practice had the potential for Residents 99 to receive suboptimal (less than the highest standard or quality) care, and experience serious adverse consequences (unwanted, uncomfortable, or dangerous effects that a drug may have) possibly resulting in bleeding, hospitalization, or death. Findings: During a review of Resident 99's admission Record (face sheet), the admission Record indicated that the facility admitted the resident on 3/25/2026, with diagnoses including urinary tract infection (UTI- an infection in the bladder/urinary tract),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents were free of any significant medication errors by failing to rotate clonidine patch (medication patch used to treat hypertension [high blood pressure- the force of the blood pushing on the blood vessel walls is too high]) administration sites for one of one sampled resident (Resident 40). This deficient practice had the potential for skin irritation and for the medication to not work as intended.Findings: During a review of Resident 40's admission Record, the admission Record indicated the facility admitted Resident 40 on 1/10/2026 with diagnoses including intercerebral hemorrhage (stroke, loss of blood flow to a part of the brain by a broken blood vessel causing bleeding into the brain), dysphagia (difficulty swallowing), and hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]). During a review of Resident 40's Minimum Data Set (MDS- a resident assessment tool) dated 1/15/2026, the MDS indicated Resident 40 could make himself understood and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure temperatures were checked and documented for one of two refrigerators (Refrigerator 1) in Medication room [ROOM NUMBER]. This deficient practice had the potential to compromise integrity of the medications stored in medication room one refrigerator.Findings: During a concurrent observation, interview, and record review on 3/28/2026 at 12:35 p.m., in Medication room [ROOM NUMBER] with Licensed Vocational Nurse 3 (LVN 3), observed and reviewed Refrigerator 1's temperature log. LVN 3 stated there were no documented temperatures on:- 3/8/2026 at 7:00 a.m.- 3/8/2026 at 11:00 p.m.- 3/15/2026 at 7:00 a.m.LVN 3 stated the medication refrigerator must be checked and documented twice a day, once on day shift (7:00 a.m. - 3:00 p.m.) and once on night shift (11:00 p.m. - 7:00 a.m.) to make sure the medications are the correct temperature and safe to give to the residents. During an interview on 3/29/2026 at 12:16 p.m., with the Assistant…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 complete and accurate medical records in accordance with accepted professional standards for one of two sampled residents (Resident 36) by failing to include the resident`s diagnosis of anxiety disorder (a mental health condition characterized by excessive, persistent, and uncontrollable fear or worry that interferes with daily life) on the current diagnoses list. This deficient practice placed Resident 36 at risk of not receiving appropriate care due to inaccurate medical care information. Findings: During a review of Resident 36's admission Record, the admission Record indicated that the facility originally admitted the resident on 6/26/2025 and readmitted on [DATE], with diagnoses including encounter for attention to gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), pressure ulcer of right buttock stage three (full-thickness loss of…

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

Based on interview and record review, the facility failed to ensure the facility arranged provisions of hospice services for one of one sampled residents (Resident 11) by failing to: 1.Ensure the hospice attending physician assessed and completed a history and physical (H&P- a comprehensive, structured evaluation performed by a clinician, combining subjective patient-reported history with objective physical exam findings to guide diagnosis and treatment). 2. Ensure the hospice agency provided training programs in hospice care for facility staff per contractual agreement. These deficient practices had the potential to negatively affect Resident 11's physical comfort, psychosocial (state of mental, emotional, and social health of an individual) well-being, and had the potential to delay or have a lack of necessary care and services.Findings: a. During a review of Resident 11's admission Record, the admission Record indicated the facility admitted the resident on 12/28/2024 with diagnoses that included metabolic encephalopathy (underlying systemic conditions or substances that disrupt…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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: 1. Ensure medications are administered in a safe manner by failing to perform hand hygiene before and after medication administration for two of six sampled residents (Resident 71 and 102) observed during medication administration. 2. Ensure Certified Nursing Assistant 1 (CNA 1) did not place her personal purse and cell phone on the bedside table belonging to one of one sampled resident (Resident 8). These deficient practices had the potential to spread infection and cross contamination (the physical movement or transfer of harmful bacteria [germs] from one person, object, or place to another) among staff and other residents.Findings: 1.a. During a review of Resident 71's admission Record, the admission Record indicated the facility admitted the resident on 8/25/2020 with diagnosis including, hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]) and chronic kidney disease (a serious,…

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

Based on interview and record review, the facility failed to implement its policy and procedures (P&P), titled Abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment, resulting in physical harm, pain, or mental anguish), Neglect (failure of staff to provide necessary care), Exploitation (illegal or improper act of using a resident's funds, property, or assets for another person's profit or advantage, often involving coercion, manipulation, or fraud) and Misappropriation (deliberate misplacement, exploitation, or wrongful temporary/permanent use of a resident's belongings or money without their consent) Prevention Program by failing to conduct required pre-employment screening prior to hiring one of two sampled employees (Certified Nursing Assistant 1 [CNA 1]). This deficient practice had the potential to place the residents at risk for elder abuseDuring a review of CNA 1's personnel file including the Personnel Action Form (PAF) dated 12/26/2024, the PAF indicated prior employment at Skilled Nursing Facility 1 (SNF 1) in the position/title of CNA.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Obtain weekly weights as ordered for one of three sampled residents (Resident 1) 2. Ensure that staff monitored and documented intake (food and fluid consumption) and output (urine and stool amounts) in accordance with professional standards of practice and per the facility's policy and procedure (P&P) for one of three sampled resident (Resident 1), who had a gastrostomy tube (G-tube - a tube surgically inserted through the abdomen directly into the stomach to provide a way to deliver nutrition and medication when a person cannot eat or drink enough by mouth) and an indwelling catheter (a tube inserted into the bladder to allow urine to drain freely). This deficient practice had the potential to result in unrecognized weight changes, nutritional decline, and dehydration (a state where the body loses more water and fluids than it takes in). During a review of Resident 1's admission Record, the admission Record indicated that the facility originally…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 significant change in status assessment (SCSA - a comprehensive assessment that must be completed when the interdisciplinary team [IDT - a group of healthcare professionals and staff from different areas who work together to create the best possible care plan for a resident] has determined that a resident meets the significant change guidelines for either major improvement or decline) Minimum Data Set (MDS - a comprehensive assessment and screening tool) was completed within the required time frame for one of three sampled residents (Resident 1). This deficient practice had the potential to negatively affect the provision of necessary care and services.Findings:During a review of Resident 1's admission Record, the admission Record indicated that the facility admitted the resident originally on 5/28/2025 and readmitted on [DATE] with diagnoses including traumatic subarachnoid hemorrhage (SAH - bleeding in the space between the brain and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow the physician's orders dated 8/26/2025 to obtain laboratory services (any examination of materials derived from the human body for purposes of providing information for the diagnosis, prevention, or treatment of any disease or impairment of, or the assessment of the health of human beings) for one of five sampled residents (Resident 1). This deficient practice had the potential to negatively affect the provision of necessary care and services to meet Resident 1's needs.Findings:During a review of Resident 1's admission Record, the admission Record indicated that the facility admitted the resident originally on 5/28/2025 and readmitted on [DATE] with diagnoses including traumatic subarachnoid hemorrhage (SAH - bleeding in the space between the brain and the tissues that cover the brain) with loss of consciousness, gastrostomy tube (G-tube, a feeding tube that is surgically placed through a small opening in the abdomen through the stomach to allow…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 infection control practices by failing to ensure Treatment Nurse 1 (TN 1) did not return disposable supplies to the treatment cart and did not disinfect a reusable plastic container prior to returning it to the treatment cart after completing wound treatment for one of one sampled resident (Resident 2).These deficient practices had the potential to result in cross contamination (germs are unintentionally transferred from one substance or object to another with harmful effect) resulting in the potential spread of germs placing residents, staff, and visitors at risk of being infected.Findings:During a review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident on 8/31/2025 with diagnoses that included cellulitis (a skin infection that causes swelling and redness) of left lower leg and diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 2'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide in-service training (training intended for those actively engaged in a profession or activity) as indicated by the facility's in-service calendar for Certified Nursing Assistants (CNA) regarding behavioral health for two of two sampled CNAs (CNA 2 and CNA 3). This deficient practice has the potential to place residents who have a behavioral health diagnosis at risk for improper care and avoidable incidences. Findings: During a review of the facility's Facility assessment dated [DATE], the Facility Assessment indicated under Common Diagnosis/Conditions: Psychiatric (branch of medicine concerned with the study, diagnosis, and treatment of mental illness)/Mood Disorders (mental health condition that primarily affects your emotional state). Common diagnosis: Psychosis (severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality), impaired cognition (the process of acquiring knowledge and…

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

2. During a review of Resident 12's admission Record, the admission Record indicated the facility admitted Resident 12 on 11/18/2024 with diagnoses including, but not limited to unspecified dementia (general term for a progressive state of decline in mental abilities), lack of coordination, a displaced (moved from proper or usual place) subtrochanteric (area below the trochanter [area below the neck of the femur located near the hip]) fracture of the right femur (longest and strongest bone in the body located from the hip to knee), subsequent (following) encounter for closed fracture (a broken bone that doesn't break the skin), and a history of falling During a review of Resident 12's Physician's Progress Note, dated 11/20/2024, the Physician's Progress Note indicated Resident 12 did not have the capacity to understand and make decisions and required skilled nursing services after surgery to his right femur on 11/16/2024. During a review of Resident 12's Minimum Data Set (MDS - an assessment and care screening tool) dated 11/22/2024, the MDS indicated the resident was not able 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 3. During a review of Resident 12's admission Record, the admission Record indicated the facility admitted Resident 12 on 11/18/2024 with diagnoses that included, but not limited to unspecified dementia (general term for a progressive state of decline in mental abilities), lack of coordination, a displaced (moved from proper or usual place) subtrochanteric (area below the trochanter [area below the neck of the femur located near the hip]) fracture of the right femur (longest and strongest bone in the body located from the hip to knee), subsequent (following) encounter for closed fracture (a broken bone that doesn't break the skin), and a history of falling. During a review of Resident 12's Physician's Progress Note, dated 11/20/2024, the Physician's Progress Note indicated Resident 12 did not have the capacity to understand and make decisions and required skilled nursing services after surgery to his right femur on 11/16/2024. During a review of Resident 12's Minimum Data Set (MDS - an assessment and care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that pain management was provided, consistent with professional standards of practice for two of two sampled residents (Resident 22 and 10) being investigated under the pain care area when: a. Resident 22 was not assessed before and after tramadol (a controlled [a medication's use and distribution are tightly controlled because of their abuse potential or risk] medication given for pain) was administered on 2/9/2025 at 8:30am. b. Resident 10 was not assessed before and after oxycodone with acetaminophen tablet (brand name is Percocet, a narcotic pain medication) was administered on 1/21/2025 at 1:10 a.m., 1/31/2025 at 1:45 a.m., and 2/01/2025 at 2 a.m. This deficient practice resulted in Resident 10 and Resident 22's pain not being assessed and placed the residents at risk for having unmanaged pain that may diminish the residents' quality of life. Findings: a. During a review of Resident 22's admission Record, the admission Record indicated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain accurate clinical records in accordance with accepted professional standards and practices by failing to ensure all medications administered to residents were documented in their medication administration record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for two of five sampled residents (Resident 22, 10) being investigated under the care area of unnecessary medications for: a. Resident 22's Xanax (controlled [a medication's use and distribution are tightly controlled because of their abuse potential or risk] medication for anxiety [feelings of fear, dread, and uneasiness]) and tramadol (controlled medication used for pain). b. Resident 10's Percocet (narcotic, controlled medication used for pain). This deficient practice had the potential to result in medication error and/or drug diversion (illegal distribution or abuse of prescription drugs). Findings: a. 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 ensure residents were free from any significant med errors for three of six sampled residents (Resident 72, Resident 70, and Resident 83) reviewed for unnecessary medications by failing to: 1. Administer Resident 72's Morphine Sulfate Contin (a medication used to control pain) 30 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) on 2/1/2025 as ordered by the physician. This deficient practice resulted in the resident not receiving the medication as scheduled, which can potentially lead to increased pain. 2. Hold parameters for midodrine (a medication to elevate blood pressure for those with low blood pressure) as ordered by the physician for Resident 70 and Resident 83. This deficient practice had the potential to cause complications such as high blood pressure that could require hospitalization. Findings: 1. During a review of Resident 72's admission Record, the admission Record indicated that the…

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

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when a steel scoop was left inside a bin containing a thickener powder used for residents` pureed diet (a pureed diet is needed for people who have trouble chewing or swallowing). This deficient practice had the potential to place five residents who are receiving pureed diet, out of 91 residents at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages). Findings: During a concurrent kitchen observation and interview on 2/10/2025 at 08:00 a.m., with Dietary Supervisor 1 (DS 1) in the facility`s kitchen, observed a container bin with transparent cover containing whitish powder. DS 1 stated the powder is a thickener used for pureed diets. Observed a stainless scoop inside the container bin with the handle buried in the thickener powder. DS 1 stated the scoop should not have been left inside the bin per facility`s policy and to avoid contaminating the contents of the container…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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: 1. Implement policies on transmission based precautions (TBP-a set of infection control measures used to prevent the spread infections that are transmitted through contact with infected person, their bodily fluids, or contaminated surfaces or objects) by failing to provide trash cans inside resident's rooms for used Personal Protective Equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) for one of five (5) sampled residents (Resident 72) reviewed for infection control. 2. Observe infection control guidelines when LVN 6 was observed leaving a resident's room during a medication pass observation while still wearing an isolation gown and gloves for one (Resident 16) of five residents who were placed on enhanced barrier precautions (EBP - an infection control method that uses targeted gown and gloves to reduce the spread of multidrug-resistant organisms [MDROs -…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 facility staff knocked and requested permission prior to entering a resident`s room for two of two residents (Resident 40 and 188) reviewed under the care area of dignity. This deficient practice violated the resident`s rights to be treated with respect and dignity which had the potential to affect the resident`s sense of self-worth and self-esteem. Findings: a. During a review of Resident 40's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including, hypertension (high blood pressure) and type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy.). During a review of Resident 40`s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 01/27/2025, the MDS indicated the resident`s cognitive (the mental action or process of acquiring knowledge and…

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

Based on interview and record review, the facility failed to follow the facility's policy and procedure titled, Advance Directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor), for one out of the five sampled residents (Resident 16) reviewed under Advance Directives care area, by failing to maintain a current copy of the resident's advance directives in the resident's clinical record. This deficient practice had the potential for the facility to not honor the resident's medical decisions regarding end-of-life treatment and had the potential to cause conflict with Resident 16's wishes regarding health care. Findings: During a review of Resident 16's admission Record, the admission Record indicated that the facility initially admitted Resident 16 on 1/9/2024 and readmitted the resident on 1/23/2024 with diagnoses including hemiplegia and hemiparesis (weakness or the inability to move on one side of the body, making it had to perform everyday activities like…

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

Based on observation, interview, and record review, the facility failed to ensure a resident who required assistance with nail trimming was provided care and services to maintain good personal hygiene for one of one sampled resident (Resident 19) reviewed under Activities of Daily Living (ADLs- is a term used to collectively describe fundamental skills required to independently care for oneself, such as eating, bathing, and mobility). This deficient practice had the potential to result in a negative impact on the resident's self- esteem and self-worth due to an unkempt appearance. Findings: During a review of Resident 19's admission Record (AR), the admission Record indicated the facility originally admitted the resident on 12/10/2018 and readmitted the resident on 2/07/2025, with diagnoses including hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]) and type two (2) diabetes mellitus (a chronic condition that affects the way the body processes blood glucose [sugar]). During a review of Resident 19'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement a resident centered activities program by failing to provide activities that meet the resident's spiritual or religious needs for one of one sampled resident (Resident 70) reviewed under the Activities care area. This deficient practice violated the resident`s right to receive religious services which has the potential to affect the resident`s sense of self-esteem and self-worth. Findings: During a review of Resident 70's admission Record, the admission Record indicated the resident was originally admitted on [DATE] and readmitted to the facility on [DATE], with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning) and schizophrenia (a chronic mental illness characterized by disruptions in thought process, perceptions, emotions, and social interactions). During a review of Resident 70`s admission Minimum Data Set (MDS - a standardized assessment and care screening tool), dated…

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

Based on interview, and record review, the facility failed to ensure one of one sampled resident (Resident 27) received treatment and services to prevent decrease in range of motion (ROM- full movement potential of a joint) by failing to clarify Resident 27`s physician order for Restorative Nursing Assistant (RNA- nursing aide program that helps residents to maintain their function and joint mobility) exercise program. This deficient practice had the potential to place the resident at risk for further range of motion (ROM- full movement potential of a joint) decline. Findings: During a review of Resident 27's admission Record (face sheet), the admission Record indicated that the facility admitted the resident on 8/23/2023, with diagnoses including dysphasia (swallowing difficulties), unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), severe protein-calorie…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 appropriate care and services to maintain acceptable parameters of nutritional status for one of one sampled resident (Resident 27) by failing to: 1. Communicate Resident 27's nutritional intake (the amount of food a person eats) percentage with the facility`s Registered Dietician (RD-a health professional who has special training in diet and nutrition). 2. Inform Resident 27`s physician regarding resident`s refusal to eat as indicated in her care plan (written guide that organizes information about the resident's care). This deficient practice had the potential to place Resident 27 at risk for weight loss. Findings: During a review of Resident 27's admission Record (face sheet), the admission Record indicated that the facility admitted the resident on 8/23/2023, with diagnoses including dysphasia (swallowing difficulties), unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure staffing information of the actual hours worked by licensed and unlicensed nursing staffing directly responsible for resident care pers shift was posted daily on 2/11/2025 and on 2/13/2025 as indicated in the facility's policy and procedure (P&P) on Staffing, Sufficient and Competent Nursing. This deficient practice had the potential to keep residents and visitors unaware of the total number of staff and the actual hours worked by staff in the facility. Findings: During an observation, interview, and concurrent record review with the Director of Staff Development (DSD) on 2/11/2025 at 2:50 p.m., observed the facility's document California Department of Public Health (CDPH) form titled Census and Direct Care Service Hours Per Patient Day (DHPPD) dated 2/11/2025, posted prominently in the facility's Nursing Station 1 counter. The DSD stated that the posted document is the facility's nursing projected hours. The DSD stated the hours are projected, not actual. The DSD stated they will not have the actual…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 monitor a resident for side effects of Trazadone (an antidepressant medication) and Xanax (an antianxiety medication) for one (Resident 72) out of five sampled residents investigated under the care area of unnecessary medications. This deficient practice had the potential to place Resident 72 t at increased risk of taking an unnecessary medication and experiencing adverse side effects. Findings: During a review of Resident 72's admission Record, the admission Record indicated that the facility initially admitted Resident 72 on 5/7/2024 and readmitted the resident on 1/17/2025 with diagnoses including infection and inflammatory reaction to prosthetic devices (bacteria have entered the body around a surgical implanted device, causing the body's immune system to react with swelling, pain redness at the implant site), acute hematogenous osteomyelitis (a bacterial infection of the bone that spreads through the bloodstream), cellulitis (a deep skin infection that can be painful and cause swelling). During a review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior by one resident towards another) for one (1) of four (4) sampled residents (Resident 2) on 10/20/2024, when Resident 1 threw water at Resident 2, wetting Resident 2's face, chest, and clothes. This deficient practice resulted in Resident 2 being subjected to physical abuse by Resident 1 while under the care of the facility and had the potential to cause Resident 2 emotional harm which could result to a feeling of embarrassment, low self-esteem, and self-worth. Findings: During a review of Resident 1's admission Record, the document indicated the facility originally admitted the resident on 2/25/2023, and re-admitted the resident on 12/30/2023, with diagnoses that included congestive heart failure (a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues), ventricular tachycardia (a fast, abnormal 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.

Based on interview and record review, the facility failed to implement their policy on acute (sudden onset) condition changes by failing to monitor a resident with hematuria (blood in the urine) for one of three sampled residents (Resident 1). This deficient practice had the potential to result in confusion in the care and services for Resident 1, which could have placed the resident at risk for not receiving appropriate care due to incomplete resident medical care information. Findings: During a review of Resident 1's admission Record, the document indicated the facility admitted the resident on 2/27/2023 with diagnoses that included metabolic encephalopathy (a broad term for any brain disease that alters brain function or structure), hereditary (passing of genetic information from parent to child) deficiency of other clotting factors, unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), paroxysmal atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and heart failure (a condition in which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement infection control practices by failing to ensure contact precautions (measures that are intended to prevent transmission of germs which are spread by direct or indirect contact with the resident or the resident's environment) were implemented for one of three sampled residents (Resident 1), upon Resident 1's return to the facility on 5/26/2024 and was diagnosed with dermatitis (a skin condition that causes swelling and irritation) consistent with scabies (a contagious skin condition characterized by a rash [an area of the skin that has changes in texture or color and may look inflamed or irritated] and intense itching). This deficient practice had the potential to result in the spread of scabies and cross contamination (the physical movement or transfer of harmful bacteria [germs] from one person, object, or place to another) among staff and other residents. Findings: A review of Resident 1's admission Record indicated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan (a plan for an individual's specific health needs and desired health outcomes) for one of three sampled residents (Resident 1) with a diagnosis of dermatitis (a skin condition that causes swelling and irritation) consistent with scabies (a contagious skin condition characterized by a rash [an area of the skin that has changes in texture or color and may look inflamed or irritated] and intense itching). This deficient practice had the potential to result in a delay or lack of delivery of necessary care and services. Findings: A review of Resident 1's admission Record indicated the facility originally admitted Resident 1 on 12/22/2023 and readmitted on [DATE] with diagnoses that included cervical spondylosis (CS - age-related wear and tear affecting the backbones of your neck) and actinic keratosis (AK - a skin disorder that causes rough, scaly patches of skin). A review of Resident 1's Minimum Data Set…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 comprehensive care plan (a care plan is a form where you can summarize a person's health conditions, specific care needs, and current treatments) were evaluated, revised, and renewed for three of six sampled residents investigated for Comprehensive Care Plans by failing to: 1. Ensure Resident 68's care plan for risk for fall was evaluated, revised, and renewed. 2. Ensure Resident 54's care plan for impaired visual function was evaluated, revised, and renewed. 3. Ensure Resident 7's care plan for potential to impairment to skin integrity was evaluated, revised, and renewed. This deficient practice had the potential to result in residents not receiving the necessary care and services to prevent falls and further decline in visual function and skin integrity. Findings: a. A review of Resident 68's admission Record indicated the facility admitted the resident on 5/26/2023 with diagnoses that included muscle weakness and fracture (broken bone) 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 complete a post-hemodialysis (HD, the removing of waste and excess fluid to prevent build up in the body for residents who have loss of kidney [organs that remove waste products from the blood and produce urine] function) assessment for one of one sampled resident (Resident 54) investigated under the Dialysis care area. This deficient practice placed the resident at risk for a delay in detecting complications resulting from HD. Findings: A review of Resident 54's admission Record indicated the facility originally admitted the resident on 5/14/2021 and readmitted on [DATE] with diagnoses that included end stage renal disease (when your kidneys can no longer support your body's needs) and type two (2) diabetes mellitus (a chronic condition that affects the way the body processes blood glucose [sugar]). A review of Resident 54's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/17/2023, indicated that the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: 1. Remove and discard from use one discontinued medication for Resident 26 in one of two inspected medication rooms (Medication room [ROOM NUMBER]). 2. Remove two expired medications from facility stock in one of two inspected medication rooms (Medication room [ROOM NUMBER].) 3. Remove and discard from use one discontinued medication for Resident 77 in one of two inspected medication carts (Medication Cart 1). 4. Remove and discard one discontinued medication for Resident 183 in one of two inspected medication carts (Medication Cart 1.) 5. Label five inhalation (a form of a medication to be inhaled as a vapor or spray) solutions with an open date for Residents 12, 24, 62, 133 and 333 in one of two inspected medication carts (Medication Cart 2). These deficient practices had the potential to compromise the therapeutic effectiveness of medications and placed Residents 12, 24, 26, 62, 77, 133, 183, 333 and other residents in the facility at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 dignity and respect for one of eight sampled residents (Resident 134) when Certified Nursing Assistant 4 (CNA 4) was observed standing over Resident 134 while assisting him with his meal. This deficient practice had the potential to affect a resident's self-worth and self- esteem. Findings: A review of Resident 134's admission Record indicated the facility admitted the resident on 11/11/2022 and re-admitted on [DATE] with diagnoses that included pneumonia (lung infection). A review of Resident 134's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 2/1/2024, indicated Resident 134 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 134 was dependent (helper does all the effort) on staff for eating. A review of Resident 134's Care Plan for…

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

Based on interview and record review, the facility failed to develop and implement a person-centered care plan (a written document that summarizes a patient's needs, goals, and care) for a resident who required scheduled and as needed pain medication for one of one sampled resident (Resident 46) investigated under the care area Pain Management. This deficient practice had the potential to result in failure to deliver necessary care and services. Findings: A review of Resident 46's admission Record indicated the facility admitted the resident on 12/22/2023 with diagnoses that included cerebral infarction (loss of blood flow to part of the brain which damages brain tissue), acute respiratory failure (a serious condition that occurs suddenly when the lungs cannot get enough oxygen), and osteoarthritis (degenerative [progressive, often irreversible deterioration] disorder of the joint resulting in pain) of the hip. A review of Resident 46's Minimum Data Set (MDS- an assessment and care screening tool) dated 12/28/2023, indicated Resident 46 had the ability to make herself-understood 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 ensure that the low air loss mattress (LAL - a medical-grade mattress designed to prevent and treat skin breakdown) was set correctly in accordance with the physician's orders and manufacturer's instructions for one of four sampled residents (Resident 13) investigated under the care area Pressure Ulcer (a wound that develops when skin is damaged by constant pressure or fiction)/Injury. This deficient practice placed the resident at risk of discomfort and development of new pressure ulcers. Findings: A review of Resident 13's admission Record indicated the facility admitted the resident on 12/26/2022 and readmitted the resident on 2/14/2024 with diagnoses that included osteomyelitis (infection of the bone) of vertebra (small bones that form the spine [back]), sacral and sacrococcygeal region (lower part of the spine), pressure ulcer of right buttock stage four (a category indicating full thickness skin loss with exposed bone, tendon, or muscle), and muscle weakness. A review of Resident 13's Minimum Data Set…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an environment free from accidents and hazards by failing to ensure a resident did not have albuterol (medication to treat lung conditions) inhalers (a device that administers medication by breathing in) readily available for self-administration at bedside for one of five sampled residents (Resident 46) investigated under the care area Accidents. This deficient practice had the potential to result in the resident self-administering medications without staff knowledge potentially resulting in overdose (an excessive and dangerous dose of a drug) with accompanying symptoms of increased heart rate, nervousness, shakiness, tremors, or chest pain. Findings: A review of Resident 46's admission Record indicated the facility admitted the resident on 12/22/2023 with diagnoses that included cerebral infarction (a stroke, loss of blood flow to part of the brain which damages brain tissue), acute respiratory failure (a serious condition that occurs suddenly when the lungs cannot get enough oxygen), and 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 interview and record review, the facility failed to ensure there was evidence documented in one of three sampled resident's (Resident 21) medical records of the toileting trial program (or bladder training, which can involve assisting a resident to the restroom at specific timed intervals) results as per the facility policy and procedure. This deficient practice has the potential for Resident 1 to not to achieve or restore normal bowel and bladder function. Findings: A review of Resident 21's admission Record indicated the facility admitted the resident on 12/10/2018 and re-admitted the resident on 10/22/2023 with diagnoses that included diabetes mellitus (a disease in which the body does not control the amount of glucose [a type of sugar] in the blood and the kidneys make a large amount of urine). A review of Resident 21's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/24/2023, indicated Resident 21 was cognitively (the process of acquiring knowledge and understanding through thought, experience, and the senses) intact with 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 monitor a resident's valproic acid (used to treat certain types of seizures [sudden, uncontrolled body movements that occur because of abnormal electrical activity in the brain] level (measures the amount of valproic acid in the blood) for a resident who was prescribed Depakote (medication used to prevent seizures) for one of six residents (Resident 31) investigated for unnecessary medications. This had the potential to place a resident at risk for having a seizure by having a subtherapeutic level (abnormally low amount which could indicate there is not enough medication in the body to be effective) or a toxic serum concentration (having too much medication in the body which can have unwanted and harmful side effects [a secondary, typically undesirable effect of a drug or medical treatment]). Findings: A review of Resident 31's admission Record indicated the facility admitted the resident on 12/19/2023 with diagnoses that included bipolar disorder (a mental health condition that affects your moods, which can swing 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.

Based on interview and record review, the facility failed to ensure a resident who was prescribed an antipsychotic medication (a medication used to treat psychosis [a mental condition in which thought and emotions are so affected that contact is lost with external reality]) was being monitored for a specific behavior for one of six sampled residents (Resident 31) investigated for unnecessary medications. This deficient practice had the potential to result in adverse reaction (undesired harmful effect resulting from a medication or other intervention) or impairment in the resident's mental or physical condition. Findings: A review of Resident 31's admission Record indicated the facility admitted the resident on 12/19/2023 with diagnoses that included bipolar disorder (a mental health condition that affects your moods, which can swing from one extreme to another). A review of Resident 31's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/23/2024, indicated Resident 31 was cognitively (the process of acquiring knowledge and understanding through…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 the established menu to meet nutritional needs by failing to provide a roll (bread) for the noon meal on 2/20/2024 for two of eight sampled residents (Resident 46 and 39) investigated under the Dining Task. This deficient practice had the potential to result in unwanted resident weight loss and had the potential for residents getting disappointed with the meal experience they look forward to. Findings: a. A review of Resident 46's admission Record indicated the facility admitted the resident on 12/22/2023 with diagnoses that included cerebral infarction (loss of blood flow to part of the brain which damages brain tissue), acute respiratory failure (a serious condition that occurs suddenly when the lungs cannot get enough oxygen), and severe sepsis (a serious condition in which the body responds improperly to an infection). A review of Resident 46's Minimum Data Set (MDS- an assessment and care screening tool) dated 12/28/2023,…

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

Based on observation, interview, and record review, the facility failed to honor a resident's preferences by failing to ensure the resident was served their ordered preference for low-fat milk (a type of milk that has some or all the fat content removed) for one of eight sampled residents (Resident 46) investigated under the Dining Task. This deficient practice had the potential to result in the resident having a decreased meal intake which could lead to unintentional weight loss and malnutrition (lack of sufficient nutrients in the body). Findings: A review of Resident 46's admission Record indicated the facility admitted the resident on 12/22/2023 with diagnoses that included cerebral infarction (loss of blood flow to part of the brain which damages brain tissue), acute respiratory failure (a serious condition that occurs suddenly when the lungs cannot get enough oxygen), and osteoarthritis (degenerative [progressive, often irreversible deterioration] disorder of the joint resulting in pain) of the hip. A review of Resident 46's Minimum Data Set (MDS- an assessment and care…

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