Camino Healthcare

Based on observation, interview, and record review, the facility failed to: 1. Ensure two of three outside trash bins properly contained with covers that were completely closed. This failure had the potential to attract pests and vermin to the area which is adjacent to the laundry room.Findings: During a concurrent observation and interview on 3/10/2026 at 8:53 a.m., with the DSD, at the trash bin storage area, two large trash bins were overfilled and partially covered. The DSD stated the trash bins should be covered because rodents and other animals can get into the trash. During an interview on 3/13/2026 at 11:49 p.m., with the DSD, the DSD stated the facility does not have policies for the disposal of cardboard boxes and outdoor trash bin disposal. During a review of the State Operations Manual-Appendix PP (SOM), dated 7/23/2025, the SOM indicated the facility must properly contain refuse (trash) and dispose of it properly.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Ensure a sign for Enhanced Barrier Precautions (infection control measure to stop germ spread), was displayed, for one of six residents, Resident 104, in Resident 104's room. This failure had the potential to expose staff and visitors to an infectious organism when touching or caring for Resident 104.Findings: During a review of Resident 104's admission Record, dated 3/4/2026, the admission Record indicated Resident 104 has cellulitis (a common, potentially serious bacterial skin infection) of the right lower limb, methicillin resistant staphylococcus aureus infection (a type of staph bacteria that causes infections resistant to many common antibiotics), and hemiplegia (partial paralysis) & hemiparesis (weakness or inability to move on one side of the body) affecting the left non-dominant side. During a review of Resident 104's History & Physical (H&P), dated 3/6/2026, the H&P indicated Resident 104 has the capacity for making medical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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. Perform hand hygiene before touching the forehead of Resident 1.This failure had the potential to result in exposing Resident 1 to harmful organisms on the hand of CNA1.During a review of Resident 1's Face Sheet, with an admission date of 4/9/2022, the Face Sheet indicated Resident 1 is diagnosed with Dementia, Alzheimer's Disease, and Dysphagia following nontraumatic intracerebral hemorrhage. During a review of Resident1's History and Physical, dated 1/2/2025, the History and Physical indicated Resident 1 does not have the capacity to understand and make decisions. During a review of Resident 1's Order Summary Report, dated 4/9/2022, the Order Summary Report indicated Resident 1 is ordered to have a fortified puree diet, pain assessments with pain management, and staff are to monitor right and left lower extremities for redness, discoloration, swelling, and pain, every shift for immobilizer use. 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 observation, interview and record review, the facility failed to implement its infection prevention and control measures for one of four sampled residents (Resident 1) by failing to change gloves (type of personal protective equipment [PPE] that is worn or used to provide protection against hazardous substances and/or environments) and perform hand hygiene (washing hands or using an alcohol-based hand sanitizer) before administering a wound treatment to Resident 1.This failure had the potential to increase the risk of infection, spread germs and bacteria and impede the healing process for Resident 1. Based on observation, interview and record review, the facility failed to implement its infection prevention and control measures for one of four sampled residents (Resident 1) by failing to change gloves (type of personal protective equipment [PPE] that is worn or used to provide protection against hazardous substances and/or environments) and perform hand hygiene (washing hands or using an alcohol-based…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) had a comprehensive care plan in place to include in and out self-catheterization (a procedure where a thin tube (catheter) is temporarily inserted into the bladder to drain urine, then immediately removed). This deficient practice placed Resident 1 at risk for insufficient care and services related to self-catheterization.Findings: During a review of Resident 1's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 1 was admitted on [DATE] with diagnoses that included fracture of the vertebra (one of the bones that make up the spinal column), paraplegia, and retention of urine (unable to urinate). During a review of Resident 1's History and Physical (H&P), dated 4/10/2025, 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…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 1) received their medication while being out of the facility on pass (permission to be able to leave the facility temporarily). This deficient practice resulted in Resident 1 not taking his prescribed antibiotics when it was due and could potentially lead to complications.Findings: During a review of Resident 1's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 1 was admitted on [DATE] with diagnoses that included fracture of the vertebra (one of the bones that make up the spinal column), paraplegia, and retention of urine (unable to urinate). During a review of Resident 1's History and Physical (H&P), dated 4/10/2025, 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 7/15/2025, 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 interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) temperature was reassessed after acetaminophen (a fever reducing medicine) was given. This deficient practice had the potential for nursing staff to delay care for Resident 1 if a given intervention was not effective.Findings: During a review of Resident 1's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 1 was admitted on [DATE] with diagnoses that included fracture of the vertebra (one of the bones that make up the spinal column), paraplegia, and retention of urine (unable to urinate). During a review of Resident 1's History and Physical (H&P), dated 4/10/2025, 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 7/15/2025, the MDS indicated Resident 1 was able to make himself understood and had the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure accurate and complete documentation was done for one of one sampled resident (Resident 1) when going out of the facility on pass (permission to be able to leave the facility temporarily). This deficient practice had the potential for facility staff to not be aware of where a resident was when they were out of the facility.Findings:During a review of Resident 1's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 1 was admitted on [DATE] with diagnoses that included fracture of the vertebra (one of the bones that make up the spinal column), paraplegia, and retention of urine (unable to urinate).During a review of Resident 1's History and Physical (H&P), dated 4/10/2025, 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 7/15/2025, 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 observation, interview, and record review, the facility failed to report an unusual occurrence to the state agency. Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with a readmission on [DATE]. Resident 1's diagnoses included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN- high blood pressure), and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body). During a review of Resident 1's History and Physical (H&P), dated 2/6/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/22/2025, the MDS indicated Resident 1 was not able to stand, or walk 10 feet. Resident 1 was dependent (helper does all the effort) on staff to transfer from chair to bed.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 ensure the Post Discharge Plan of Care was completed and contained the amount and lists of post discharge medications, for 1 of 4 sampled residents (Resident 1) who was discharged to a Board and Care facility ([B&C] a small residential facility, often referred to as a residential care facility for the elderly (RCFE) or assisted living facility, that provides room, board, and personal care services for a small group of individuals, typically 6 to 10 residents), as indicated in the facility ' s policy and procedure (P&P) titled Discharge Summary. This failure resulted in Resident 1 being discharged with 78 controlled medications (drug prescription specifically regulated by the government due to potential for abuse or harm) and placed the resident at risk for drug overdose, hospitalization and death. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses 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 the Norco (strong pain medicine) medication removed on 3/1 at 5 p.m., 3/13 at 4 p.m., 3/14 at 9 p.m., and the 2 tablets on 3/18 (no years indicated), as indicated in the Controlled Medication (drug prescription specifically regulated by the government due to potential for abuse or harm) Count Sheet dated 8/5/2024, for 1 of 4 sampled residents (Resident 1), were documented in the resident ' s e-MAR (Electronic Medication Administration Record) . This failure had the potential to cause drug diversion (unlawful use of drugs), healthcare personnel miscommunication and cause the resident, drug overdose. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of Alzheimer ' s disease (progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain), cardiomegaly (occurs when the heart is abnormally…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 Infection Control Policy/Procedure, by failing to disinfect the wrist blood pressure monitor before and after use, by 1 of 4 sampled residents (Resident 2). This failure had the potential to spread germs and increase the risk of infections among residents and staff. Findings: During a concurrent observation and interview on 5/14/2025 at 10:05 a.m. with the Licensed Vocational Nurse (LVN 1) at Resident 2 ' s bedside, LVN 1 was observed putting the wrist blood pressure monitor on Resident 2 ' s wrist, had several attempts to check and was unsuccessful in obtaining the blood pressure readings. LVN 1 removed the monitor from the resident ' s wrist, put the blood pressure monitor inside the drawer of the Medication cart 1 without disinfecting. LVN 1 stated she failed to disinfect the wrist blood pressure monitor before and after using on the resident. LVN 2 stated failing to disinfect the wrist…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 an environment free of accident hazards as possible for two of three residents (Residents 2 & 3), by failing to: 1. Ensure Resident 2 ' s care plan was individualized with interventions provided after the fall on 4/1/2025. 2. Conduct an Interdisciplinary Team ([IDT] group of healthcare professionals, including resident/ resident representative, working together to provide residents with needed care) to discuss safety interventions after Resident 2 ' s fall on 4/1/2025. 3. Conduct an accurate fall risk assessment after Resident 3 ' s fall on 1/26/2027. Resident 3. 4. Implement the rehabilitation services recommendations after Resident 3 ' s fall on 2/7/2025 which indicated to apply bed railings, and cushion pad along the bedside to reduce the risk of falls and soften fall. These failures placed Residents 2 and 3 at risk for severe injury, hospitalization and death. Findings: 1). During a review of Resident 2 ' s admission Record, the 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.

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 hazard free environment for one of 9 sampled residents (Resident 1) by failing to: 1) Implement its Policy and Procedure (P&P) titled, Smoking Policy which indicated, no cigarette/tobacco products were allowed to be kept in the possession of the residents. 2) Review, update and document a quarterly Smoking Evaluation for the resident. 3) Ensure Resident 1's smoking Care Plan had current and accurate interventions. These failures had the potential to endanger the health and safety of residents, staff and visitors. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 1's diagnoses included nicotine dependence (a chronic condition characterized by a compulsive and uncontrollable urge to use tobacco products containing nicotine, despite negative consequences), chronic obstructive pulmonary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 notify one of three sampled residents ' (Resident 1) physician, for the resident ' s scratch marks on the left hand. This deficient practice had the potential to worsen the skin condition when left untreated. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated, Resident 1 was admitted to the facility on [DATE]. Resident 1 ' s diagnoses included cerebral infarction (a stroke, specifically the death of brain tissue due to a lack of blood flow), bipolar disorder (a mental health condition characterized by significant and persistent mood swings), and aphasia (a language disorder that affects a person ' s ability to communicate). During a review of Resident 1 ' s History and Physical (H&P), dated 4/1/2025, 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 2/27/2025, 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 interview and record review, the facility failed to ensure, one of three sampled residents ' (Resident 1), urinalysis ([UA]- a laboratory test that examines a urine sample to detect a urinary tract infection [UTI, infection in the urinary system-kidneys, bladder, urethra]) order was carried out and sent to the laboratory (facility conducting the urine test) per the physician ' s order. This deficient practice had the potential for delayed treatment if Resident 1 had an unidentified UTI. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated, Resident 1 was admitted to the facility on [DATE]. Resident 1 ' s diagnoses included cerebral infarction (a stroke, specifically the death of brain tissue due to a lack of blood flow), bipolar disorder (a mental health condition characterized by significant and persistent mood swings), and aphasia (a language disorder that affects a person ' s ability to communicate). During a review of Resident 1 ' s History and Physical (H&P),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain a clean air vent above Resident 15's bed and to ensure the room temperature was between 71- and 81-degrees Fahrenheit for Residents' 5, 38, and 301's rooms. These deficient practices had the potential for the resident to be exposed to dust and allergens affecting her respiratory health and the increased level of discomfort and to negatively impact the residents' quality of life. Findings: a). During an initial tour on 12/17/2024 at 11:31 a.m., the air vent above the head of Resident 15's bed was covered with dust. During a review of the admission Record, the admission record indicated Resident 15 was admitted to the facility on [DATE] with diagnoses that included breast cancer, muscle weakness, and difficulty walking. During a review of the Minimum Data Set (MDS - a resident assessment tool) dated 11/19/2024, the MDS indicated that Resident 15 usually made herself understood and was usually able to understand others. During a review of the…

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

Based on observation, and interview, the facility failed to ensure two sharps container (a puncture-proof container used to contain used and discarded needles and other sharp tools for patient care) on Medication Cart #2 and Medication Cart #4 were replaced with a new one when it reached the Full line. This deficient practice had the potential to result in staff or residents to sustain an injury. Findings: During an observation on 12/19/2024 at 9:26 a.m., the sharps container on Medication Cart #4 was full and had objects protruding out from the sharp's container lid. During an observation on 12/19/2024 at 9:33 a.m., the sharps container on Medication Cart #2 had objects in it that was past the Full line. During a concurrent observation and interview on 12/19/2024 at 2 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Medication Cart #2 and Medication Cart #4 was past the full line and Medication Cart #4 had items that were protruding out of the container lid. LVN 1 stated the sharps container had to be switched to a new one once items in the container have reached the Full…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Minimum Data Set ([MDS] a resident assessment tool) was completed accurately for one of 21 sampled residents (Resident 20). This deficient practice had the potential to negatively affect the plan of care and delivery of care and services for Resident 20. Findings: During a review of Resident 20's admission Record, the admission Record indicated, Resident 20 was admitted to the facility on [DATE] with diagnoses including End Stage Renal Disease ([ESRD] irreversible kidney failure), heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and cirrhosis of liver (a condition in which the liver is scarred and permanently damaged). During a review of Resident 20's History and Physical (H&P) dated 7/23/2023, the H&P indicated, Resident 20 had the capacity to understand and make decisions. During a review of Resident 20's MDS assessment dated [DATE], the MDS 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 interview and record review, the facility failed to ensure one of five residents (Resident 21) received a Pre-admission Screening and Resident Review ([PASRR] a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) level II assessment. This deficient practice had the potential to result in Resident 21 not receiving the required services for her mental health condition. Findings: During a review of Resident 21's admission Record, the admission Record indicated Resident 21 was admitted to the facility on [DATE] with diagnoses including depression (mood disorder that causes a persistent feeling of sadness and loss of interest that could interfere with daily living), Schizophrenia (a mental illness that is characterized by disturbances in thought), and anxiety (a feeling of fear, dread, and uneasiness). During a review of Resident 21's Care Plan, dated 7/31/2023, the Care Plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to initiate a comprehensive care plan for one out of two sampled residents (Resident 20) who was non-compliant with fluid restriction (medical treatment that limits the amount of fluid a person can consume each day) as ordered by the physician. This deficient practice had the potential to place Resident 20 at risk for not receiving the appropriate interventions to prevent fluid overload (a condition where the body has too much water). Findings: During a review of Resident 20's admission Record, the admission Record indicated, Resident 20 was admitted to the facility on [DATE] with diagnoses including End Stage Renal Disease ([ESRD] irreversible kidney failure), heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and dependence on renal dialysis ( a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney (s) have…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 resident, Resident 16, received grooming of his long fingernails. This deficient practice had the potential to cause the resident to scratch and cause skin break down, potentially causing skin infection. Findings: During a review of Resident 16's admission Record, the admission Record indicated Resident 16 was admitted to the facility on [DATE] with diagnoses including diabetes (a disorder characterized by difficulty in blood sugar control), hypertension ([HTN]-high blood pressure), and dementia (a progressive state of decline in mental abilities). During a review of Resident 16's History and Physical (H&P), dated 11/1/2024, the H&P indicated Resident 16 did not have the capacity for medical decision making. During a review of Resident 16's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 11/8/2024, the MDS indicated Resident 16 had severe cognitive impairment. Resident 16 was dependent on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of 1 sampled resident, Resident 16, who had a 10 pounds weight loss within 30 days, was reported to the physician. This deficient practice had the potential to result in a delay in care for Resident 16. Findings: During a review of Resident 16's admission Record, the admission Record indicated Resident 16 was admitted to the facility on [DATE] with diagnoses including diabetes (a disorder characterized by difficulty in blood sugar control), hypertension ([HTN]-high blood pressure), and dementia (a progressive state of decline in mental abilities). During a review of Resident 16's History and Physical (H&P), dated 11/1/2024, the H&P indicated Resident 16 did not have the capacity for medical decision making. During a review of Resident 16's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 11/8/2024, the MDS indicated Resident 16 had severe cognitive impairment. Resident 16 was dependent on 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 a peripheral intravenous line ([IV] - a thin tube inserted into a vein for administration of medications, fluids and/or blood products) was removed after IV antibiotic (a drug used to treat infections caused by bacteria) was completed for one of two sampled residents (Resident 75). This deficient practice had the potential for the IV insertion site to develop infection and/or hospitalization for Resident 75. Findings: During a review of Resident 75's admission Record, the admission Record indicated, Resident 75 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated, Resident 75's diagnoses included End Stage Renal Disease ([ESRD] - irreversible kidney failure), sepsis (a life-threatening blood infection), and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 75's History and Physical (H&P), dated 9/27/2024, the H&P…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 39) had her oxygen saturation ([O2 sat]- a measurement of how much oxygen the blood is carrying as a percentage) levels checked to keep the oxygen (O2) saturation above 90% as indicated in the physician's orders and care plan. This deficient practice had the potential to result in Resident 39 experiencing respiratory distress. Findings: During an observation on 12/18/2024 at 12:41 p.m., Resident 39 had an oxygen concentrator machine (a machine used to deliver oxygen to an individual) and a nasal cannula ([NC]- a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) by her bedside, but the equipment was not in use. During a review of Resident 39's admission Record (Face Sheet), the admission Record indicated Resident 39 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (CVA-stroke, loss of blood flow to a part of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure, two of three sampled residents (Resident 20 and 75), who received hemodialysis ([HD] - a treatment to cleanse the blood of wastes and extra fluids artificially through a machine) treatment, received care in accordance with professional standards of practice by failing to: 1. Implement Resident 20's fluid restriction (medical treatment that limits the amount of fluids a person can consume each day) order accurately. This deficient practice placed Resident 20 at risk for swelling, discomfort, and shortness of breath. 2. Collaborate and communicate with the dialysis center, which hypertensive medications (drugs that can lower blood pressure) were to be held for Resident 20 before dialysis treatment. This deficient practice had the potential to result in adverse condition for Resident 20 during dialysis treatment. 3. Ensure Resident 75's dialysis emergency kit (E-KIT - supplies to help meet the needs of a dialysis resident in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure one of one sampled resident (Resident 60) was provided necessary behavioral health care services for treatment of the residents mental condition by ensuring a psychiatrist (a physician who specializes in psychiatry - the branch of medicine devoted to the diagnosis, prevention, study, and treatment of mental disorders) was notified when Resident 60 had episodes of refusal of care. This deficient practice had the potential to result in lack of interventions to Resident 60's refusal of care and worsening of his mental health condition. Findings: During a review of Resident 60's admission Record, the admission Record indicated, Resident 60 was admitted to the facility on [DATE]. Resident 60's diagnoses included multiple myeloma (a cancer that begins in plasma cells), anemia (a condition where the body does not have enough healthy red blood cells), and hypertension ([HTN] - high blood pressure). During a review of Resident 60's History and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Ensure a follow-up appointment for urology (a medical and surgical specialty that deals with diseases of the urinary tract and male reproductive system in both men and women) evaluation/referral was completed for one of one sampled resident (Resident 80). This deficient practice had the potential to result in the delay of necessary care and services for Resident 80. Findings: During a review of Resident 80's admission Record, the admission Record indicated, Resident 80 was admitted to the facility on [DATE]. The admission Record indicated, Resident 80's diagnoses included urinary retention (a condition that makes it difficult to empty the bladder), obstructive uropathy (a condition in which the flow of urine is blocked), and acute cystitis (infection of the bladder). During a review of Resident 80's History and Physical (H&P), dated 724/2024, the H&P indicated, Resident 80 had the capacity to understand and make decisions. 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 appropriate pharmaceutical services to meet the needs of two of 7 sampled residents (Residents 3 and 55), by failing to ensure: a. Resident 3's jardiance (medication used to control high blood sugar), apixiban (medication given to thin the blood to prevent blood clots), breo ellipta (medication used to improve air flow in lung disease), metoprolol tartrate (medication used to lower the blood pressure), and sitagliplin (medication used to control high blood sugar) were ordered timely from the pharmacy to prevent outage. This deficient practice put Resident 3's health at risk due to missed doses of the medications. b. Licensed Vocational Nurse (LVN) 1 documented the administration of carvedilol (medication used to treat high blood pressure) in a timely manner. This deficient practice had the potential to result in Resident 55 receiving a duplicate dose of Carvedilol. Findings: a). During a review of Resident 3's admission Record,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Ensure Resident 3 received her Jardiance (medication used to control high blood sugar) dose as ordered by the physician. This deficient practice put Resident 3's health at risk due to a missed dose of medication. Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including diabetes (a disorder characterized by difficulty in blood sugar control), hypertension ([HTN]-high blood pressure), and dementia (a progressive state of decline in mental abilities). During a review of Resident 3's History and Physical (H&P), dated 11/1/2024, the H&P indicated Resident 3 can make needs known but cannot make medical decisions. During a review of Resident 3's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 9/2/2024, the MDS indicated Resident 3 had severe cognitive impairment. Resident 3 was dependent on staff 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: 1. Ensure the medication refrigerator did not contain an emergency kit (a box that contains a small supply of medications) and three bags of ertapenem (medication given to treat infection) that were past the discard date. This deficient practice had the potential to result in harm to a resident if administered. Findings: During a concurrent observation and interview with the Assistant Director of Nursing (ADON) in the medication storage room, the medication refrigerator was observed with an emergency kit labeled to be discarded after September 2024. and three bags of ertapenem that were past the discard date. The ertapenem bags indicated they should be discarded on 12/13/2024, 12/14/2024, and 12/16/2024. The ADON stated the emergency kit and ertapenem should not be there. The ADON stated, if the medications were used, a resident could have harmful effects. During a review of the facility's policy and procedure (P&P) titled, Medication Storage in the Facility, dated May 2022, the P&P indicated outdated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 Resident 16 had a Complete Blood Count ([CBC] a blood test that measures the number and type of cells in your blood), Comprehensive Metabolic Panel ([CMP] a blood test that measures 14 substances in your blood to provide an overall picture of your body's chemical balance), Hemoglobin A1C ([HgA1c] a blood test that measures the average blood sugar level over the past two to three months), Thyroid Synthesizing Hormone ([TSH] a blood test used to determine the level of hormones being produced by the thyroid), and Lipid panel (a blood test that determines the level of fat in the blood) completed on 11/4/2024 per physician's order. This deficient practice had the potential to result in a lack of required monitoring of Resident 16's health conditions. Findings: During a review of Resident 16's admission Record, the admission Record indicated Resident 16 was admitted to the facility on [DATE] with diagnoses including diabetes (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 ensure that the hospice (compassionate care for people who are near end of life) services meet professional standards for one of one sampled resident (Resident 71) by failing to: 1. Ensure hospice representative participates with facility interdisciplinary team ([IDT] - team members from different disciplines who come together to discuss resident care) care conference meeting. Findings: During a review of Resident 71's admission Record, the admission Record indicated, Resident 71 was admitted to the facility on [DATE]. The admission Record indicated, Resident 71's diagnoses included protein calorie malnutrition ([PCM] - a nutritional condition that occurs when a person doesn't consume enough protein and calories to meet their nutritional needs), chronic obstructive pulmonary disease ([CPOD] - a chronic lung disease causing difficulty in breathing), and adult failure to thrive (a decline caused by chronic diseases and functional impairments which can…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of 3 residents' (Resident 2) low air loss mattress (LAL, a medical mattress that uses air to prevent and treat pressure wounds, also known as bed sores) was set in the appropriate mattress setting. This deficient practice had the potential to delay wound healing process and risk for further skin breakdown. Findings: During a review of Resident 2s admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 2 ' s Minimum Data Set ([MDS] a resident assessment tool), dated 10/27/2024, the MDS indicated Resident 2 had no cognitive (the ability to think and reason) impairment. The MDS indicated Resident 2 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity) for Activities of Daily Living…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 3 residents' (Resident 2) urinal containing urine was not placed on the bedside table when meal tray was served. This deficient practice had the potential for food cross contamination. Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 2 ' s Minimum Data Set ([MDS] a resident assessment tool), dated 10/27/2024, the MDS indicated Resident 2 had no cognitive (the ability to think and reason) impairment. The MDS indicated Resident 2 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity) for Activities of Daily Living (ADLs) such as rolling left to right and requires partial/moderate assistance (helper does less than half of the effort.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 out of four residents (Resident 1), had telephone orders for Hydroxyzine given by the ordering provider entered into the electronic medical record ([EMR]- a digital version of a resident ' s medical history). This deficient practice had the potential for Resident 1 not being able to receive the medication if they ask for it. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE]. Resident 1 ' s diagnoses included osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of the right hip, muscle weakness, and pain in the right hip. During a review of Resident 1 ' s Minimum Data Set ([MDS]- a resident assessment tool), dated 10/12/2024, the MDS indicated Resident 1 was cognitively intact (ability to reason, understand, remember, judge, and learn). During a concurrent interview and record review on 11/20/2024 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 respiratory care and services for one out of four residents (Resident 3) by failing to: 1. Administer continuous oxygen (O2) 2 liters per minute (L/min) to Resident 3 via nasal cannula ([NC] a small plastic tube, which fits into the person ' s nostrils for providing supplemental O2) according to the physician ' s orders. 2. Ensure Resident 3 ' s O2 equipment was labelled and dated according to its Policy and Procedure (P&P). These failures had the potential to lead to respiratory distress and infection for Resident 3. Findings: During a review of Resident 3 ' s admission Record, the admission record indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 3 ' s diagnoses included pneumonitis (swelling and irritation of lung tissue) due to inhalation (breathing in) of food and vomit and chronic pulmonary obstructive disease ([COPD], a chronic lung disease causing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure an abuse allegation was reported to the State Survey Agency in a timely manner for one of 3 sampled residents (Resident 1). This deficient practice had the potential to result in further abuse to Resident 1. Findings: During a review of Resident 1 ' s admission record (face sheet), the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnosis that include chronic kidney disease (a disease characterized by progressive damage and loss of function in the kidneys), urinary tract infection (an infection in any part of the urinary system), osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down), and Type 2 diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). During a review of Resident 1 ' s Minimum Data Set (MDS- an assessment and care screening tool), dated 6/25/2024, indicated Resident 1 was 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon interview and record review, the facility failed to: 1. Ensure a new prescription order for Bethanechol (a medication used to relieve, prevent, or lowers the incidence of urinary muscle spasms) was carried out for one of 3 sampled residents (Resident 1). This deficient practice has the potential to result in developing complications of illness and delay of care. Findings: A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on 9/2019 and readmitted on [DATE], with diagnoses that included osteoarthritis of the right hip (type of arthritis that occurs when flexible tissue at the ends of bones wears down), benign prostatic hyperplasia (age-associated prostate gland enlargement that can cause urination difficulty), alcohol dependence (a chronic disease in which a person craves drinks that contain alcohol and is unable to control his or her drinking) and anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) discharge planning was developed and implemented per the facility ' s policy and procedure by failing to: 1. Ensure Resident 1 ' s discharge needs were identified on admission. 2. Ensure the Interdisciplinary Team (IDT) was involved in developing Resident 1 ' s discharge plan. 3. Ensure Resident 1 ' s discharge plan was developed and implemented timely. These deficient practices had the potential to result in psychological stress, ineffective discharge planning, and can lead to delay and unsafe discharge. Findings: During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including diabetes (high blood sugar), hypertension (high blood pressure), and muscle weakness (weakness (a lack of strength in the muscles). During a review of Resident 1 ' s History and Physical (H&P) dated 10/13/2023, 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 and interview the facility failed to ensure three of 18 sampled residents (Residents 236, 46 and 20) call light device were placed within reach at all times. This deficient practice had the potential to result in a delay in the residents to obtain necessary care and services. Findings: a). During a review of Resident 236's admission record, the admission record indicated Resident 236 was initially admitted to the facility on [DATE], with diagnoses that included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) and retention of urine, urinary retention (a condition in which you are unable to empty all the urine from your bladder). During a review of Resident 236's history and physical (H&P), dated 11/8/20203, the H&P indicated Resident 236 could make needs known but could not make medical decisions. During a review of Resident 236's Minimum Data Set ([MDS] a comprehensive assessment and care-screening tool), dated 11/14/2023, the MDS 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.

Based on observation, interview, and record review, the facility failed to accurately account for five doses of controlled medications (medications with a high potential for abuse) affecting Residents 17, 22, 25, 46, and 133 in one of two inspected medication carts (Station 2 Cart 2) This deficient practice increased the risk that Residents 17, 22, 25, 46, and 133 could have received too much or too little medication due to lack of documentation potentially resulting in serious health complications requiring hospitalization. Findings: During a concurrent observation and interview on 12/15/2023 at 12:25 p.m. with Licensed Vocational Nurse (LVN) 2 at Station 2 Cart 2 the following discrepancies were found between the Controlled Medication Count Sheet (a log signed by the nurse with the date and time each controlled substance is given to a resident) and the medication card (a bubble pack from the dispensing pharmacy labeled with the resident's information that contains the individual doses of the medication): 1. Resident 17's Controlled Medication Count Sheet for apap/codeine (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: 1. Ensure the indwelling urinary catheter drainage bag (a tube that allows urine to drain from the bladder into a bag that is usually attached to the thigh) for one of one sampled resident (Resident 236) was not touching the floor. This failure placed the patient at risk for acquiring urinary tract infections. 2. Ensure a correct stocking process was folllowed when restocking supplies in the red zone (COVID-19 [a virus to potentially cause severe respiratory illness] confrmed area). This failure placed the residents and staffs at risk for contracting COVID-19 and the spread of COVID-19 the entire facility 3. Ensure laundry personnel wore a gown (personal protective equipment) while handling contaminated linen and failed to change soiled gloves after handling contaminated linen that had feces and body fluid. This failure placed the facility residents and staffs at increased risk for infection. Findings: a). During a review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to notify one of five Residents (Resident 133) of the room change on 12/13/2023 per the facility's policy. This deficient practice resulted to Resident 133 feeling frustrated with the room change. Findings: During a review of Resident 133's admission Record (Face Sheet), the Face Sheet indicated Resident 133 was admitted to the facility on [DATE]. Resident 133's diagnoses included metabolic encephalopathy (an alteration in consciousness caused due to brain dysfunction), spinal stenosis (a narrowing of the spinal canal putting the pressure on the spinal cord and nerves), and osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time). During a review of Residents 133's History and Physical (H&P), dated 11/28/2023, the H&P indicated, Resident 133 had the fluctuating capacity to understand and make decisions. During a review of Resident 133's Minimum Data Set ([MDS] a standardized assessment and care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure one of 10 sampled residents (Resident 52) medical records were updated to show documentation that 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) were discussed and written information was provided to the residents and/or responsible parties. 2. Ensure the Physician Orders for Life-Sustaining Treatment (POLST, a written medical order from a physician, nurse practitioner or physician assistant that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness) was completed for one out five Residents (Resident 133). This deficient practice had the potential to cause conflict with the residents' treatment wishes regarding health care in case of medical emergencies. Findings: 1. 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 a preadmission screening and resident review Level I screening document (PASRR) was completed accurately for one of one residents (Resident 2) who was diagnosed with a mental illness prior to admission in the facility. This deficient practice had the potential to result in Resident 2 not receiving the necessary and appropriate psychiatric level of treatment and evaluation in the facility. Findings: During a review of Resident 2's admission record, the admission record indicated Resident 52 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia (loss of the ability to think, remember, and reason to levels that affect daily life and activities), schizoaffective disorder (a mental disorder with symptoms of hallucinations or delusions and mood disorder like depression), and schizophrenia (a mental disorder that affects a person's ability to think, feel and behave clearly). 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 develop a comprehensive and resident centered care plan for three of nine sampled resident (Residents 52, 283 and 4) by failing to: 1. Develop a care plan to address Resident 52's behavior of changing the amount of oxygen infused from 2 liters to 3.5 liters which was not consistent with the physician's order. 2. Ensure Resident 283 had a plan of care and a physician's order to receive continuous oxygen at 2 liters per minute. 3. Develop a care plan to address Resident 4's bilateral great ingrown toenail. This deficient practice had the potential to a poor quality nursing care provided to Residents 52, 283 and 4. Findings: a). During an observation on 12/12/2023 at 1:11 p.m. in Resident 52's room, the oxygen was infusing at 3.5L and Resident 52 was putting the nasal canula back on. The oxygen tubing, bag and humidification bottle were dated 11/29/2023. Resident 52 did not appear to have any discomfort or respiratory distress at the time. During a review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 52 and Resident 283) received respiratory care consistent with professional standards of practice by failing to: 1. Ensure the oxygen (air) nasal cannula (a device used to deliver supplemental oxygen) tubing, storage bag and humidifier (liquid that moistens the air) bottle were changed after seven days from 11/29/2023 and the oxygen nasal cannula tubing, storage bag, and humidifier bottle was labeled with the date of change to be used as reference for changing humidifier bottles in seven days for Resident 52. 2. Ensure Resident 283 received the correct amount of oxygen ordered at 2 liters per minute as by the physician. These failures had the potential to result in unsafe use or storage of oxygen equipment, respiratory infection and respiratory distress (being unable to breathe comfortably), and/or hospitalization. Findings: a). During an observation on 12/12/2023 at 1:11 p.m. in Resident 52's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement their Infection prevention and control policy and procedure (P&P) by failing to report the facility ' s Coronavirus Disease ([Covid-19] a highly contagious infection caused by a virus that could easily spread from person to person) outbreak (at least one confirmed case of Covid-19 who had resided in the facility for at least 7 days) to the California Department of Public Health (CDPH) District Office. These deficient practices had the potential to result in the spread of Covid-19 and infections to residents, staff, and visitors. Findings: During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted on [DATE] with diagnoses including diabetes (high blood sugar), hypertension (high blood pressure), and heart failure (the heart is unable to pump blood around the body). During a review of Resident 1 ' s History and Physical (H&P), the H&P indicated Resident 1 had the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident who receive dialysis (the process of removing waste products and excess fluid from the body using a machine when the kidneys are not able to do so) was provided proper transportation to and from hemodialysis appointments at a dialysis facility for Resident 1. This deficient practice had the potential for delayed dialysis treatments and safety issues. Findings: During a review of Resident 1's admission record, Resident 1 was admitted on [DATE] with diagnoses that included end stage renal disease (ESRD- a medical condition in which a person's kidneys stop functioning on a permanent basis leading to the need for dialysis treatment or a kidney transplant to maintain life), hypertension (high blood pressure), heart failure (a condition in which the heart doesn't pump blood as well as it should and depression (persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities). During a review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the floormat (a material placed on the floor to protect the resident from injury during a fall) as indicated in the comprehensive person-centered care plan, for one of 3 sampled resident's (Resident 2), who had episodes of fall, was implemented. This deficient practice had the potential that Resident 2 will not be protected during another fall and placed the resident at risk to sustain severe injuries. Findings: During a review of Residents 2's admission Record indicated that Resident 2 was re-admitted to the facility on [DATE], with diagnosis that included history of abnormalities of gait (manner of walking) and mobility (ability to move) and muscle weakness. During a review of Resident 2's History and Physical (H/P) dated 8/5/2023, the H/P indicated Resident 2 had the capacity to understand and to make decisions. During a review of Resident 2's MDS Set (MDS, a standardized assessment and care screening tool), dated 9/8/2023, 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 the care plan for 1 of 3 sampled residents (Resident 2), who had a recurrent fall and a status post fall episode dated 9/1/2023, was reassessed and revised. This deficient practice placed the resident at risk to sustain severe injuries and affect the highest practicable physical, mental and psychosocial well-being of the affected resident. Findings: During a review of Residents 2's admission Record indicated that Resident 2 was re-admitted to the facility on [DATE], with diagnosis that included history of abnormalities of gait (manner of walking) and mobility (ability to move) and muscle weakness. During a review of Resident 2's History and Physical (H/P) dated 8/5/2023, the H/P indicated Resident 2 had the capacity to understand and to make decisions. During a review of Resident 2's MDS Set (MDS, a standardized assessment and care screening tool), dated 9/8/2023, the MDS indicated Resident 2 usually had the ability to understand and be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three residents (Resident 1), who did not have a mental health disorder diagnosis, was not prescribed Seroquel medication, an antipsychotic medication to treat mental health conditions including schizophrenia and bipolar disorder. This failure resulted to Resident 1's unnecessary use of the antipsychotic medication and placed the resident at risk for life-threatening adverse reactions which could lead to serious injury or death. Findings: During a review of Residents 1's admission Record, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 had diagnosis that included history of dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and history of fall. During a review of Resident 1's Hospital History and Physical (H/P) dated 9/15/2023, indicated Resident 1 can make needs known but could not make medical…

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