Devonshire Care Center

Based on observation, interview, and record review, the facility failed to ensure services provided met professional standards, when two nursing staff members were observed using their personal cell phones in the patient care areas. This failure had the potential to affect the quality of care the residents would receive in the facility. Findings: On April 29, 2025, at 10 a.m. an unannounced visit was made to the facility for the investigation of a complaint regarding quality of care. On April 29, 2025, at 10:20 a.m., an observation and concurrent interview was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 was observed looking at her personal cell phone, with an earbud in her right ear, sitting at nurse ' s station two. LVN 1 stated she should not have been on her cell phone, or have an ear bud in, the facility has rules about personal cell phone use. On April 29, 2025, at 12 p.m., an observation and concurrent interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 was observed at nurse ' s station one, leaning onto countertop, texting on her cell phone.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 follow-up appointments and laboratory work were completed according to the discharge instructions from the acute hospital, for one of six residents (Resident A). This failure resulted in a delay in care and treatment for Resident A and had a potential to affect the resident's overall health condition. Findings: On April 29, 2025, at 10:00 a.m. an unannounced visit was conducted to the facility for the investigation of a complaint regarding quality of care. On April 29, 2025, at 12:20 p.m., an interview was conducted with Resident A. Resident A stated he was admitted to the facility for rehabilitation services after he had surgical repair of a hernia (a bulging of an organ or tissue through an abnormal opening). On April 29, 2025, at 2:25 p.m., a follow up interview was conducted with Resident A. Resident A stated he had not had a follow up appointment with the surgeon since his surgery. Resident A stated he has heart and breathing problems, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the California Department of Health (CDPH - a state agency) was notified timely or within two hours after an abuse allegation against a Certified Nursing Assistant (CNA) was reported to the facility staff according to the facility's policy and procedure, for one of three residents reviewed (Resident A). This failure had the potential for a delay in the investigation and implementation of the abuse protocol and exposed the vulnerable residents to further abuse. Findings: On March 9, 2025, at 1:30 p.m., an unannounced visit was conducted at the facility to investigate an allegation of abuse. On March 9, 2025, at 3:22 p.m., during an interview with Resident A and Resident A's family member, Resident A stated CNA 1 kept on putting her cellphone in his pocket on April 27, 2025. Resident A stated she told her family members about it when they visited her on April 28, 2025. On March 9, 2025, Resident A's record was reviewed. Resident 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 accurate documentation of the residents' wishes regarding their care were maintained for 12 of 18 residents reviewed for Advance Directives (AD - a written instruction relating to the provision of health care when the individual is incapacitated) (Residents 14, 21, 32, 40, 41, 50, 55, 59, 61, 71, 78, and 138), when: 1. For Resident 14, the signing doctor was different from the physician's name on the Physician Orders for Life-Sustaining Treatment (POLST - documents a patient's preferences for end-of-life care in the face of serious illness or irreversible conditions); 2. For Resident 32, the POLST did not have the physician's information or license number on the form; 3. For Resident 41, the POLST was not signed by the physician since January 28, 2025; 4. For Resident 50, there was no physician information and physician signature on the POLST form; 5. For Residents 21, 55, 59 and 61, there was no documented evidence the POLST was reviewed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 resident care plans were initiated and/or updated when: 1. No discharge care plans were developed and/or updated for Residents 33, 71, 78 and 139. This failure had the potential for the residents' pre and post-discharge needs to not be anticipated and addressed by the facility staff; 2. No care plan was developed for the use of a indwelling catheter (a flexible tube inserted into the bladder to drain urine) for Resident 13. This failure had the potential to result in Resident 13's indwelling catheter care issues to not be addressed and monitored by the facility staff; and 3. No care plan was developed regarding the change in condition on April 3, 2025, regarding a urinary tract infection (UTI) for Resident 138. This failure had the potential for Resident 138's UTI to not be addressed and monitored by the facility staff. Findings: 1a. On April 8, 2025, at 1:30 p.m., the (name on county) Ombudsman (OMB) was present in the facility to assist…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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, for four of four residents, (Residents 14, 18, 49, and 8), the facility failed to ensure the residents were not left soiled, wet, and unchanged by staff. These failures resulted in Resident 8, 14, 18, and 49, being left soiled in their urine, feces, and wet linen for hours and feeling ignored and not cared for. In addition, the failure has the potential for the residents to develop skin conditions and infection which could affect the resident's overall health condition. Findings: 1.On April 9, 2025, at 12:50 p.m., an interview with Certified Nursing Assistant, (CNA) 1 was conducted. CNA 1 stated Resident 8 complained to her she was soiled and CNA 2 answered the light, came into the room, did not acknowledge her need, walked out and never came back to change her. CNA 1 stated she observed Resident 8 entire bed linen was soiled. On April 9, 2025, Resident 8's record was reviewed. Resident 8 was admitted on [DATE], with diagnoses which included, type 2 diabetes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 sufficient staff were provided to meet the needs of the residents, 1. For four of 88 residents (Residents 14,18, 46, and 51) complained that staff failed to assist with activities of daily living (ADL- daily care activities) in a timely manner; and 2. The facility did not meet the required minimum of Actual Total Direct Care Service Hours (Actual DCSH) of 3.5 and the actual CNA DCSH of 2.4 hours for the month of March 2025. These deficient practices caused feelings of frustrations and anger, among the residents, and negatively affected the quality of care for the residents. Findings: 1. On April 7, 2025, at 1:11 p.m., during an interview with Resident 14, Resident 14 stated the call light was not answered in a timely manner. Resident 14 stated 30 percent of the time the call light is not answered at all. Resident 14 stated the CNA's go to lunch and no one covered them. Resident 14 further stated there was no teamwork, and she used…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 food of the temperature, flavor, consistency, and appearance preferred by residents, when: 1) Residents 14, 19, 41, 32, 50, 61, 71, and 289 complained of the food being tasteless, poor appearance, and temperatures were either too hot or too cold; and 2) Resident 67 complained snacks were not available for most of the residents. These failures could potentially lead to weight loss and a general lack of enjoyment in daily living, which could lead to potentially negative clinical outcomes. Findings: On April 7, 2025, at 10:30 a.m., an interview was conducted with Resident 67. Resident 67 stated he recently had asked staff for a snack at night because he felt hungry. Resident 67 stated he was told by the night staff there was not anything for him as, they had run out of snacks five minutes before he asked. On April 7, 2025, at 11:33 a.m., an interview was conducted with Resident 289. Resident 289 stated he had been without teeth even prior to admission and could eat anything he wants. Resident 289 stated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, sanitary food preparation and storage practices were followed in the kitchen when: 1. One open box of breakfast patties was exposed and open to air in the walk-in freezer; and 2. Black wet debris was observed where the metal walls met the flooring on all four sides of the walk-in refrigerator. These failures had the potential to cause food-borne illness in a highly susceptible resident population. Findings: 1.On April 7, 2025, at 9:30 a.m., an observation with the Dietary Manager (DM) was conducted in the kitchen. One open box of breakfast patties was observed exposed and open to air in the walk-in freezer. During a concurrent interview the DM stated this could cause possible cross-contamination. The DM further stated all food items should be sealed to avoid food deterioration. A review of the facility's policy and procedure, titled Food Storage: Cold Food, dated September 2017, indicated .all foods will be stored wrapped or in a covered container .to prevent cross contamination . 2. On April 7,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure infection prevention and control practices were upheld when: 1. One staff was observed placing the ice scoop on top of the transport cart instead of the designated container, while refilling the residents' water pitchers with ice; 2. Resident 236's peripheral (away from the center) intravenous line (IV- into the vein) was not labeled with a date and licensed nurse initials; This had the potential for the IV site to not be changed timely, resulting in infiltration or infection of the IV site; and 3. During medication administration observation, Licensed Vocational Nurse (LVN) 1 was observed not disinfecting the blood pressure cuff in between patient use. In addition, LVN 1 did not follow infection control practices when administering medications to Resident 16. These failures had the potential to spread infection among the vulnerable residents of the facility. 1. On April 7, 2025, at 9:27 a.m., a concurrent observation and interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure call light was within reach for use, for one of one resident reviewed for accommodations of needs (Resident 17). This failure had the potential to cause delay of care and to cause resident's needs to not be met in a timely manner. Findings: On April 7, 2025, at 9:54 a.m., Resident 17 was observed with Certified Nursing Assistant (CNA) 1 was conducted. Resident 17's call light was observed tucked in his bedside drawer which was located behind him. On April 9, 2025, Resident 17's record was reviewed. Resident 17 was admitted on [DATE], with diagnoses which included, cerebral infarction (lack of blood flow to the brain), seizures (disturbance of brain activity), and ulcerative colitis (inflammation of the inner lining of large intestines). Resident 17's History and Physical, dated October 27, 2024, indicated Resident 17 was alert and oriented to person, place, and situation and able to make his needs known. Resident 17's Minimum Data…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 exercise reasonable care for the protection of the resident's property from theft or loss to occur, for one of one resident reviewed for personal property (Resident 27), when the resident's lower dentures were lost. This failure resulted in Resident 27 feeling distressed about the loss of her bottom dentures. Findings: On April 7, 2025, at 12:25 p.m., a concurrent observation and interview was conducted with Resident 27 in the room. Resident 27 was observed sitting in bed and watching television. Resident 27 stated she had lost her bottom teeth approximately two weeks ago. Resident 27 stated she believed her bottom dentures may have gone to the laundry and she told the nurse on the first morning the dentures were missing. On April 10, 2025, at 3 p.m., an interview with Resident 27 was conducted in the activity room at the resident's request. Resident 27 stated the CNA who worked yesterday had been unable to find them. A concurrent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - a clinical assessment tool) was accurately coded, for one of three residents reviewed for dialysis (Resident 52). This failure resulted in an inaccurate MDS assessment to be submitted to CMS (Centers for Medicare and Medicaid Services). Findings: On April 8, 2025, Resident 52's record was reviewed. Resident 52 was admitted to the facility on [DATE] with diagnoses which included congestive heart failure (serious condition where the heart does not pump blood efficiently), chronic (persisting for a long time) kidney disease stage 3 (moderate damage), and presence of an automatic cardiac defibrillator (a small battery-powered device placed in the chest which detects and stops irregular heartbeats). Review of Resident 52's indicated the resident was placed under hospice services and was not receiving dialysis services. A review of Resident 52's MDS Section O, dated September 11, 2024, indicated Resident 52 was neither 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, for one of 21 residents reviewed (Resident 138), the facility failed to ensure the physician was notified timely of Resident 138's urine culture and sensitivity result. This failure resulted in Resident 138 not receiving prompt treatment for the urinary tract infection. Findings: On April 7, 2025, Resident 138's record was reviewed. Resident 138 was admitted to the facility on [DATE], with diagnoses which included diabetes (abnormal blood sugars) and chronic (persisting for a long time) kidney disease stage 3b (moderate kidney damage). A review of Resident 138's eINTERACT Change in Condition, dated April 3, 2025, at 7:14 p.m., indicated Resident 138 complained of burning during urination. Subsequently the physician was notified and the physician recommended a urinalysis with culture and sensitivity if indicated. A review of Resident 138's urinalysis report indicated the urine specimen was collected on April 4, 2025, at 6 a.m., and the result was reported to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to coordinate optometry services when the resident requested it for one of one Residents, (Resident 40), reviewed for vision/hearing. In addition, Resident 40 was admitted on [DATE], with a pair of glasses that was missing the right lens. This failure could have caused Resident 40 sensory deprivation and had the potential to result in physical discomfort. Findings: On April 8, 2025, at 10:23 a.m., Resident 40 was observed to be wearing his eyeglasses on with the right lens missing. In a concurrent interview with Resident 40, he stated he had waited months to see the optometrist (an eye specialist). A review of Resident 40's record indicated Resident 40 was readmitted to the facility on [DATE], with diagnoses which included major depressive disorder (feelings of sadness and loss of interest), and diabetes cellulitis (high blood sugar levels). A review of Resident 40's Inventory of Personal Effects, dated January 17, 2025, indicated Resident 40…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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, for two of three residents reviewed for urinary catheter (used to drain urine from the bladder) (Residents 13 and 59), the facility failed to identify, assess, and address signs and symptoms related to urinary catheter complications, when: 1. Resident 13's suprapubic catheter (a tube placed through the abdominal wall directly into the bladder) tubing was found to have an excessive amount of sediment. In addition, the follow up appointment with the urologist was not done timely; and 2. Resident 59's indwelling foley catheter (urinary catheter used for continuous drainage of the bladder) tubing was found to have an excessive amount of sediment. In addition, the follow up urology appointment scheduled on November 19, 2024, was not done accordingly. These failures had increased the risk of urinary tract infection for Residents 13 and 59. Findings: 1. On April 7, 2025, at 10:28 a.m., Resident 59 was observed sitting in his wheelchair. Resident 59's 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow Resident 289's physician order to provide a regular textured, thin liquid consistency diet. This deficit practice had the potential for Resident 289's needs to not be met and placed the resident at risk for weight loss. Findings: On April 7, 2025, at 11:33 a.m., a concurrent observation and interview was conducted with Resident 289. Resident 289 was sitting in bed. In a concurrent interview, Resident 289 stated he could eat whatever he wants even without teeth when he was at home. Resident 289 stated he had been receiving a pureed diet since his admit to the facility and he should be getting a regular diet. A review of Resident 289's record was reviewed. Resident 289 was admitted to the facility on [DATE], with diagnoses which included open wound of left cheek and temporomandibular area (the joint that connects the lower jaw (mandible) to the skull), sequela (limited jaw movement, clicking or popping sounds, and even long-term…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility document review, the facility failed to ensure the performance evaluation was completed annually, for one of eight direct care staff reviewed (DCS 5). Findings: On April 2025, 2:45 p.m., a concurrent interview and facility document review of DCS 5 personnel file was conducted with the Director of Staff Development (DSD). The DSD confirmed and acknowledged DCS 5 was hired on January 3, 2012, and no annual performance evaluation documentation was readily available in the employee personnel file. A review of the facility's policy and procedure titled, Performance Evaluations, dated November 1, 2023, indicated, .The first performance evaluations may be after completion of the first 90 days of employment .After that review, performance evaluation may be conducted annually, on or around your anniversary date.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure storage of medical supplies and medication conformed to national standards and the facility policy and procedure when: 1. Four Biopatch IV (intravenous- into the vein) dressings (used to absorb exudate and to cover a wound caused by IV lines) were found outdated inside the Station 1 IV cart, readily available for use; and 2. Fluocinonide 0.05% (percent- unit of measurement) topical solution (used to treat the itching, redness, dryness, crusting, scaling, inflammation, and discomfort of various skin conditions) with an open date of [DATE], with the label torn and faded, was found in the treatment cart, readily available for use. This had the potential for the IV dressings and outdated topical solution to be used on the vulnerable residents of the facility, which could lead to adverse effects from use of these outdated IV supplies and medication. Findings: 1. On [DATE], at 4:58 p.m., an inspection of Station 1 IV medication cart was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe environment when loose wires were observed hanging at the base of the back wall in the room, for one of one resident reviewed for environment (Resident 67). This failure had the potential to affect the safety and wellbeing of the resident. Findings: On April 7, 2025, at 10:30 a.m., loose hanging wires were observed at the base of the back wall in Resident 67's room. Resident 67's record was reviewed. Resident 67's admission Record, indicated the resident was admitted to the facility on [DATE], with diagnoses which included surgical amputation, muscle weakness, unsteady on his feet, and diabetes mellitus (body can't control sugar in the blood). Resident 67's History and Physical, dated February 21, 2025, indicated Resident 67 had the capacity to understand and make decisions. Resident 67's Minimum Data Set (MDS-an assessment tool), dated February 24, 2025, indicated Resident 67 had a BIMS (Brief Interview for Mental Status)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 scheduled hemodialysis (a treatment using a machine and special filter to clean the blood of a kidney failure person) treatments were received, for one of three residents reviewed (Resident 4), when transportation to the dialysis center was not arranged. This failure resulted in Resident 4 to missed dialysis treatments while at the facility. In addition, this failure had the potential for Resident 4 to increased risk of medical complications including fluid overload (excess fluid in the blood), edema (swelling), shortness of breath, and high blood pressure. Findings: On March 27, 2025, at 9 a.m., an unannounced visit was made to the facility for the investigation of a complaint regarding quality of care and treatment. On March 27, 2025, Resident 4's record was reviewed. Resident 4 was admitted to the facility on [DATE], with diagnoses which included end stage renal disease (a severe condition where the kidneys have permanently lost most of 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 ensure appropriate monitoring was conducted according to the facility's policy and procedure, for three of six residents (Residents A, B, and C), when the residents sustained a fall. This failure had the potential for a delay in the care and treatment to address possible neurological complications related to fall incident for Residents A, B, and C. Findings: On February 19, 2025, at 8:45 a.m., an unannounced visit to the facility was conducted to investigate complaints of quality of care. 1. On February 19, 2025, a review of Resident A's medical record was conducted. Resident A was admitted to the facility on [DATE], with diagnoses which included Parkinson ' s (a disorder of the central nervous system that affects movement and includes tremors) disease, subdural hemorrhage (caused by a head injury, bursts blood vessels and blood pools, pushing the brain), and aphasia (language disorder, unable to communicate effectively). 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 pain management was provided according to the physician's order and plan of care, for two of six residents (Residents B and D). This failure had the potential to result in Residents B and D's pain to not be managed. Findings: On February 19. 2025, at 8:45 a.m., an unannounced visit to the facility was conducted to investigate complaints of quality of care. 1. On February 20, 2025, at 10:20 a.m., a review of Resident B ' s medical record was conducted. Resident B was admitted to the facility on [DATE], with diagnoses which included encephalopathy (brain disease which alters function or structure) and cerebral infarct (a stroke-blood flow to the brain is interrupted, leading to brain tissue death). A review of Resident B ' s Medication Administration Record (MAR), included a physician's order, dated January 6, 2025, which indicated, Acetaminophen (pain medication) Tablet 325 MG (milligram - unit of measurement) Give 2 (two) tablet by mouth every 4…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to report an injury of unknown origin (the cause of injury was not observed by any person or could not be explained by the resident) to California Department of Public Health (CDPH), for one of three residents (Resident 1), when Resident 1 had discoloration on the both upper extremities, lower abdomen, and left lateral trunk on March 10, 2025. This failure had the potential to result into a delayed investigation to rule out abuse and neglect. Findings: On March 12, 2025, at 9:10 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding an injury of unknown origin. On March 12, 2025, Resident 1's medical record was reviewed. A review of Resident 1's admission Record, indicated the resident was admitted to the facility on [DATE], with diagnoses which includes chronic respiratory failure (condition of lungs unable to adequately exchange oxygen and carbon dioxide over an extended period), cirrhosis of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a care plan was developed to address the rashes, for five of the six residents (Residents 2, 6, 7, 8 and 10). This failure had the potential to result in unmet needs and a potential for the rashes to worsen. Findings: On January 14, 2025, at 9:10 a.m., an unannounced visit was conducted at the facility to investigate a quality of care, infection control, misappropriation of property and resident rights issue. 1. A review of Resident 2's admission record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses which included aftercare following surgery on the genitourinary system (relating to the genital and urinary organs), obstructive and reflux uropathy (conditions that affect the urinary system), calculus of kidney (hard deposit of minerals and salts that forms in the kidney), heart failure (occurs when the heart is unable to pump enough blood and oxygen to the body), atrial fibrillation (rapid heart rate that causes poor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure resident's money are protected from theft and loss, for one of four sampled residents (Resident 1), when the residents money was missing and not accounted for after the resident was admitted to the facility. This failure had the potential for a misappropriation of resident's funds to occur. Findings: On January 14, 2025, at 9:10 a.m., an unannounced visit was conducted at the facility to investigate a quality-of-care, infection control, misappropriation of property, resident rights and resident neglect issues. A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE], and discharged on December 1, 2025, with diagnoses which included surgical aftercare of skin and subcutaneous tissue (a layer of tissue beneath the skin), squamous cell carcinoma (type of cancer that starts as a growth of cells on the skin) of left upper limb, hypothyroidism (condition in which thyroid gland does not produce enough thyroid…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented according to the facility policies and procedures and Centers for Disease and Prevention Control (CDC) guidelines, when the facility had COVID -19 (respiratory infection caused by the SARS-CoV virus) outbreak with 33 residents and 12 staff tested positive for COVID-19, when: 1.The Director of Nursing (DON) was observed wearing an N95 respirator mask (a type of respiratory protective device or personal protective equipment [PPE] designed to achieve a very close facial fit and very efficient filtration of airborne [suspended in air] particles) which was not fit-tested (a procedure that verifies that a respirator fits a person's face and provides the expected level of protection). In addition, the DON had a beard while wearing an N95 mask; 2. 46 out of 70 current direct care staff (Registered Nurses [RN] 1, 2, 3, 4, Licensed Vocational Nurses [LVN] 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an allegation of physical abuse involving Resident 1 was reported to the California Department of Public Health (CDPH - a state agency), Omdubsman, and law enforcement immediately, or not later than two hours after the allegation was made according to the facility's policy and procedure, for one of three residents (Resident 1). This failure had the potential to place Resident 1 at risk for harm from further abuse. Findings: On January 16, 2025, at 3:51 p.m., CDPH received a facsimile (fax - telephonic transmission) report of a complaint from Adult Protective Services Department (APS) indicating an allegation of abuse involving Resident 1. The report indicated the reporting individual to APS alleged Resident 1 was assaulted by another resident at the facility, but the incident was not reported by the facility. On January 30, 2025, at 10:13 a.m., an unannounced visit was conducted at the facility for complaint investigations. On February 3, 2025,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to conduct a thorough investigation of an allegation of abuse, for one of three residents (Resident 1), when Resident 1 reported to the facility staff on December 20, 2024, that someone pulled her hair. This failure resulted in Resident 1 to not be provided sufficient protection, and potentially exposed the resident to further abuse. Findings: On January 16, 2025, at 3:51 p.m., the California Department of Public Health (CDPH – state agency) received a facsimile (fax - telephonic transmission) report of a complaint from the Adult Protective Services Department (APS) containing an allegation of abuse involving Resident 1. The report indicated the reporting individual to APS alleged Resident 1 was assaulted by a fellow resident at the facility, but the incident was not reported by the facility. On January 30, 2025, at 10:13 a.m., an unannounced visit was conducted at the facility for complaint investigations. On February 3, 2025, Resident 1 ' s record was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow the physician ' s treatment orders for skin conditions, for two of three residents (Residents 3 and 4). This failure had the potential to result in the worsening of Resident 3 and 4 ' s skin conditions. Findings: On February 3, 2025, at 10 a.m., an unannounced visit was conducted at the facility to investigate complaint intakes. 1. On February 3, 2025, at 11:22 a.m., Resident 3 was observed lying in bed. On February 3, 2025, a review of Resident 3 ' s record indicated the resident was admitted to the facility on [DATE], with diagnoses which included gastrostomy status (presence of a surgical opening in the stomach) and ileostomy status (a piece of the upper small intestines is diverted to an artificial opening in the abdominal wall, allowing waste to leave the body). A review of Resident 3 ' s History and Physical Examination, dated January 9, 2025, indicated Resident 3 had the capacity to understand and make decisions. A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed ensure the physician ' s orders for treatment of pressure injuries (a localized area of skin and/or underlying tissue damage caused by prolonged pressure, shear, and/or friction) was conducted, for two of three residents reviewed (Residents 3 and 4). This failure had the potential to result in the worsening of Resident 3 and 4 ' s pressure injuries. Findings: On February 3, 2025, at 10 a.m., an unannounced visit was conducted at the facility to investigate complaint intakes. 1.On February 3, 2025, at 11:22 a.m., Resident 3 was observed lying in bed. In a concurrent interview, Resident 3 stated she had a pressure wound to her bottom. On February 3, 2025, Resident 3 ' s record was reviewed. A review of Resident 3 ' s record indicated Resident 3 was admitted to the facility on [DATE], with diagnoses which included anemia (when the blood produces a lower-than-normal amount of healthy red blood cells) in chronic (occurs over time) kidney disease,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure consults were arranged for four of the seven sampled residents (Residents 3, 4, 6 and 7) in accordance with the physician order. This failure had the potential to result in delayed provision of care and treatment for the residents to reach the highest practicable physical, mental, and psychosocial well-being. Findings: On November 14, 2024, at 9:15 a.m., an unannounced visit was conducted at the facility to investigate a quality-of-care issue. 1. A review of Resident 3 ' s admission record indicated Resident 3 was admitted to the facility on [DATE]. Resident 3 was admitted with diagnoses which included lymphedema (a chronic condition that causes swelling in the body due to buildup of lymph fluid), atherosclerosis of arteries of extremities (when plaque builds up in the walls of arteries, reducing the blood flow), peripheral vascular disease (affects blood vessels outside the brain and heart) and anxiety disorder (condition that causes persistent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 list of home medications were obtained timely to ensure routine medications were made available and administered for one of the four sampled residents (Resident 2) on admission to the facility. This failure to make the medications readily available had the potential to cause an adverse effect on the health of the resident. Findings: On October 8, 2024, at 8:56 a.m., an unannounced visit was conducted at the facility to investigate a complaint on resident ' s rights and quality of care issue. A review of Resident 2 ' s admission record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2 ' s diagnoses included sprain in the right knee (when ankle rolls or twists in an odd way), falls, difficulty walking, pain in the right knee and muscle weakness. A review of Resident 2 ' s progress notes dated September 23, 2024, by Registered Nurse (RN) 3 indicated, admitted .from (hospital 1) .under the care of (name of physician at skilled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 appropriate infection control practices, when one visitor and one staff failed to wear personal protective equipment (PPE) before entering a room with a signage for contact isolation precaution (required to protect against either direct or indirect transmission). This failure had the potential to result in the spread of infection, cross-contamination and spread of disease that could affect other residents in the facility, visitors, and staff. Findings: On July 17, 2024, at 9:03 a.m., an unannounced visit was conducted at the facility to investigate infection control issue. On July 17, 2024, at 9:42 a.m., during facility tour observation, Resident 1's room was observed with a signage for contact isolation, and a visitor was sitting on Resident 1's bed not wearing any PPE. On July 17, 2024, at 9:50 a.m., during an interview, the visitor stated facility staff did not inform him Resident 1 was on contact isolation precaution and he should wear a gown before entering the room. On July 17, 2024, at 9:59 a.m.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 necessary services to maintain appropriate hygiene was provided, for one of eight residents reviewed (Resident 1), when Resident 1 did not receive fingernail care. This failure had the potential to negatively impact the physiological and psychological well-being for Resident 1. In addition, this failure had the potential for Resident 1 to acquire food borne illness and infection. Findings: On July 3, 2024, at 8:37 a.m., during a concurrent observation and interview with Resident 1, Resident 1's fingernails were observed to be discolored yellow with dark debris underneath, long, and untrimmed. In a concurrent interview, Resident 1 stated he was unable to trim and clean his fingernails on his own. Resident 1 stated the staff had not provided nail care to him. On July 3, 2024, at 9 a.m., Resident 1 was concurrently observed with Licensed Vocational Nurse (LVN) 1. LVN 1 stated the podiatrist (a specialist in the care for feet) would…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure necessary services to prevent skin breakdown was provided, for one of eight residents reviewed (Resident 1), when Resident 1 developed skin irritation on the neck. This failure had the potential for Resident 1 to develop worsening skin irritation and infection. Findings: On July 3, 2024, at 8:37 a.m., during a concurrent observation and interview with Resident 1, there was a red area of skin irritation on the right side of the neck between the resident's skin folds. In a concurrent interview, Resident 1 stated there was no treatment provided for the redness on the skin of the neck. On July 3, 2024, at 9 a.m., Resident 1 was concurrently observed with Licensed Vocational Nurse (LVN) 1. LVN 1 stated the Certified Nursing Assistant (CNA) and the Treatment Nurse (TN) performed resident skin checks. LVN 1 stated he was not aware of the skin issue on Resident 1's neck area and did not notice it when he was providing care to Resident 1.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure call lights were answered in a timely manner, for one of nine residents (Resident 5), when Resident 5 waited 15 minutes for the call light to be answered. This failure had the potential for Resident 5 to have needs unmet. Findings: On March 7, 2024, at 10 a.m., an unannounced visit to the facility was conducted to investigate four complaints and one Facility Reported Incident (FRI). On March 7, 2024, at 11:15 a.m., an interview was conducted with Resident 5. Resident 5 stated the staff were terrible about responding to the call light. Resident 5 stated staff would come in to turn the call light off, leave, and not return. On March 7, 2024, at 11:40 a.m. observed Resident 5 activated his call light. At 11:55 a.m., a staff member came into Resident 5's room to address the call light. On March 7, 2024, at 12:30 p.m., an interview was conducted with Certified Nursing Assistant, (CNA 1). CNA 1 stated that call lights should be answered…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure appropriate care and treatment services for pressure injuries (PIs - localized damage to the skin and underlying soft tissue over a bony prominence or from a medical device) were provided, for two of seven residents reviewed (Residents 1 and 5), when: 1. The facility failed to assess Resident 1's intergluteal cleft linear (the deep [NAME] or groove that lies between the two gluteal regions), and the right buttock linear excoriations, (raw wearing of the skin), weekly. This failure had the potential for the facility not to be able to determine if the wound was healing or worsening; and 2. The facility failed to place an air mattress on the bed at admission according to the physician's order for Resident 5. In addition, the facility failed to carry out the wound care specialist's recommendation for the provision of an air mattress for Resident 5. This failure resulted in the delay of implementation of care and treatment for 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, for one of nine residents (Resident 7), had floor mats on both sides of the bed. This failure increased the risk of Resident 7 to have an injury if she fell out of bed on the right side. Findings: On March 7, 2024, at 10 a.m., an unannounced visit to the facility was conducted to investigate for four complaints and one Facility Reported Incident, (FRI). On March 7, 2024, at 11:37 a.m., observed Resident 7 lying in bed. Resident 7's bed was in the lowest position and had one floor mat on the left side of the bed. On March 7, 2024, at 11:37 a.m., an interview was conducted with Resident 7. Resident 7 stated she had a fall previously but was unsure of when her fall had occurred. On March 7, 2023, at 12:30 p.m., an interview was conducted with Certified Nursing Assistant, (CNA 1). CNA 1 stated floor mats should be on each side of the bed. CNA 1 stated Resident 7 should have floor mats on each side of the bed. A review of Resident 7's…

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

Based on interviews, record reviews, and facility policy review, the facility failed to ensure 2 (Resident #56 and Resident #296) of 2 sampled residents reviewed for privacy, did not share a bathroom with residents of the opposite sex. Findings included: A review of the facility policy titled, Confidentiality of Information and Personal Privacy, revised in October 2017, revealed Our facility will protect and safeguard resident confidentiality and personal privacy. The policy revealed, 2. The facility will strive to protect the resident's privacy regarding his or her: a. accommodations; b. medical treatment; c. written and telephone communications; d. personal care; e. visits; and f. family and resident group meetings. 1. A review of Resident #56's admission Record revealed the facility admitted the resident on 11/04/2022, with diagnoses to include acute respiratory failure with hypoxia and type 2 diabetes mellitus. A review of Resident #56's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) 02/22/2024, revealed the resident had a Brief Interview for Mental…

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

Based on interviews, record reviews, and facility policy review, the facility failed to ensure a Level II mental health evaluation was completed for 2 (Resident #17 and Resident #41) of 4 sampled residents reviewed for preadmission screening and resident review (PASARR). Findings included: A review of the facility policy titled, Preadmission screening Resident review, with an effective date of 02/01/2023, revealed The facility PASRR [preadmission screening resident review] Designee will be responsible to access and ensure updates to the PASRR is done. 1. A review of Resident #41's admission Record revealed the facility admitted the resident on 01/19/2024 with diagnoses to include alcohol abuse with alcohol-induced anxiety disorder and post-traumatic stress disorder. A review of Resident #41's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/24/2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. A review of Resident #41's care plan, initiated on…

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

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure all medications were available to be administered during medication administration for 1 (Resident #68) of 5 residents observed for medication administration. Findings included: A review of the facility policy titled, Pharmacy Services Overview, revised in April 2019, revealed, The facility shall accurately and safely provide or obtain pharmaceutical services, including the provision of routine and emergency medications and biologicals, and the services of a licensed consultant pharmacist. The policy revealed, 4. Residents have sufficient supply of their prescribed medications and receive medications (routine, emergency or as needed) in a timely manner. A review of Resident #68's admission Record revealed the facility admitted the resident on 01/05/2023 with diagnoses that included lymphedema and mild protein-calorie malnutrition. A review of Resident #68's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/18/2023, revealed the resident had a Brief…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews, and record review, the facility failed to ensure staff changed their gloves during the provision of incontinence care between dirty and clean tasks for 1 (Resident #17) of 1 sampled resident reviewed for bladder and bowel incontinence. Findings included: A review of Resident #17's admission Record revealed the facility admitted the resident on 02/23/2024 with diagnoses to include metabolic encephalopathy and urinary tract infection. A review of Resident #17's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/26/2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS revealed Resident #17 was dependent on staff for toileting hygiene and was always incontinent of bladder and bowel function. A review of Resident #17's care plan, created on 03/04/2024, revealed the resident experienced urinary incontinence related to a urinary tract infection. Interventions directed staff to provide assistance with perineal care as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 plan of care (POC) with specific goals and objectives to address the resident's condition, for one of four sampled residents (Resident 1) when Resident 1 complained of painful urination on September 7, 2023. These failures increased the potential to result in inconsistent and inadequate provision of care for Resident 1. Findings: On October 18, 2023, at 10:32 a.m., an unannounced visit was conducted at the facility for a complaint investigation. On October 18, 2023, Resident 1's medical record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included abscess (swollen area filled with pus) of the abdominal (stomach) wall, bowel obstruction (blockage of the intestines) with surgical repair with ileostomy (loop of the intestine is brought through the skin to pass waste outside the body), and diabetes mellitus (abnormal sugar in the blood). Review of Resident 1's eInteract Change of Condition (COC) Evaluation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 laboratory (lab) tests were completed as ordered by the physician, for one of four residents reviewed (Resident 1) when the physician ordered urinalysis (UA-test to determine if a urinary tract infection [UTI] is present) was not completed. This failure had the potential to result in the delay of diagnoses and necessary treatments for Resident 1. Findings: On October 18, 2023, at 10:32 a.m., an unannounced visit was conducted at the facility for a complaint investigation. On October 18, 2023, Resident 1 ' s medical record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included abscess (swollen area filled with pus) of the abdominal (stomach) wall, bowel obstruction (blockage of the intestines) with surgical repair with ileostomy (loop of the intestine is brought through the skin to pass waste outside the body), and diabetes mellitus (abnormal sugar in the blood). Review of Resident 1 ' s eInteract Change…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 physician ordered consultation services for two of three residents (Resident 1 and 2) when: 1. A follow up dental appointment was not scheduled for Resident 1, and; 2. An ophthalmologist appointment was not scheduled for Resident 2. These failures had the possibility to delay treatment and care for the residents. Findings: On July 24, at 8:05 a.m., an unannounced visit was conducted at the facility for a complaint investigation. 1. On July 24, 2023, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (DM- abnormal sugar in the blood), paraplegia (paralysis of the lower limbs) and spinal stenosis (narrowing of the spinal column which can cause the nerves to be compressed). Review of Resident 1's physician History and Physical indicated Resident 1 had capacity to understand and make decisions. Review of Resident 1's Physician Order Summary indicated, .May have Dental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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, for three of three sampled residents (Residents 23, 44, and 7), the facility failed to ensure: 1a. Resident 23's new skin injury (left upper arm bruise) identified by the licensed nurses in their nursing weekly summaries from the period of March 1 to May 15, 2021, was addressed and referred to the physician for appropriate care and treatment. In addition, the facility's licensed nurses failed to create a care plan, conduct an ongoing assessment and evaluation of the skin injury, and monitor the resident for complications after it had been identified; 1b. Resident 23's redness to the right lower leg, edema (swelling) of the right foot, and blackish discoloration on the right big toe and fourth toe were identified, addressed, and referred to the physician for appropriate and timely care and treatment. These failures had the potential for the delay in necessary care and treatment of possible complications related to skin injuries/problems; 1c. Resident 44's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure licensed nurses implemented the facility's policy and procedure on narcotic drug reconciliation and proper documentation in the narcotic count sheets for 14 of 15 residents reviewed (Residents 10, 37, 53, 313, 314, 315, 316, 317, 318, 319, 321, 322, 323, and 324). This failure had the potential for narcotic drug diversion (transfer of a controlled substance or other medication from a lawful to an unlawful channel of distribution or use) to occur. Findings: On May 19, 2021, at 11:57 a.m., narcotic drug reconciliation from medication cart 1 was conducted with Licensed Vocational Nurse (LVN) 1. The narcotic count sheets were observed in a hardbound book. The bubble packs for the narcotic medications were observed to have a number on the bubble pack. In a concurrent interview with LVN 1, she stated the number on the narcotic bubble packs indicated the page number in the hardbound book. She stated the incoming shift licensed nurse (LN)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure: 1. Expired and outdated medications were not stored and readily available for use. This failure had the potential for residents to receive medications with less efficacy; 2. Medication requiring refrigeration was stored appropriately. This failure had the potential for the residents to receive medications with decreased efficacy; and 3. Discontinued medications were immediately removed and not readily available for use. This failure had the potential for the residents to receive unnecessary medications or for medication error to occur. Findings: 1. On [DATE], at 10:54 a.m., a concurrent observation and interview was conducted with Registered Nurse Supervisor (RNS) 1 during a medication room inspection in Nursing Station 1. The following were observed: - One opened vial of Afluria influenza vaccine (vaccine to prevent flu) in the medication refrigerator with an open date of [DATE]. RNS 1 stated the influenza vaccine should 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.

Based on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained in the food and nutrition services when four food items in the walk-in refrigerator were not labeled with open dates or use-by-dates. This failure had the potential for the growth of harmful microorganisms which may result in food-borne illnesses in a medically vulnerable population. Findings: On May 17, 2021, at 9:20 a.m., an initial tour of the kitchen was conducted with the Dietary Supervisor (DS). The following food items were observed in the walk-in refrigerator: - One Imperial Beef Base, 16 ounces plastic container; - One minced garlic - 32 ounces bottle; and - Two half sandwiches of peanut butter and jelly wrapped in clear plastic. The food items in plastic and bottle containers were opened and used, and not labeled with open dates and use-by-dates. The two half sandwiches were not labeled to indicate when the sandwiches were prepared and stored. A concurrent interview was conducted with the DS. The DS stated she used the black marker to label the food items…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2a. On May 17, 2021, at 11:49 a.m., Resident 1 was observed lying in bed. Resident 1 was alert and able to verbalize her needs. The oxygen tubing was observed laying on top of her bed. The nasal cannula prongs (a device used to deliver oxygen consists of a lightweight tube with pointed parts placed in the nostrils) was discolored. The oxygen tubing was dated April 29, 2021. Resident 1 was observed putting on the nasal cannula in her nose and taking it off several times. On May 17, 2021, at 11:55 a.m., a concurrent observation and interview was conducted with LVN 2. LVN 2 stated the oxygen was off and the oxygen tubing was dated April 29, 2021. LVN 2 stated the oxygen tubing was being changed every Thursday during day shift. 2b. On May 17, 2021, at 11:43 a.m., Resident 18 was observed sitting at the edge of the bed with oxygen on at five liters per minute through nasal cannula. Resident 18 was alert, oriented, and able to verbalize his needs. Resident 18 stated he tried not to use his oxygen today for 45 minutes,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident was evaluated for the safe self-administration of medications, for one of one resident reviewed (Resident 23). This failure had the potential for the resident to administer the medication in an unsafe manner and to experience adverse (harmful) effects. Findings: On May 18, 2021, at 9:25 a.m., a concurrent observation and interview was conducted with Resident 23. Resident 23 was sitting on her bed with both legs in front of her. Resident 23 was observed to have reddish discoloration on the lower part of her right leg and foot. Resident 23's right foot appeared to be swollen, and a blackish discoloration on the right big toe was also observed. In a concurrent interview with Resident 23, she stated she kept a tube of lotion in her bedside drawer, and she used it daily when her right leg and foot were hurting. Resident 23 showed the tube of an antifungal cream (treatment for fungal infections) from the bedside table drawer…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 information regarding formulating an Advance Directive (AD - a written instruction, such as a living will, relating to the provision of treatment and services when the individual is rendered unable to make decisions) was provided to the resident's representative (RR), for three of 15 residents reviewed for AD (Residents 53, 4, and 33). This failure had the potential to result in not determining and/or following the residents' wishes related to the provision of medical treatment and health care services when the residents become unable to make decisions for themselves. Findings: 1. On May 19, 2021, Resident 53's record was reviewed. Resident 53 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss). The Social Services Assessment and Documentation, dated January 15, 2021, indicated, .Advance Directives .No .Additional conversation regarding advance care planning provided .No .Advance directive educational…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a safe and secured environment was provided for the resident's belongings when the resident representative (RR) reported missing personal items and belongings upon the resident's discharge from the facility on May 2, 2021, for one of three residents reviewed for personal property (Resident 63). In addition, the facility failed to promptly respond to the RR's report of missing belongings. These failures had the potential to negatively impact the well-being of Resident 63. Findings: On May 13, 2021, at 8:31 a.m., Resident 63's RR was interviewed. He stated when Resident 63 was discharged to home on May 2, 2021, he found out Resident 63 did not have her upper denture and two sets of pajamas. He stated Resident 63 was admitted to the facility with both upper and lower dentures. He stated he brought the two sets of pajamas (one pink printed pajama and one blue with white trim pajama) on April 22, 2021 (a day after Resident 63's admission). The RR…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 free from verbal abuse, when Resident 2 was heard yelling while using foul language towards Resident 20. This failure had the potential for Resident 20 to be subjected to verbal abuse which could negatively affect the resident's emotional and psychosocial wellbeing. Findings: On May 19, 2021, at 9:52 a.m., while conducting a medication cart inspection with Licensed Vocational Nurse (LVN) 1, Resident 2 was overheard yelling shut up at Resident 20. In a concurrent interview with LVN 1, she stated Resident 2 was mean to staff and would sometimes yell at Resident 20 when she would make the loud noises. On May 19, 2021, at 9:55 a.m., Certified Nursing Assistant (CNA) 6 was observed going into Resident 2's room after she heard her yelling at Resident 20. CNA 6 was observed providing care to Resident 2. On May 19, 2021, at 10:00 a.m. CNA 6 was interviewed. She stated Resident 2 was verbally abusive to staff and would…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure, for one of five residents reviewed (Resident 27), metformin (medication used to treat high blood sugar levels in the blood) was administered with food as ordered by the physician and according to current professional standards of practice. This failure had the potential for the resident to experience medication adverse effects. Findings: On May 19, 2021, at 9:11 a.m., a medication administration observation with LVN 3 was conducted for Resident 27. Resident 27's medications included one metformin HCL (Hydrochloride) 1000 mg (milligram - a unit of measurement) tablet. LVN 3 was observed to dispense a medication from a bubble pack with a label Metformin HCL .Give with food. On May 19, 2021 at 9:28 a.m., LVN 3 was observed to enter Resident 27's room and administered medications, including metformin, to Resident 27. Resident 27 swallowed all medications individually, taking medications with bottled water. LVN 3 did not administer…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 complete discharge summary was provided to the resident or resident representative upon the resident's discharge from the facility, for one of four closed record sampled residents reviewed (Resident 63). This failure had the potential to cause confusion to the resident, the resident representative, and/or caregivers involved with the resident's care and could increase the risk for an unsafe discharge transition to the community. Findings: On May 20, 2021, Resident 63's record was reviewed. Resident 63 was admitted to the facility on [DATE], with diagnoses which included cervical fracture (break in the neck). The Progress Notes, dated May 2, 2021, at 11:47 a.m., indicated, .PATIENT (Resident) DC (discharge to) HOME TO (address) ON 5/2/2021 (May 2, 2021) PER FAMILY REQUEST. HH (Home Health) RN/PT (Registered Nurse/Physical Therapy) TO FOLLOW AND TO BE APPORVED (sic) AND ARRANGED BY MED GRP (medical group). DME (durable medical equipment) TO BE…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident's fingernails were kept clean and well-trimmed, for one of two residents reviewed for activities of daily living (ADLs) (Resident 4). This failure had the potential to result in injury and/or the spread of infection. Findings: On May 17, 2021, at 11:14 a.m., Resident 4 was observed sitting in a wheelchair in the hallway. She was observed to have long fingernails with black matter deposits underneath her fingernails. On May 17, 2021, at 1:03 p.m., Resident 4 was observed when the lunch meal tray was served. She was sitting on her wheelchair and a Certified Nursing Assistant (CNA) was observed to serve Resident 4's meal tray without providing hand hygiene to the resident. Resident 4 was observed to get the bread off the tray with her hands and ate it. On May 19, 2021, at 11:51 a.m., Resident 4 was observed lying in bed with long fingernails and with black matter underneath her fingernails. On May 19, 2021, at 12:30 p.m.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 care and treatment to manage pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure to the skin) was provided, for one of one residents reviewed for pressure ulcers (Resident 53) when: 1. The wound dressing on the right hip wound was not replaced immediately after being dislodged; and 2. The Registered Dietitian's (RD) recommendation for Vitamin C (supplement) was not referred to the physician for appropriate action. In addition, the RD's recommendation for Proheal (protein liquid supplement) was not evaluated after the order was completed in 30 days. These failures had the potential for Resident 53 to experience delayed wound healing or worsening of multiple pressure ulcers. Findings: On May 18, 2021, at 9:42 a.m., Certified Nursing Assistant (CNA) 6 was observed providing care to Resident 53. Resident 53 was lying on her left side with both of her legs flexed by the knees toward her buttocks.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. On May 18, 2021, at 11:30 a.m., Resident 6 was observed awake, lying in bed. The bed was observed to have u shape grab bar on each side of the bed. The bed was observed to be on a high position. In a concurrent interview with Resident 6, she stated she fell from bed reaching for something from the night stand. On May 19, 2021, the record of Resident 6 was reviewed. Resident 6 was admitted to the facility on [DATE], with diagnosis of muscle weakness. The plan of care for falls, dated June 22, 2015, indicated, 1/2 side rails to bed for bed mobility . The Order Summary Report, dated May 16, 2017, indicated 1/2 (one half) SIDE RAILS AS AN ENABLER FOR TURNING AND REPOSITIONING IN BED . The FALL RISK EVALUATION, dated May 8, 2021, indicated a score of 14 (score of 12 or above indicates high risk of for falls). The IDT (Interdisciplinary Team) notes, dated May 10, 2021, indicated, .On may (sic) 7th, at around 5:00 pm, she was being assisted by staff in repositioning in bed. In the process, she overextended self and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a physician's order was obtained for oxygen use, for one of four sampled residents (Resident 27). This failure resulted in Resident 27's continuous oxygen use without a specific physician's order. In addition this failure had the potential for Resident 27 to receive unnecessary oxygen treatment without proper physician's evaluation. Findings: On May 17, 2021, at 1:34 p.m., a concurrent observation and interview was conducted for Resident 27. Resident 27 was alert, oriented and able to verbalize her needs. Resident 27 was observed with oxygen on at three liters per minute through nasal cannula (a device used to deliver oxygen using a plastic tubing placed in the nostrils). Resident 27 stated she had been using the oxygen continuously. On May 18, 2021, at 9:53 a.m., Resident 27 was observed being transported by paramedics out of the facility with oxygen on through nasal cannula attached to a portable oxygen tank. On May 19, 2021, 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 and interview, the facility failed to ensure two of 66 residents (Residents 2 and 20) had a functioning call light (a device used by a patient to signal his or her needs for assistance) in their room. This failure resulted for residents not to have a means of directly contacting the staff for assistance. Findings: 1. On May 18, 2021, at 10:08 a.m., the call lights for room [ROOM NUMBER] were checked. The call lights for room [ROOM NUMBER]A, 14B, and 14C were not working when there was no light observed outside of the residents' room and at the nurses station when the call light buttons were pressed. On May 19, 2021, at 10:29 a.m., the call lights for room [ROOM NUMBER] were still observed not working. On May 19, 2021, at 10:40 a.m., an interview was conducted with Registered Nurse Supervisor (RNS) 1. RNS 1 stated staff were responsible to ensure call lights were working and within reach. She stated if the call lights were not working, they needed to contact maintenance to fix it. She stated…

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