Hemet Hills Post Acute

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 resident reviewed for infection control (Resident 8), proper infection control measures were implemented when Certified Nursing Assistant (CNA) 1 did not wear personal protective equipment (PPE - equipment, such as gloves and gown, used to protect against infection or illness) upon entering Resident 8's room, who was on contact isolation precautions (an infection control intervention to reduce transmission of multidrug-resistant organisms (bacteria that have become resistant to multiple antibiotics)).The failure had the potential to result in cross contamination and increasing the spread of infection among a vulnerable population.Findings:On December 5, 2025, at 11:40 a.m., an observation was conducted outside Resident 8's room. A contact isolation sign was posted outside Resident 8's room, along with a PPE cart containing gowns and gloves. The sign indicated, .STAFF MUST.Put on gloves before room entry.Put on gown…

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

Based on interview and record review, the facility failed to ensure blood glucose meters (glucometer - a blood sugar meter measures the amount of sugar in a small sample of blood) were calibrated and documented according to the facility protocol and current professional standards of practice on multiple days on November 2025. This failure had the potential to result in inaccurate blood glucose readings for residents requiring routine monitoring.Findings:A review of Station Three, Cart C November 2025 Quality Assurance Log indicated missing documentation for the following dates, with blank entries for time, staff performing, machine lot number, test strip lot number, low control, high control, and actions taken: -November 14, 2025;-November 15, 2025; and -November 19, 2025. On December 1, 2025, at 10:52 a.m., an interview and review of Station Three Quality Assurance Log were conducted with the Licensed Vocational Nurse (LVN 1). LVN 1 stated, glucometer calibration was the responsibility of the night shift nurse and was documented on the assurance logs located on the medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 assess and verify the resident's history of obstructive sleep apnea (OSA - person's breathing repeatedly stops and starts during sleep due to a blocked airway) and coordinate necessary CPAP (Continuous positive airway pressure - a machined use to treat OSA) treatment with the physician, for one of five sampled residents (Resident A).This failure had the potential to result in untreated sleep apnea for Resident A, placing the resident at risk for respiratory complications, hypoxia (low oxygen), and sleep disruption. Findings:On July 7, 2025, at 10:18 a.m., an unannounced visit to the facility was conducted to investigate a quality-of-care issue.On July 7, 2025, at 4:28 p.m., during an interview with Resident A, Resident A stated she had been on CPAP for 20 years and last used it the day before she was admitted to the facility. Resident A stated she was not allowed to use her CPAP machine in the facility. Resident A stated she sleeps almost always in a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure interventions for fall prevention were implemented for two of seven residents, (Resident 1 and Resident 7).This failure had the potential for Resident 1 and Resident 7 to fall and sustain serious injuries. Findings:On July 30, 2025, at 11:07 a.m., an unannounced visit to the facility on a complaint investigation was initiated.1.A review of Resident 1's medical records indicated that resident was admitted on [DATE], with diagnoses of systemic lupus erythematosus, (SLE - a chronic autoimmune disease where the body's immune system mistakenly attacks its own healthy tissues and organs), chronic obstructive pulmonary disease, (COPD - a chronic inflammatory disease that causes obstructed airflow from the lungs), type 2 diabetes mellitus, (a chronic condition that affects the way the body uses sugar. The body either resists the effects of insulin - a hormone that regulates the movement of sugar into the cells - or doesn't produce enough…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 for two of six sampled residents (Residents 1 and 2) to ensure: 1. The call light was placed within reach for Resident 1; and 2. The call light was answered timely for Resident 2. These failures had the potential to compromise the timely delivery of resident care. Findings: On June 10, 2025, at 10:48 a.m., during a concurrent observation and interview with Resident 1 in the resident ' s room, Resident 1 was observed to be unable to move her right arm. Resident 1 stated, she was cold and would like a blanket. Resident 1 stated, she could not reach her call light. Resident 1 ' s call light was observed to be placed on the right side of the bed rail, which was in the down position. On June 10, 2025, at 10:54 a.m., during a concurrent observation and interview with Certified Nursing Assistant (CNA) 1 in Resident 1's room, CNA 1 stated, Resident 1 had right-sided weakness and was able to use the call light only if it was placed on the left side.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 abuse was reported to the California Department of Public Health within two hours for one of five sampled residents (Resident 1). This failure had the potential to leave Resident 1 unprotected, result in further abuse, and delay the initiation of an investigation. Findings: On June 12, 2025, Resident 1's admission Record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss) and protein-calorie malnutrition (deficient intake of protein and calories to meet the body ' s energy and tissue-building needs). A further review of Resident 1's HISTORY AND PHYSICAL EXAMINATION, dated September 29, 2024, indicated Resident 1 does not have the capacity to understand and make decisions. A review of Resident 1's SBAR (Situation, Background, Appearance, Review), dated May 17, 2025, indicated, Resident 1 had increased confusion, making allegation of prior abuse. A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of eight residents, (Resident 3), was safe from a fall, when the Certified Nursing Assistant, (CNA 1), repositioned Resident 3 away from her while changing Resident 3's briefs. This failure caused discoloration to the top of the head accompanied with 4/10 pain, discoloration to the left side of cheek, and skin tear to the left elbow. Resident 3 was transferred to the hospital for evaluation. Findings: On March 21, 2025, at 11:42 a.m., an unannounced visit to the facility on four complaints and a Facility Reported Incident was initiated. A review of Resident 3's medical records indicated he was originally admitted to the facility on [DATE], with diagnoses of chronic obstructive pulmonary disease, (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), Alzheimer's disease, (progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 - an assessment tool) quarterly assessments were completed within 14 calendar days, as required by Center for Medicare and Medicaid Services (CMS - an agency that administers the nation's major healthcare programs), for 19 of 27 residents reviewed for resident assessment (Residents 3, 14, 25, 30, 41, 45, 76, 81, 83, 86, 89, 106, 124, 127, 128, 129, 130, 131 and 141). This deficient practice resulted in late completion of quarterly assessments in Residents 3, 14, 25, 30, 41, 45, 76, 81, 83, 86, 89, 106, 124, 127, 128, 129, 130, 131 and 141, potentially resulting in delay in updating and creating residents' care plan affecting residents' quality of care. Findings: 1a. A record review of Resident 3's MDS Quarterly assessment dated [DATE], indicated Resident 3's assessment was completed on January 8, 2025, 53 calendar days after the assessment reference date (the final day of the observation period during which the…

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

Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS - an assessment tool) annual and quarterly assessments were transmitted timely for 21 of 27 residents (Residents 3, 14, 25, 30, 41, 45, 70, 76, 81, 83, 85, 86, 89, 106, 124, 127, 128, 129, 130, 131 and 141) reviewed for resident assessment. This failure had the potential to cause gaps in the development or implementation of the resident's care plan, potentially affecting the quality of care. Findings: On January 17, 2025, at 11:26 a.m., a concurrent interview and record review of Residents 3, 14, 25, 30, 41, 45, 70, 76, 81, 83, 85, 86, 89, 106, 124, 127, 128, 129, 130, 131 and 141's MDS assessments were conducted with the MDS Coordinator (MDSC). The resident assessments indicated the following: 1. Resident 3's MDS Quarterly assessment had an Assessment Reference Date (ARD - the final day of the observation period for the MDS assessment) of November 16, 2024, and was transmitted on January 8, 2025; 2. Resident 14's MDS Quarterly assessment had an ARD of November 16, 2024, and was transmitted 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, interview, and record review, the facility failed to provide food with appetizing taste for 10 of 177 sampled residents (Residents 102, 104, 124, 130, 123, 6, 253, 140, 27 and 85). This failure had the potential to decrease the nutritional intake and affect Residents 102, 104, 124, 130, 123, 6, 253, 140, 27 and 85's nutritional status. Findings: On January 13, 2025, the following interviews were conducted: - at 10:00 a.m., Resident 102 stated, the food is not good, it's a mess, noodles gummy. - at 11:10 a.m., Resident 104 stated, the food is too small and tiny, not good. - at 11:37 a.m., Resident 124 stated, the food taste awful, and they served overcooked and burnt eggs. - at 11:40 a.m., Resident 130 stated, the food does not taste good. - at 12:36 p.m., Resident 123 stated, the food was not good, too bland, and no taste. - at 4:09 p.m., Resident 6 stated, I do not like the food, the rice is hard. On January 14, 2025, the following interviews were conducted: - at 9:45 a.m., Resident 253 stated, the food was just okay, it was hospital food. - at 10:20 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.

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. Eight out of twelve storage shelves in the dry storage room had brown grime, corrosion, and chipped coating. 2. Seven out of seven storage shelves in the walk-in refrigerator had white buildup, brown grime, and dirt. 3. Seven out of seven storage shelves in the freezer had brown grime and chipped coating. 4. Two electric fans mounted on the wall above the preparation sink and dishwashing area had white debris on the blades and covers. These failures had the potential to cause foodborne illness (stomach illness acquired from ingesting contaminated food) in a vulnerable population of 168 out of 177 residents who received food prepared in the kitchen. Findings: 1. On January 13, 2025, at 10:11 a.m., a concurrent observation and interview were conducted with the Dietary Services Supervisor (DSS) in the dry storage room. Eight out of twelve storage shelves had brown grime, corrosion, and chipped coating. Onions, potatoes, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide Advance Directive (AD-a written instruction related to the provision of health care when the resident is no longer able to make decisions) education, materials, and follow-up for two of three residents reviewed for AD (Residents 73 and 130) and/or their resident representatives (RP). This failure had the potential in Residents 73 and 130's medical preferences not being honored during critical healthcare decisions. Findings: 1. A review of Resident 73's admission Record, indicated Resident 73 was admitted to the facility on [DATE]. A review of Resident 73's History and Physical dated May 25, 2024, indicated Resident 73 had the capacity to understand and make decisions. A review of Resident 73's Advance Directive Acknowledgement Form, dated May 26, 2024, indicated Resident 73 has not executed an AD. A review of Resident 73's Social History Review (Quarterly), dated December 6, 2024, indicated, .Self-responsible .Advance Directive .None 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 the annual comprehensive assessment for two of 27 residents reviewed for resident assessment (Residents 70 and 85) were completed within 14 calendar days, as required by the Center for Medicare and Medicaid Services (CMS - an agency that administers the nation's major healthcare programs). This failure had the potential for Residents 70 and 85 to not receive resident centered care (care focusing on the needs of individuals). Findings: 1a. A review of Resident 70's Minimum Data Set (MDS - an assessment tool) annual assessment dated [DATE], indicated the assessment was completed on January 11, 2025, 37 days after the assessment reference date (the final day of observation period during which the resident's status is assessed and documented). 1b. A review of Resident 85's Minimum Data Set annual assessment dated [DATE], indicated the assessment was completed on January 11, 2025, 35 days after the assessment reference date. On January 17, 2025, at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to notify the physician when the resident missed a follow-up visit for a surgical wound to the spine for one of six residents reviewed for skin conditions (Resident 24). This failure had the potential to delay the care and treatment of Resident 24's skin condition which could result in skin infections and worsening of the wound. Findings: On January 14, 2025, at 2:08 p.m., a concurrent observation and interview were conducted with Resident 24. Resident 24 was alert and sitting up in a chair. Resident 24 stated he missed his follow-up visit with a physician for his wound, was dismissed by staff, and was unsure if he was rescheduled for a new follow-up visit. Resident 24's record was reviewed. Resident 24 was admitted to the facility on [DATE], with diagnoses which included disease of the spinal cord (a weakened portion of the spine), and pressure ulcer of unspecified site, unspecified stage (skin breakdown). A review of Resident 24's history…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 six residents (Resident 104) reviewed for pressure injuries: 1. The care plan interventions for the right heel pressure injury (PI - localized damage to the skin and underlying soft tissue over a bony prominence or from a medical device) were implemented. 2. The Registered Dietitian (RD) nutritional recommendations for wound healing were communicated to the physician. These failures had the potential to result in Resident 104 not receiving the necessary nutrition and devices needed to heal and prevent the worsening of the pressure injury. Findings: A review of Resident 104's admission Record, indicated Resident 104 was admitted to the facility on [DATE], with diagnoses which included protein-calorie malnutrition (a condition where the body does not get enough protein and nutrients from food). A review of Resident 104's History and Physical dated December 22, 2024, indicated Resident 104 has the capacity to make…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 order for oxygen therapy, for one of six residents reviewed for respiratory care (Residents 49). This failure had the potential to place Resident 49 at risk of respiratory distress and a decline in medical condition. Findings: On January 13, 2025, at 10:59 a.m., during a concurrent observation and interview with Resident 49, Resident 49 was observed sitting in bed with a nasal cannula (a device used to deliver oxygen) attached to his nose, with the oxygen set at zero liters per minute (LPM- unit of measurement). Resident 49 stated he used oxygen to help with his breathing. A review of Resident 49 admission Record, indicated, Resident 49 was admitted to the facility on [DATE], with multiple diagnoses that included pulmonary fibrosis (a chronic lung disease making it difficult to breathe) and anxiety (a feeling of fear, dread, and uneasiness). A review of Resident 49's Order Summary Report for the month of January…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 for one of six residents (Resident 152), a pain assessment and evaluation was conducted before and after the administration of narcotic (controlled drug that induces stupor, coma, or insensibility to pain) pain medication from December 2024 through January 2025. This failure had the potential to result in unrelieved or ummanaged pain, which could lead to a decline in Resident 152's overall health and well-being. Findings: A review of Resident 152's admission Record, indicated Resident 152 was admitted to the facility on [DATE], with diagnoses which included rheumatoid arthritis (inflammation in the joints that causes pain and swelling). A review of Resident 152's History and Physical, dated December 6, 2024, indicated Resident 152 had the capacity to understand and make decisions. A review of Resident 152's Order Summary Report, dated December 2, 2024, indicated, .Norco (a narcotic) Oral Tablet 5-325 mg (milligram - unit of measurement)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 PRN (as needed) narcotic (controlled drug that induces stupor, coma, or insensibility to pain) pain medications that were signed out were properly administered and recorded in the Medication Administration Record (MAR), for one of six residents (Resident 152). This failure resulted in delays in identifying medication discrepancies and increased the risk of controlled substance diversion. Findings: A review of Resident 152's admission Record, indicated Resident 152 was admitted to the facility on [DATE], with diagnoses which included rheumatoid arthritis (inflammation in the joints that causes pain and swelling). A review of Resident 152's History and Physical dated December 6, 2024, indicated Resident 152 has the capacity to understand and make decisions. A review of Resident 152's Order Summary Report, dated December 2, 2024, indicated, .Norco (a narcotic) Oral Tablet 5-325 mg (milligram - unit of measurement)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 proper infection control measures were implemented when: 1. Resident 290's oxygen humidifier (a medical device used to humidify oxygen) was found on the floor. 2. Resident 291's nasal cannula (a device used to deliver oxygen) was found on the floor. These failures had the potential to result in cross-contamination, increasing the spread of infection to an already vulnerable population of residents in the facility. Findings: 1. On January 13, 2025, at 12:10 p.m., Resident 290 was observed sitting in bed with oxygen via nasal cannula attached to an oxygen concentrator with the oxygen humidifier on the floor. On January 13, 2025, at 12:15 p.m., during an observation and interview with Licensed Vocational Nurse (LVN 1) in Resident 290's room, LVN 1 stated Resident 290 had an order for oxygen at 3 LPM for sob (shortness of breath). LVN 1 further stated that the oxygen humidifier should be attached to the concentrator and not placed on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure consistent fingernail care to maintain grooming was provided, for four of four sampled residents (Resident 1, Resident 2, Resident 3, and Resident 4). This failure resulted in poor hand hygiene and had the potential to result in infections and skin injury. Findings: On September 26, 2024, at 7:30 a.m., an unannounced visit was conducted at the facility to investigate one complaint. During an observation on [DATE], at 8:45 a.m., Resident 1 was sitting in bed, with a sheet covering the left arm. Resident 1 had her arm resting on her abdomen with the call light next to her hand. The right arm had limited movement, and no movement of the left arm. The fingernails on the right hand were medium length with uneven edges and discoloration, with dark debris under the fingernails. During an observation on September 26, 2024, at 12:45 p.m., a Certified Nursing Assistant (CNA) was at the bedside feeding Resident 1 lunch. The fingernails were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide appropriate care and services to prevent urinary tract infection (a bacterial infection that affects the urinary tract, which includes the bladder, uretha, and kidneys) for one of six sampled residents, when: 1. Foley catheter (flexible tube that drains urine from the bladder into a collection bag) care was not consistently provided in accordance with the care plan. 2. Urinary output was not consistently monitored in accordance with the physician order. These failures could have contributed to the recurrent UTI which led for Resident 5 to be transferred to the general acute care hospital (GACH), where the resident was diagnosed with sepsis. Findings: On September 26, 2024, at 7:30 a.m., an unannounced visit to the facility was conducted to investigate quality care issues. A review of Resident 5's medical record indicated, Resident 5 was admitted to the facility on [DATE], with diagnoses which included benign prostate hyperplasia (BPH-prostate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 proper infection control measures were implemented when multiple staff did not perform hand hygiene during donning (putting on gloves and gown) of PPE (Personal Protective Equipment - mask, gown, gloves, face shield or goggles) and failed to don a face shield or goggles to go inside Droplet Isolation (droplets from coughing, sneezing, or talking may contain viruses or bacteria and generally travel no more than three feet from the patient) rooms when providing care. This failure had the potential to result in the transmission of infection to an already vulnerable population of residents in the facility. Findings: During an observation on September 26, 2024, at 8:22 a.m., a Certified Nurse Assistant (CNA) grabbed a box of gloves from one isolation cart in the hallway and moved it to another isolation cart. The CNA was observed wearing an N95 mask, as she donned a gown and gloves, without performing hand hygiene and the CNA did not put on a face shield or goggles prior to entering a resident's room on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide respiratory care and treatment in accordance with the facility policy and procedures for one of two residents (Resident 2) reviewed for oxygen treatment. This failure had the potential to result in ineffective oxygen therapy, respiratory distress, and decline in the residents ' health condition. Findings: On September 26, 2024, at 7:30 am, an unannounced visit to the facility was conducted for the investigation of two complaints. During a concurrent observation and interview on September 26, 2024, at 2:17 p.m., in Resident 2 ' s room, Resident 2 had an oxygen concentrator set up next to the bed, oxygen set at three liters per minute (LPM). The humidification bottle was empty, and was completely dry. Resident 2 stated the water bottle on the oxygen machine had been empty since the previous day. Resident 2 said she said she forgot to tell the staff because she has a bad memory. During an interview on September 26, 2024, at 3:20…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent medication errors, as resident 's medications were administered outside of the physician's ordered parameters, for two out of seven sampled residents (Residents 3 and 4). The failure had the potential to cause harm to residents, such as adverse reactions, side effects, or ineffective treatment. Findings: On October 21, 2024, at 8:58 a.m., an unannounced visit was made to the facility for a quality-of-care issue. On October 21, 2024, at 9:20 a.m., an interview was conducted with LVN 1, who stated, the process to administer medications includes, check (vital signs) first, verify physician's orders and ordered parameters (instructions to administer or hold medications depending on vital signs), administer or withhold medications. LVN 1 stated if medications were administered, the nurse would document in resident 's Medication Administration Record (MAR) by initialing under the date and time administered. LVN 1 stated, if medications were held,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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, facility staff failed for one of seven sampled residents (Resident 2) to follow-up on the resident's blood pressure (BP) to assess the effectiveness of the as needed (PRN) BP medication. This failure had the potential to result in not knowing whether the blood pressure medication effectively lowered the resident's blood pressure or if the blood pressure dropped too low after taking the medicatiion. Findings: On October 21, 2024, at 8:58 a.m., an unannounced visit was made to the facility for a quality-of-care issue. A review of Resident 2 ' s medical records, titled, Face sheet, undated, indicated, resident was admitted to the facility on [DATE], with a diagnosis of hypertension {HTN}-high blood pressure). A review of Resident 2 ' s care plan, dated September 15, 2024, indicated: - . complications related (r/t) (HTN) .Interventions . Administer medications as ordered. Observe, document and notify (physician) of adverse side effect . report abnormal findings to (physician) .…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to verify accuracy of the prescribed parameters for a blood pressure (BP) medication, for one of seven sampled residents (Resident 2). This failure had the potentially to cause harmful side effects from the blood pressure medication for Resident 2. Findings: On October 21, 2024, at 8:58 a.m., an unannounced visit was made to the facility for a quality-of-care issue. A review of Resident 2's medical records, titled, Face sheet, undated, indicated, resident was admitted to the facility on [DATE], with a diagnosis of hypertension {HTN}-high blood pressure). A review of Resident 2's physician orders, dated September 13, 2024, indicated, . Metoprolol Succinate . 50MG ({Milligrams}-a unit of measure) . (daily) . for HTN hold if sbp ({SBP}-top number of blood pressure) < (below) 110 or Pulse > (above) 60 . A review of Resident 2's Medication Administration Record (MAR), dated September 2024, indicated, Metoprolol was administered outside of the prescribed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 staff donned (put on) required Protective Personal Equipment ({PPE}-equipment worn to protect against the spread of infection to self or others) when entering a contact precautions (Precautions for resident known or suspected to be infected with transmissible microbes) isolation room for Resident 1. This failure had the potential to spread harmful microbes (germs) to residents, staff and others within the facility. Findings: On October 21, 2024, at 8:58 a.m. an unannounced visit to the facility was made for a quality-of-care issue. On October 21, 2024, at 11:25 a.m., an observation of Resident 1's room door was made, which indicated, a sign stating resident was on contact precautions, requiring staff to wash their hands, and don PPE of a mask, gloves, and gown before entering Resident 1's room. A review of Resident 1's medical record, titled, Face Sheet, undated, indicated, resident was admitted to the facility on [DATE], with a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that hospice services for two of three residents, (Resident 1 and Resident 3) ' s were properly coordinated, as two hospice companies did not provide a monthly schedule indicating when hospice staff would be visiting. This failure had the potential to disrupt the continuity of coordinated, quality care. Findings: On October 29, 2024, at 10:47 a.m., an unannounced visit to the facility on a complaint investigation was initiated. 1. A review of Resident 1 ' s medical records indicated she was admitted on [DATE], with diagnoses of encounter for palliative care, (an interdisciplinary medical caregiving approach aimed at optimizing quality of life and mitigating suffering among people with serious, complex, and terminal illnesses) and end stage renal disease (ESRD - the final, permanent stage of chronic kidney disease, where kidney function has declined to the point that the kidneys can no longer function on their own). 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 the physician was notified, for one of six residents (Resident 1), when Resident 1 refused to come back inside the facility and had an aggressive behavior including threatening to hurt himself on July 9, 2024. This failure had the potential for the physician to be unaware of Resident 1 ' s condition and delayed provision of possible treatment. Findings: On July 26, 2024, at 2:14 p.m., an unannounced visit to the facility on four complaints and two facility reported incidents were initiated. A review of Resident 1 ' s medical records indicated Resident 1 was admitted on [DATE], with diagnoses of parkinsonism, (a clinical syndrome characterized by tremor, progressive hesitation and halting of body movements, rigidity, and postural instability), dementia, (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), dysarthria, (unclear…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 home like environment was provided, for two of six residents (Resident 2 and Resident 4), when: 1. The wall on the left side of the entry door had horizontal black scuff marks along the whole surface of the wall inside Residents 2 and 4's rooms; 2. There was a one inch by one inch dent, with the wallpaper peeling away from the wall surface on the same wall adjacent from Resident 4 ' s bed (closest to the entry door), above the base board; and 3. There were 14 dried orange, brown droplet-like smudges on the wall, baseboard, and the edge of the floor; and approximately six-inch black vertical scuff mark on the same wall, adjacent from Resident 2 ' s bed, (furthest from the entry door). These failures placed the residents at risk for low self-esteem and living in an unkempt environment. Findings: On July 26, 2024, at 2:14 p.m., an unannounced visit to the facility on four complaints and two facility reported incidents were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 plan of care was developed and/or implemented, for one of six residents (Resident 1) when Resident 1 had episodes of aggressive behavior. This failure had the potential to result in staff not providing care and interventions not being implemented that would affect the residents' highest practicable well-being. Findings: On July 26, 2024, at 2:14 p.m., an unannounced visit to the facility on four complaints and two facility reported incidents were initiated. A review of Resident 1 ' s medical records indicated he was admitted on [DATE], with diagnoses of parkinsonism, (a clinical syndrome characterized by tremor, progressive hesitation and halting of body movements, rigidity, and postural instability), dementia, (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), dysarthria, (unclear articulation of speech), and anarthria,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide care and services for activities of daily living (ADLs), for one of six sampled residents (Resident 2), when the resident failed to receive showers as scheduled. This failure had the potential to negatively affect the resident's physical and psychosocial well-being. Findings: On July 26, 2024, at 2:14 p.m., an unannounced visit to the facility on four complaints and two Facility Reported Incidents were initiated. A review of Resident 2 ' s medical record indicated he was admitted on [DATE], with diagnoses of intervertebral disc degeneration (a condition of the discs between vertebrae with loss of cushioning muscle wasting and atrophy, dorsalgia, presents as localized pain or discomfort in the back), cardiac arrhythmia, (irregular heartbeat), and scoliosis, (a sideways curvature of the spine). A review of Resident 2 ' s History and Physical, dated July 19, 2024, indicated he had the capacity to understand and make decisions. A review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure physician order was followed, for one of six residents (Resident 3), when Midodrine (a medication used to increase blood pressure) was not held when the systolic blood pressure, (SBP) was greater than 120. This failure had the potential for Resident 3 to have dangerously high blood pressure. Findings: On July 26, 2024, at 2:14 p.m., an unannounced visit to the facility on four complaints and two Facility Reported Incidents were initiated. A review of Resident 3 ' s medical records indicated he was admitted on [DATE], with diagnoses of stroke, acute kidney failure, (occurs when the kidneys suddenly become unable to filter waste products from the blood), diabetes mellitus type 2, (a chronic condition that affects the way the body uses sugar. The body either resists the effects of insulin - a hormone that regulates the movement of sugar into the cells - or doesn't produce enough insulin to maintain normal sugar levels), and orthostatic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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, for one of six residents (Resident 1), was free from unnecessary psychotropic medications (medications used to treat mental illness), when there was no appropriate indication for use for Ativan (medication used to treat anxiety) and Seroquel (medication to treat mental disorders). In addition, an informed consent was not obtained from Resident 1's responsible party for the use of Ativan and Seroquel. These failures had the potential for Resident 1 to receive unnecessary antipsychotic medications. Findings: On July 26, 2024, at 2:14 p.m., an unannounced visit to the facility on four complaints and two facility reported incidents were initiated. A review of Resident 1 ' s medical records indicated he was admitted on [DATE], with diagnoses of parkinsonism, (a clinical syndrome characterized by tremor, progressive hesitation and halting of body movements, rigidity, and postural instability), dementia, (a chronic or persistent disorder of the…

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

Based on observation, interview, and record review, the facility failed to display direct care daily staffing information (DHPPD-Direct Care Service Hours Per Patient Day) in a prominent location, readily accessible to the residents and visitors. This failure had the potential to result in residents, visitors, and staff not being fully informed of staffing levels in the facility based on resident needs. Findings: On June 10, 2024, at 5:23 p.m., an unannounced visit to the facility was conducted to investigate quality care issues. On June 10, 2024, at 5:44 p.m., observed there was no posting of the daily staffing in any location within the facility. On June 10, 2024, at 6:05 p.m., an interview was conducted with the Licensed Vocational Nurse (LVN). The LVN stated that the facility daily staffing was not posted in a visible location, they were posted in a binder at the nurses ' station. On June 10, 2024, at 11:27 p.m., an interview was conducted with the facility ' s Director of Nursing, (DON). The DON stated that the staffing ratios were not posted in a public location. The DON…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 an assessment for self-administration of medication was conducted, for one of eight residents (Resident 2). This failure had the potential to result in an unsafe self-administration of medication by Resident 2. Findings: On June 6, 2024, at 8 a.m., an unannounced visit was conducted at the facility to investigate a complaint intake. On June 6, 2024, at 08:25 a.m., Resident 2 was observed lying in bed. Two bottles of eye drops labeled brimonidine HCL 0.2% (eye drop medication to lower pressure in the eyes) and dorzolamide HCL 0.2 % (eye drop medication to treat increased pressure in the eyes) was observed in the resident's open bedside dresser. In a concurrent interview with Resident 2, he stated the eye drop medications were his and they were kept at his drawer. Resident 2 stated he administers his own eye drop medications by himself. On June 6, 2024, at 5:10 p.m., a concurrent interview and record review was conducted with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident's equipment are kept clean and sanitary, for one of eight residents reviewed (Resident 1), when Resident 1's wheelchair safety belts contained layers of dry crusted food. This failure has the potential for Resident 1 to continue to have an unclean environment and further develop infections. Findings: On June 6, 2024, at 8 a.m., an unannounced visit was conducted at the facility to investigate a facility reported incident and complaint intake. On June 6, 2024, at 09:20 a.m., Resident 1 was observed sitting in his wheelchair in front of the nurse's station. Resident 1's wheelchair safety belts was observed placed around his waist. The safety belts were noted dirty and contained layers of dry crusted food covering the belt straps. On June 6, 2024, at 9:38 a.m., Resident 1 was concurrently observed with Licensed Vocational Nurse (LVN) 1. LVN 1 observed Resident 1's wheelchair safety belts and stated the belts were dirty. LVN 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 consistent oral care and personal grooming was provided, for one of eight residents (Resident 1). This failure resulted in poor oral hygiene and had the potential to affect Resident 1's dignity and diminish his quality of life. Findings: On June 6, 2024, at 8 a.m., an unannounced visit was conducted at the facility to investigate a complaint intake on quality of life. On June 6, 2024, at 09:20 a.m., Resident 1 was observed sitting in his wheelchair in front of the nurse's station. Resident 1 was observed to have mucus draining from the resident's left nostril. In a concurrent interview with Resident 1, he was well and doing good. While the interview with Resident 1 was being conducted, a foul odor was noticeable coming out from the resident 's mouth. On June 6, 2024, at 09:38 a.m., a concurrent interview and observation with Licensed Vocational Nurse (LVN) 1 was conducted of Resident 1. LVN 1 stated there was fluid coming from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide showers twice per week for one of three residents (Resident 1). This failure had the potential to result for Resident 1 to develop body odor, skin breakdown and had the potential to affect Resident 1 ' s overall wellbeing. Findings: On May 22, 2024, at 8:11 a.m., an unannounced visit was conducted at the facility to investigate quality care issues. On May 22, 2024, at 9:27 a.m., during a concurrent observation and interview with Resident 1 in his room, Resident 1 was sitting on his wheelchair, alert and conversant. Resident 1 stated he did not receive shower a couple of times. A review of Resident 1 ' s medical records indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included anoxic brain damage (complete lack of oxygen to the brain), legal blindness (complete loss of sight) and quadriplegia (a person ' s both arms and both legs stop working). Resident 1 ' s Minimum Data Set (MDS- an assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to address one of three sampled residents' (Resident 2) multiple episodes of poor meal intake and refusal of meals. In addition, Resident 2 was not consistently provided with food substitutes, during episodes of poor intake and refusals of meals. These failures increased Resident 2's risk for inadequate nutrition and hydration. Findings: On May 21, 2024, at 8:11 am, an unannounced visit was conducted at the facility to investigate quality care issues. A review of Resident 2 ' s medical record indicated, Resident 2 was admitted to the facility on [DATE], with diagnoses which included vascular dementia (impaired blood flow to the brain causing changes to memory, thinking and behavior), depression (mental illness), dysphagia (difficulty swallowing). A review of Resident 2 ' s Minimum Data Set (MDS- an assessment tool) dated April 10, 2024, indicated Resident 2 ' s cognition was moderately impaired, and Resident 2 required supervision with eating. A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure new interventions were initated to prevent fall incidents, for one of three residents (Resident C) when Resident C had fall episodes on March 6, 9, 15, 18, 20, and 26, 2024. This failure resulted to Resident C experiencing multiple falls and had the potential for further falls with injury and could compromise overall health condition. Findings: On April 22, 2024, at 12:00 p.m., an unannounced visit to the facility for the investigation of two complaints was conducted. On April 23, 2024, at 11:50 a.m., a review of Resident C's medical record was conducted. Resident C was admitted to the facility on [DATE], with diagnoses which included sarcopenia (age related progressive loss of muscle mass and strength), transient ischemic attack (TIA- a brief stroke-like attack resolving within minutes to hours), and multiple falls. Resident C's history and physical, dated December 22, 2023, indicated .received patient from [name] hospital after…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 transportation services were provided timely for residents receiving dialysis (the process of removing waste products in the blood), for four of six residents reviewed (Resident A, B, C, and D). This failure resulted to Residents A, B, C, and D, to arrive late at the dialysis center and received incomplete dialysis run time. This failure had the potential for the dialysis residents to experience complications related to incomplete dialysis treatment. Findings: On May 2, 2024, at 9:15 a.m., an unannounced visit was conducted for the investigation of two complaints. 1. On May 2, 2024, Resident A's medical record was reviewed. Resident A's record indicated he was admitted to the facility on [DATE], with diagnoses which included sepsis (a life-threatening complication of an infection) and hemodialysis (a process of filtering the blood of a person whose kidneys are not working normally). Resident A's physician order, dated March 30, 2024, indicated,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a care plan was developed, for one of three residents (Resident C), when: 1. Resident C had an order for a brace (restricting movement and relieving pressure to promote healing) to be applied to the right arm due to fracture (broken bone); and 2. Resident C had a diagnosis of congenital deafness (hearing loss that is present at birth) and required the use of white board for communication. These failures had the potential to have a delay in treatment and services to maintain or improve the highest practicable physical, mental, psychosocial well-being of Resident C. Findings: On March 5, 2024, at 9:30 a.m., an unannounced visit to the facility was conducted to investigate a complaint regarding quality of care. On March 5, 2024, Resident A's record was reviewed. Resident C was admitted to the facility on [DATE], with diagnoses which included altered mental status (define), diabetes mellitus (high blood sugar), dementia (impaired ability to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided, for one of three residents (Resident A) who required close monitoring and supervision, when Resident A was left unsupervised during care. This failure resulted in Resident A to have wandered into Resident B's room and hit Resident B multiple times while she was lying in bed. Findings: On March 5, 2024, at 9:30 a.m., an unannounced visit to the facility was conducted to investigate a facility reported incident regarding resident-to-resident abuse. On March 5, 2024, at 9:50 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated Resident A was found by staff standing over Resident B's bed in the room on February 19, 2024, at around 8:45 p.m. The DON stated Resident A wandered into Resident B's room, screamed, yelled at Resident B for unknown reason and hit Resident B in the head multiple times. The DON stated Residents A and B reside in different rooms and Resident A had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 showers and/or bed baths were provided, for three of three residents reviewed (Residents 2, 3, and 4). This failure had the potential to decrease the quality of living for Residents 2, 3, and 4, and could potentially contribute to skin conditions. Findings: On February 27, 2024, at 8:45 a.m., an unannounced visit was made to the facility to investigate a quality of care issue. 1. On February 27, 2024, at 9:44 a.m., an interview was conducted with Resident 3. She stated the facility staff were to assist her in receiving a shower two times per week, on Mondays and Thursdays. She stated she did not received her shower on February 26, 2024 (Monday) as scheduled. On February 27, 2024, Resident 3 ' s admission medical records was reviewed. Resident 3 was admitted to the facility on [DATE], with a primary diagnosis of multiple sclerosis (progress disease involving damage to the nerve cells, resulting multiple impairments, including…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 was provided to promote wound healing, for one of three residents reviewed (Resident 2), when: 1. The facility staff failed to consistently monitor and evaluate Resident 3 ' s pressure injuries (PI - Injury to skin and underlying tissue resulting from prolonged pressure on the skin); 2. The facility did not provide the low air loss (LAL - a type of mattress equipped with small air-filled cells that allow constantly circulating air flow to prevent and treat pressure injuries) as ordered by the physician; 3. The facility did not refer to the physician a new PI on Resident 2's sacrococyx area (sacrum an coccyx - tailbone) when the resident was re-admitted from the acute hospital on February 15, 2024, for appropriate treatment; and 4. The facility did not refer to the physician the wound consultant's treatment recommendations to address the PI on Resident 2's sacrococyx area. These failures had the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the California Department of Health (CDPH) was notified of an allegation of financial abuse immediately or within two hours after knowledge of the allegation of abuse, for one of three residents reviewed (Resident 1). This failure had the potential in a delay in the investigation of abuse and could subject Resident 1 to further financial abuse by the alleged abuser. Findings: On February 06, 2024, at 8:35 a.m., an unannounced visit was made to the facility to investigate an allegation of financial abuse. On February 06, 2024, at 8:55 a.m., an interview was conducted with Resident 1 ' s Representative (RR). The RR stated Resident 1 had a private caregiver (CG) who assists Resident 1 with her needs and appointments. The RR stated Resident 1 informed her that she gave the debit card and food stamps card with their pin# to the CG. The RR stated she checked Resident 1 ' s bank accounts and noticed the spending had gone up significantly. The RR 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.

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 was provided, for one of three residents reviewed (Resident 5), when there was no medication treatment initiated for Resident 5's rash on the groin. In addition, there was no follow up assessment to monitor the status of the rash on the groin. These failures had the potential for a delay in the care and treatment of Resident 5 rash on the groin and could potentially affect the overall condition of the resident. Findings: On February 27, 2024, at an unannounced visit was made to the facility for a quality of care issue. On February 27, 2024, Resident 5 ' s record was reviewed. Resident 5 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss). A review of Resident 4 ' s Progress Notes, dated January 19, 2024, at 4:23 p.m., indicated, .2nd admission skin evaluation .Resident noted with the following skin issues upon admission .Fungal rash to the groin skin with redness, swollen,…

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

Based on observation, interview, and record review, the facility failed to provide an environment free of verbal abuse, for one of four residents reviewed (Resident 1), when a Certified Nursing Assistant (CNA) yelled at Resident 1. This failure resulted to Resident 1 being subjected to verbal abuse which could negatively affect the emotional and psychosocial wellbeing of Resident 1. Findings: On November 8, 2023, at 9:40 a.m., an unannounced visit to the facility was conducted to investigate an allegation of verbal abuse. On November 8, 2023, at 9:45 a.m., the Administrator (ADM) was interviewed. The ADM stated the alleged incident happened on October 30, 2023, at 5:15 p.m., when CNA 1 was verbally abusive to Resident 1. She stated LN 2 witnessed CNA 1 yelling at Resident 1 saying, If you throw that (referring to a cup of water) at me, I will throw you to the f .g shower, after Resident 1 was ready to throw a cup of water at CNA 1. The ADM stated CNA 1 should have talked to the administration or the charge nurse if she was having a bad day and request to not to work to prevent any…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 Physician Orders for Life Sustaining Treatment (POLST), for one of six residents (Resident 1) was signed by the physician to indicate the resident's request for a do not resuscitate measures (DNR - no code). This failure resulted in Resident 1 receiving an unwanted treatment. Findings: On [DATE], at 10:06 an unannounced visit was conducted at the facility for a death complaint. On [DATE], Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included muscle wasting and ovarian cancer (cancer of the female reproductive organs). Review of Resident 1's Physician Order Summary indicated .DNR . dated [DATE]. Review of Resident 1's POLST dated [DATE], indicated, .Do Not Attempt Resuscitation/DNR (Allow Natural Death) . the physician signature was missing on the document. Review of Resident 1's nursing progress note dated [DATE], at 6:30 a.m., indicated, .found unresponsive .call to 911…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two-person physical assist was provided during provision of care according to the plan of care, for one of three residents reviewed (Resident A). This failure had the potential to place Resident A at risk for accidents and injuries. Findings: On May 18, 2023, at 9:35 a.m., an unannounced visit to the facility was conducted to investigate a facility reported incident. On May 18, 2023, at 9:40 a.m., an interview was conducted with the Administrator (ADM). She stated an investigation of an alleged physical abuse involving an unknown Certified Nursing Assistant toward Resident A was initiated on May 14, 2023. On May 18, 2023, at 10:30 a.m., Resident A was observed in bed, awake, and alert. Resident A was able to answer with yes or no to basic questions using a communication board. Resident A appeared overweight and had contracture (occurs when your muscles, tendons, joints, or other tissues tighten or shorten causing a deformity) of…

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

Based on observation, interview, and record review, the facility failed to ensure the garbage bin lid was securely closed. This failure had increased the potential to attract rodents and spread infection affecting 121 medically compromised residents. Findings: On April 17, 2023, at 11:15 a.m., during the initial tour of the kitchen with the Food Service Director (FSD), the garbage bin located outside the building was observed to be over-filled and the lid was not securely closed. The garbage bin was observed opened approximately one and a half feet-high. In a concurent interview with the FSD, he stated the garbage bin lid should be closed at all times, to prevent rodents being attracted and preventing spread of infection. On April 21, 2023, at 8:08 p.m., the Registered Dietician (RD) was interviewed. The RD stated the garbage bin lid must be securely closed and not overflowing. A review of the facility's policy and procedure titled , SANITATION ROUNDS QUICK CHECKLIST, dated November 2020, indicated, .Dumpster .closed no trash laying around .

Based on interview and facility record review, the facility failed to have a written Quality Assurance Performance Improvement (QAPI - a systematic, interdisciplinary, comprehensive, and data-driven approach to maintain and improve safety, quality of care, and quality of life of the residents) plan in place to address the facility's systemic process issues related to pressure injuries (PIs) and foot care. These failures resulted in multiple residents to not receive appropriate care and treatment for pressure injuries and foot care. In addition, these failures had the potential to place other residents residing at the facility to be at risk for not achieving their highest physical, mental, psychosocial well-being. Findings: On April 21, 2023, at 6:42 p.m., the Administrator (ADM) and the Director of Nursing (DON) were verbally notified of the Immediate Jeopardy (IJ- situation in which the provider's noncompliance with one or more requirements of participation has caused or likely to cause serious injury, harm, impairment, or death to a resident), due to the facility's failure to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a copy of the Advance Directive (AD - written statement of a person's wishes regarding medical treatment) was available in the residents' records, for eight of 12 residents reviewed for AD (Residents 457, 83, 61, 99, 308, 54, 92, and 311.) This failure had the potential for Residents 457, 83, 61, 99, 308, 54, 92 and 311's AD to not be readily retrievable by the staff and the physician, making them unaware of, and unable to honor the residents' wishes regarding their medical treatment. Findings: 1. On April 18, 2023, Resident 457's record was reviewed. Resident 457 was admitted to the facility on [DATE]. The Social Services Assessment and History, dated April 13, 2023, indicated Resident 457 had a Power of Attorney (POA- a type of AD) for healthcare and finance. 2. On April 18, 2023, Resident 83's record was reviewed. Resident 83 was admitted to the facility on [DATE]. The Social Service Evaluation, dated October 21, 2022, indicated Resident 83…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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. The physician evaluated the overall condition, for three of five residents reviewed for pressure injuries (Residents 92, 98, and 18). This failure resulted in Residents 92, 98, and 18 to not receive prompt and appropriate care and treatment for their pressure injuries; and 2. The physician evaluated the overall condition, for three of five residents reviewed for foot care (Residents 98, 84, and 47). This failure resulted in Residents 98, 84, and 47 not to receive prompt and appropriate foot care and necessary podiatry services (medical care and treatment of the human foot and their ailments). Findings: 1a. On April 18, 2023, at 12:24 p.m., Resident 92 was observed awake and sitting in her wheelchair. Resident 92 was observed to be slow to respond but able to answer simple instructions when a staff delivered her lunch tray. She was observed to be assisted by a staff with feeding. On April 21, 2023, Resident 92'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.

Based on interview and record review, the facility failed to ensure annual performance reviews were conducted, for three of five Certified Nursing Assistants (CNAs [CNAs 2, 3, and 4) employee file reviewed for sufficient and competent staffing. This failure had the potential for facility staff to not develop and maintain the necessary skills and competencies in order to provide adequate and safe care and services to the residents. Findings: On April 21, 2023, at 9:41 a.m., a concurrent interview and review of facility employee records was conducted with the Human Resources Director (HRD). The HRD stated the facility staff's yearly performance evaluations included a skills competency assessment and was being conducted yearly in February. The HRD further stated direct care staff performance evaluation was important to evaluate the staff's need for further training or identify areas needed for them to improve. The records of five CNAs were concurrently reviewed with the HRD. She stated the following CNAs did not have an anuual performance review on the following years: - CNA 2; years…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provision of pharmacy services met the needs of the residents when: 1. Discontinued medications in the medication cart that were no longer used were stored along with active medications for resident use. This had the potential for residents to receive wrong, and ineffective medications; and 2. The thermometer in the medication refrigerator displayed 32 °F (degree Fahrenheit; unit of measurement). This had the potential for residents to receive ineffective medication therapy. Findings: 1. On April 18, 2023, at 11:56 a.m., during the medication room inspection in Nursing Station 1 with Registered Nurse (RN) 4, the following expired medications were observed stored in the medication refrigerator: - Three 0.5-ml (milliliter - unit of measurement) powdered vials of Shingrix (vaccine for shingles, a viral infection that causes painful skin rash) with the expiration date of October 15, 2022; - Two 0.5-ml powdered vials of Shingrix with the expiration date of January 27, 2023; and - One powdered injectable…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 residents were receiving pain medications according to the physician orders with adequate indications, for two of five residents reviewed for unnecessary medications (Residents 92 and 311), when the residents received oxycodone/acetaminophen (potent Schedule II narcotic pain medication combined with Tylenol) with documented pain level below 3 (mild pain in pain rating scale). This resulted in the two residents unnecessarily receiving narcotic pain medications. Findings: 1. On April 19, 2023, Resident 92's medical record was reviewed, and it indicated the resident was admitted on [DATE] with diagnoses which included bipolar disorder (mental illness), dementia (memory loss), seizures (epilepsy), sarcopenia (gradual loss of muscle strength), diabetes mellitus (abnormal blood sugar), and history of falling. There was a physician order, dated February 10, 2023, for acetaminophen (Tylenol - over-the-counter medication for mild pain or fever) 325 mg…

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

Based on observation, interview, and record review, the facility failed to ensure food items were stored, prepared, and served under sanitary conditions, when two containers of sour cream were found inside the walk-in refrigerator past the used by date (the last date recommended for the use of the product while at peak quality). This failure had the potential to result in food borne illnesses to medically vulnerable residents who are on oral feeding in the facility. Findings: On April 17, 2023, at 10:30 a.m., during a brief tour of the kitchen with the Food Service Director (FSD), two five pounds containers of sour cream were observed stored in the walk-in refrigerator, with used-by date of March 5, 2023. On April 17, 2023, at 10:40 a.m., in an interview with the FSD, the FSD stated the containers of sour cream should had been discarded by the used by date. On April 21, 2023, at 8:08 p.m., the Registered Dietician (RD) was interviewed. The RD stated to prevent food borne illness the food should have been discarded by the used by by date. The facility's policy and procedure titled,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 measures were implemented when: 1. Multiple staff who provided resident care were observed to not perform hand hygiene; and 2. One resident (Resident 78) was not placed on Enhanced Barrier Precautions (EBP - infection control intervention designed to reduce transmission of resistant organisms that required use of gown and glove during high contact resident care activities) when the resident had VRE (Vancomycin Resistant Enterococcus [MDRO - multi-drug resistant organism; a type of infection which is resistant to more than one antibiotic]) in the urine. These failures had the potential to increase the spread of pathogens (germs) and infections by staff to residents. Findings: 1. On April 17, 2023, at 12:33 p.m., an observation was conducted inside room [ROOM NUMBER]. Certified Nursing Assistant (CNA) 6 was observed feeding Resident 310, while wearing gloves. CNA 6 was observed to then feed Resident 92 after. CNA 6…

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

Based on interview and record review, the facility failed to provide initial and ongoing wound care training, for five of five Licensed Nurses (LNs) (Licensed Vocational Nurse [LVN]s 1, 7, 8, 6, and Registered Nurse [RN] 2), who provided wound care to residents with pressure injuries (PI - localized damage to the skin and underlying soft tissue over a bony prominence or from a medical device). This failure resulted in inaccurate assessment and a delay in the care and treatment for the residents who had pressure injuries. Findings: On April 21, 2023, at 2:40 p.m., a concurrent interview was conducted with the Administrator (Adm), Director of Nursing (DON), RN 1, Registered Dietitian (RD), LVN 1, and LVN 6 regarding pressure related injuries (PIs - bedsore) and wound care trainings to address PIs. The following staff interviews were conducted: - LVN 1 stated the Treatment Team was put together in April 2022. LVN 1 stated she took an eight hour online class on wound management trainings. LVN 1 further stated the facility had a wound care protocol, and had paperwork printed and placed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 treated with dignity and respect, for one of five residents reviewed for dignity (Resident 13), when the resident waited to be fed while the other resident seated at the same table (Resident 14) had been eating for 15 minutes, and Licensed Vocational Nurse (LVN) 1 was observed standing while feeding Resident 13. These failures had the potential for Resident 13 to not attain her highest practicable physical and psychosocial wellbeing. Findings: 1. On April 17, 2023, at 12:50 p.m., during meal observation in the main dining area, Residents 13 was observed seated at the same table with Resident 14. Certified Nurse Assistant (CNA) 1 was observed to serve Resident 14's tray first, then Resident 13's tray was served a minute later. CNA 1 was overheard stating that she would be back later to assist Resident 13 with feeding. On April 17, 2023, at 12:55 p.m., Resident 14 was observed to start eating by herself. Resident 13…

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

Based on observation, interview, and record review, the facility failed to ensure the residents needs were accommodated, for one of six residents reviewed for environment (Resident 4), when the call light was observed not within the resident's reach. This failure had the potential for Resident 4 not to be able to notify staff of necessary assistance she needed. Findings: 1. On April 17, 2023, at 11:18 a.m., Resident 4 was heard calling for assistance. In a concurrent observation of Resident 4's room, her call light was observed on the floor and not within the reach of the resident. On April 17, 2023, at 11:19 a.m., Licensed Vocational Nurse (LVN) 2 was seen walking towards another room and LVN was called to Resident 4's room. On April 17, 2023, at 11:20 a.m. LVN 2 was interviewed. LVN 2 stated the call light was on the floor and was not clipped within Resident 4's reach. LVN 2 stated the call light should have been clipped to the bed within Resident 4's reach On April 19, 2023, at 1:30 p.m., Registered Nurse (RN) 1 was interviewed. RN 1 stated the call light should have been within…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 Resident Representative (RR) was notified when the resident returned to the facility from the hospital, for one of one resident reviewed (Resident 17). This failure resulted for Resident 17's RR to not be notified of the resident's current status in the facility after coming back from the hospital. Findings: On April 18, 2023, at 2:30 p.m., Resident 17's RR was interviewed. The RR stated he called the facility two weeks ago, the facility staff informed him Resident 17 was hospitalized . He stated he tried to get hold of the facility the following day, but their phone was out of order. Resident 17's RR stated he was not given feedback as to what transpired in the hospital, and when Resident 17 returned to the facility. On April 18, 2023, Resident 17's record was reviewed. Resident 17 was originally admitted to the facility on [DATE], with diagnoses which included cerebral infarction (when a clot blocks a blood vessel in the brain) and aphasia…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain a safe, clean, and homelike environment, for three rooms (rooms [ROOM NUMBER]). These failures could potentially placed residents residing in rooms [ROOM NUMBER] at risk for accidents. Findings: 1. On April 17, 2023, at 10:30 a.m., an observation of room [ROOM NUMBER] was conducted. room [ROOM NUMBER] was observed to have a wallpaper above the cooling unit peeling away from the wall (at the seam, along the border of the cooling unit) and the wall underneath was exposed. 2. On April 17, 2023, at 12:30 p.m., room [ROOM NUMBER] was observed to have one of the nightstands to have a portion of the metal track sticking out from a drawer. 3. On April 17, 2023, at 4:40 p.m., a concurrent observation and interview was conducted with Resident 359 (room [ROOM NUMBER]). Resident 359 was observed sitting in a wheelchair beside her bed. In a concurrent interview with Resident 359, she stated the light in the bathroom was too dim and she could…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 an individualized baseline care plan (specific interventions to provide effective and person centered care to meet the resident's needs) was initiated within 48 hours after admission to address bowel and bladder needs, for one of eight newly admitted residents reviewed (Resident 359). This failure had the potential to cause inadequate management of Resident 359's toileting needs and could affect the overall condition of Resident 358 Findings: On April 17, 2023, at 3:03 p.m., an interview with Resident 359 was conducted. Resident 359 stated she would call for assistance to use the bathroom and it would take the staff about 45 minutes to get assistance. On April 18, 2023, Resident 359's record was reviewed. Resident 359 was admitted on [DATE], diagnoses which included diabetes mellitus (abnormal blood sugars) and history of falling. A review of Resident 359's Progress Notes, indicated the following: - April 14, 2023, at 11:00 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 services provided meet professional standards of practice, for two of 25 sampled residents (Residents 457 and 85) when medications brought in by the residents were stored on top of the bedside table. In addition, Residents 457 and 85's medications did not have a physician's order. These failures had the potential for Residents 457 and 85 to receive medications unsafely. Findings: 1. On April 17, 2023, at 12:05 p.m., an observation with a concurrent interview was conducted with Resident 457. Resident 457 was observed sitting in bed, alert, and interviewable. The following were observed on top of Resident 457's bedside table: - A white pill organizer labeled with days of the week from Sunday to Saturday. One small purple oval tablet and 1 pink/blue capsule were observed inside the slot for Tuesday and one round white tablet inside the slot for Wednesday; - An open bottle of Goodsense Sterile eyedrops (a medication use to add moisture…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain or improve hearing difficulty, for one of one resident reviewed for communication-sensory (Resident 5). This failure had the potential for Resident 5 to not effectively communicate and express her needs. Findings: On April 18, 2023, at 10:59 a.m., an observation and attempted interview was conducted with Resident 5. Resident 5 was observed sitting in a wheelchair going into her room. During an attempt to interview Resident 5, Resident continuously stated What?, shook her head, and stated I can't hear you. On April 19, 2023, Resident 5's medical record was reviewed. Resident 5 was admitted on [DATE], with diagnoses which included syncope (a loss of consciousness for a short period of time) and fall. A review of Resident 5's Minimum Data Set (MDS - an assessment tool), dated January 29, 2023, indicated, Resident 5 had minimal difficulty in hearing and did not have a hearing aid. The MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure nutritional care and services were provided, for one of seven residents reviewed for nutrition (Resident 83) when the Registered Dietician's (RD) recommendations were not referred to the physician to address Resident 83's significant weight loss of 12.30% in six months. This failure had the potential for a delay in the care and treatment which may result in further weight loss and worsening of Resident 83's overall condition. Findings: On April 17, 2023, at 11:59 a.m., Resident 83 was observed sitting in bed and not able to answer simple questions. Resident 83 was observed to have only eaten the soup and ice cream from her lunch tray. On April 19, 2023, Resident 83's record was reviewed. Resident 83 was admitted to the facility on [DATE], with diagnoses which included dysphagia (difficulty swallowing). A review of Resident 83's Minimum Data Set (MDS - an assessment tool), dated January 19, 2023, indicated Resident 83 had a BIMS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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, for one of five residents reviewed for unnecessary medications (Resident 92), antipsychotic medications (for treatment of schizophrenia, mental illness characterized by disordered thinking, hallucinations, and/or delusions) were not started unless: 1. Non-pharmacological interventions were attempted and failed; 2. Documentation was made in the resident's record the targeted behaviors presented danger to themselves and others, and caused a significant distress; and 3. The resident's behaviors were monitored for responses to and effectiveness of the medications. This had the potential for Resident 92 to receive unnecessary psychotropic medication. Findings: On April 19, 2023, Resident 92's medical record was reviewed and it indicated the resident was admitted on [DATE] with the diagnoses that included expressive language disorder, dysphagia (difficulty swallowing), bipolar disorder (psychiatric illness characterized by both manic and depressive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 vials and pens of insulin (hormone used to control blood sugar) were stored in the medication refrigerator as specified by the manufacturer's guidelines when the insulin vials and pens were stored in the medication cart at room temperature instead of refrigerated. This had the potential for less effective, expired medications to be administered to the residents. Findings: On April 18, 2023, at 2:39 p.m., during an inspection of the medication cart (Cart C) in Nursing Station 2 with Licensed Vocational Nurse (LVN) 10, there were insulin vials and pens stored at room temperature as follows: - One 10-ml vial of Humulin R Insulin, no open date; - Two 3-ml Insulin Lispro KwikPen, no open date; and - One 3-ml Insulin Glargine prefilled pen, no open date. They were labeled with the indication, Refrig til [sic.] open then room temp. Discard unused med aft (after) 28 days . In a concurrent with LVN 10, she stated according to the label, the insulin vials and pens should be refrigerated until opened then stored…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 physician was notified timely, for one of 25 residents reviewed (Resident 78), when the resident had a low potassium (electrolyte for muscles and nerves) level. This failure resulted in Resident 78 not to receive appropriate treatment and evaluation to address the resident's low potassium level and placed the resident at risk for further health complications. Findings: On April 24, 2023, Resident 78's record was reviewed. Resident 78 was admitted on [DATE], with diagnoses which included atrial fibrillation (irregular heart beat) and heart failure (inability of the heart to pump blood efficiently). The physician's order, dated March 7, 2023, indicated, Lasix (diuretic medication which could cause electrolyte imbalance [including potassium]) Oral Tablet 40 MG (milligram - unit of measurement) by mouth one time a day . The care plan titled, Altered cardiovascular status, dated March 8, 2023, was reviewed. The document indicated, .Goals .the…

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

Based on interview and record review, the facility failed to ensure, for one of five Certified Nursing Assistants employee file reviewed (CNA 4), received the federally mandated annual trainings for CNAs. This failure had the potential for residents to receive inadequate or unsafe care. Findings: On April 21, 2023, at 9:41 a.m., a concurrent interview and review of facility employee records was conducted with the Human Resources Director (HRD). CNA 4's record indicated she completed the mandatory training for abuse and neglect, and dementia training on January 7, 2022. In a concurrent interview with the HRD, she stated CNA 4 did not have a current annual mandatory training for abuse, neglect, and dementia training in January 2023. She stated CNA 4 should have completed the annual mandatory training by March 31, 2023. The undated facility document titled, (name of facility) University Mandatory In-Service Program,indicated, .What is it? .E-learning courses that address federally mandated annual training topics for all skilled nursing locations using the (name of facility) University…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 plan of care (POC) was updated, for two of 27 residents reviewed (Residents 6 and 255), when: 1. For Resident 6, the IDT (Interdisciplinary Team) recommendation for the bed height and the decline in bowel and bladder status were not addressed in the POC; and 2. For Resident 255, the POC did not address the resident's preference to not be woken up for blood sugar (BS) checks before breakfast. These failures had the potential to result in a delay of the implementation of appropriate interventions to address the care and treatment for Residents 6 and 255. Findings: 1a. On February 25, 2020, at 9:42 a.m., Resident 6 was observed awake and was in a semi-sitting position in bed. He was observed leaning towards the right side of the bed. His bed was observed to be in a regular height position. On February 26, 2020, at 9:43 a.m., Resident 6 was observed in bed, in a semi-sitting position, and was watching TV. His bed was observed 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 residents' fingernails were cleaned and trimmed, for six of eight residents reviewed for activities of daily living (Residents 33, 105, 8, 80, 42, and 154). These failures had the potential to result in injury and infection. Findings: 1. On February 25, 2020, at 10:01 a.m., Resident 33 was observed sitting up in bed, awake, and watching TV. The nails on all her fingers were observed to be approximately 0.5 cm (one half centimeter [a unit of measurement]) long from the tips of her fingers. There were opaque, yellowish material underneath the nails of all ten fingers. On February 26, 2020, at 11 a.m., Resident 33 was observed awake and lying in bed. There were no changes observed in the length and characteristics of her fingernails. During a concurrent interview, she stated her fingernails were dirty. On February 26, 2020, at 11:25 a.m, Resident 33 was observed with Licensed Vocational Nurse (LVN) 1. During a concurrent 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 the necessary care and treatment were provided, for four of 28 residents reviewed (Residents 33, 22, 255, and 21), when: 1. For Resident 33, the facility failed to identify, assess, and monitor the wound on her left forearm; 2. For Resident 22, the facility failed to notify the physician after she had five episodes of diarrhea (loose stool) in one shift; 3. For Resident 255, the facility failed to ensure the resident's blood sugar (BS) was checked before breakfast as ordered by the physician; and 4. For Resident 21, the facility failed to monitor the edema (swelling caused by excess fluid) on both her lower extremities. These failures had the potential to result in a delay of care and treatment for Residents 33, 22, 255, and 21. Findings: 1. On February 25, 2020, at 10:01 a.m., Resident 33 was observed lying in bed, awake, and watching TV. Resident 33's left forearm was observed to have a blackish lesion with reddish edges,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 Medication Regimen Review (MRR, process by which a consultant pharmacist reviewed a resident's medications) recommendations were acted upon timely, for two of five residents reviewed for unnecessary medications (Residents 80 and 18). This failure had the potential to resulted in a delay in the provision of treatment for Resident 80 and the monitoring for the effectiveness of Atorvastatin (medication to treat high cholesterol level) for Resident 18. Findings: 1. On February 25, 2020, Resident 80's record was reviewed. Resident 80 was admitted to the facility on [DATE], with diagnoses which included osteoarthritis (inflammation of the joints). The Lab Results Report, dated October 14, 2019, included Vitamin D, 25-Hydroxy level (blood test to measure Vitamin D [vitamin needed to make bones strong] level in the body). Resident 80's Vitamin D, 25-Hydroxy level was 7 (seven; normal range was 30 -100). The Order Summary Report, included a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the menu was followed, when the appropriate portion size was not served, for 34 of 34 residents with a diet order of cardiac (diet for residents with heart related diseases) and cardiac/controlled carbohydrate (CCHO [diet for residents with heart related disease and abnormal blood sugar]). In addition, spiral pasta was not served as indicated in the menu, for nine of nine residents with renal (kidney) diet. These failures had the potential for 41 residents to not receive adequate nutrition which could further compromise their medical status. Findings: On February 26, 2020, the Diet Spreadsheet, for the lunch meal to be served on February 26, 2020, was reviewed. The document indicated the following menu to be followed for specific diet orders: - Cardiac and CCHO cardiac diets, 2 oz (ounces) bkd (baked) chicken; and - Renal and CCHO renal diets, spiral pasta. On February 26, 2020, at 10:44 a.m., the Dietary Supervisor (DS) 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 ensure the therapeutic diet was served to residents as ordered by the physician when the appropriate portion size was not served, for 34 of 34 residents with a diet order of cardiac (diet for residents with heart related diseases) and cardiac/controlled carbohydrate (CCHO [diet for residents with heart related disease and abnormal blood sugar]). In addition, spiral pasta was not served as indicated in the menu, for nine of nine residents with renal (kidney) diet. These failures had the potential for 41 residents to not receive adequate nutrition which could further compromise their medical status. Findings: On February 26, 2020, the Diet Spreadsheet, for the lunch meal to be served on February 26, 2020, was reviewed. The document indicated the following menu to be followed for specific diet orders: - Cardiac and CCHO cardiac diets, 2 oz (ounces) bkd (baked) chicken; and - Renal and CCHO renal diets, spiral pasta. On February 26, 2020, 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.

Based on observation, interview, and record review, the facility failed to ensure infection control was implemented when multiple staff who provided patient care were observed to have long and/or artificial fingernails. This failure had the potential for the residents to acquire infections due to harmful bacteria harbored underneath the artificial fingernails, and for resident/s to acquire injury due to the length of staff's fingernails. Findings: On February 26, 2020, at 2:34 p.m., Registered Nurse (RN) 4 was observed in Unit 1. RN 4 was observed to have hot pink fingernail polish on and her fingernails were observed to be approximately two to three millimeters ([mm] a unit of measurement) past the fingertips. In a concurrent interview with RN 4, she stated her nails were gel (a manicure product that can be used like nail polish). She stated it was important to not have long nails for sanitary issues and to not injure the residents. She further stated there was no facility policy on gel nails, but the fingernails were not to be longer than the fingertips. On February 26, 2020, at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a scheduled eye appointment was followed up, for one of two residents (Resident 154) reviewed for vision. This failure had the potential for Resident 154 to not receive the necessary treatment timely to maintain effective vision. Findings: On February 24, 2020, at 11:28 a.m., Resident 154 was observed lying in bed and watching TV. In a concurrent interview, Resident 154 stated she needed glasses to be able to read. She stated she had not had an eye check up while she was in the facility. On February 26, 2020, at 9:08 a.m., Resident 154 was observed lying in bed and watching TV. In a concurrent interview, she stated she could not see the TV clearly and could only see colors and some movements. She stated she would like to have new glasses so she can see the TV program better. On February 26, 2020, Resident 154's record was reviewed. Resident 154 was admitted to the facility on [DATE], with diagnoses which included rheumatoid…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 an assessment was conducted and care and treatment were provided, when a resident had a decline in bowel and bladder status, for one of 28 residents reviewed (Resident 6). This failure had the potential for a delay of treatment to restore Resident 6's bowel and bladder function. Findings: On February 25, 2020, at 9:42 a.m., Resident 6 was observed awake and in a semi-sitting position in bed. On February 26, 2020, Resident 6's record was reviewed. He was admitted to the facility on [DATE], with diagnoses which included prostate (part of the male reproductive organ that produces semen) cancer. The Minimum Data Set (MDS - assessment tool), dated November 13, 2019, indicated Resident 6 required limited assistance with toileting. The MDS indicated he was continent of bowel and bladder (able to voluntarily control retention of urine or feces in the body) status. The MDS indicated Resident 6 was independent in daily decision making. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the residents' fluid intake were being monitored while on fluid restrictions, for two of two residents reviewed (Residents 55 and 140). This failure had the potential for the residents to have fluid overload and complications. Findings: 1. On February 27, 2020, the record of Resident 55 was reviewed. He was admitted to the facility on [DATE], with diagnoses which included end stage renal disease (damage to the kidneys and loss of normal function) with hemodialysis (a treatment to filter waste and water from the blood). The Order Summary Report, included a physician order, dated June 19, 2019, which indicated, .1.5 liters (unit of measurement) daily fluids (sic) restrictions . On February 27, 2020, at 4:05 p.m., Resident 55 was observed lying in bed. An unopened 236 ml (milliliter) bottled water and an opened bottled with approximately 450 ml of water left in the bottle were observed on top of Resident 55's over bed table. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the use of Lasix (medication to treat edema [swelling]) was monitored related to the indication of edema, for one of five residents reviewed for unnecessary medications (Resident 18). This failure had the potential for Resident 18 to receive unnecessary medication. Findings: On February 25, 2020, at 3:53 p.m., Resident 18's record was reviewed. Resident 18 was admitted to the facility on [DATE], with diagnoses which included peripheral vascular disease (circulatory condition in which narrowed blood vessels reduced blood flow to the limbs). The untitled document, dated February 28, 2019, indicated, .The resident has Peripheral Vascular Disease .History of edema .(Resident 18's name) extremities will be free from .edema .Monitor for edema and encourage resident to elevate legs . The Progress Notes, dated March 14, 2019, at 10:41 a.m., indicated, .Spoke with MD (physician) regarding patient's LLE (left lower extremity) edema. New…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 physician's order for comprehensive metabolic panel (CMP - blood test that measured the levels of sugar and electrolytes in the body and kidney function) and lipid panel (blood test to monitor the fatty substances in the blood) were completed as ordered by the physician, for one of 27 residents reviewed (Resident 18). These failures had the potential for medical condition/s to not be identified timely and/or a delay in the care and treatment for Resident 18. Findings: On February 25, 2020, Resident 18's record was reviewed. Resident 18 was admitted to the facility on [DATE], with diagnoses which included hypertension (elevated blood pressure) and peripheral vascular disease (circulatory condition in which narrowed blood vessels reduced blood flow to the limbs). The Consultation Report, dated September 5, 2019, included recommendation to monitor fasting lipid panel on the next convenient lab day. The report indicated the physician agreed 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.