Meadowbrook Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the nebulizer (a small device that converts liquid medication into an inhalable mist) used to administer respiratory treatment was changed after seven days, in accordance with the facility policy and procedure, for one (Resident 12) of one resident reviewed for oxygen use. This failure had the potential to result in bacterial growth that could affect the health of the vulnerable resident population.Findings: During an observation on September 22, 2025, at 11:33 a.m., Resident 12 was observed in bed, awake and alert. A nebulizer set-up was observed in a clear plastic bag, hanging on the wall. The clear plastic bag was labeled with Resident 12's name, room number and a date of 8/25. During an observation on September 24, 2025, at 10:05 a.m., a clear plastic bag was observed hanging on the wall labeled with Resident 12's name, room number and a date of 8/25. During an interview on September 24, 2025, at 10:19 a.m., 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 the medication error rate was below five percent (%) when three medication errors out of 28 opportunities was observed for one of six residents (Resident 33) observed for medication administration.This failed facility practice resulted in a medication error rate of 10.71 percent (3 errors out of 28 opportunities) and has the potential for Resident 33 to experience the side effects of the medications not given as prescribed by the physician.Findings: On September 24, 2025, at 8:45 a.m., a medication pass observation on Resident 33 was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 was observed verifying medication with the physician's orders in the electronic Medication Administration Record (eMAR) as she prepared the following medications:- One tablet of Metoprolol (medication used to treat high blood pressure) 25 milligrams (mg- unit of measurement);- One tablet of Lisinopril (medication used to treat high blood pressure)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 six residents (Resident 33) observed for medication pass, was free from significant medication error when the medications celexocib (pain medication), potassium chloride (potassium supplement) ER (Extended Release), and ferrous sulfate tablet supplement, were not administered with food as ordered by the physicianThis failure had the potential for Resident 33 to experience the side effects of these medications. Findings:On September 24, 2025, at 8:45 a.m., a medication pass observation on Resident 33 was conducted with Licensed Vocational Nurse (LVN) 1. Included in the morning medications prepared by LVN 1 for Resident 33 were the following medications that had an instruction to give with food:- One tablet of Ferrous sulfate 325 milligrams (mg-unit of measurement);-One tablet of celecoxib 200 mg; and-Two tablets of potassium chloride ER 20 mEq (milliequivalent - unit of measurement).On September 24, 2025, at 9:04 a.m., 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 the diet order was followed according to physician's order for one of 52 residents reviewed (Resident 5), when Resident 5 was observed to receive a pureed diet on September 22, 2025, during lunch.This failure had the potential to compromise Resident 5's nutritional and medical condition.Findings:On September 22, 2025, at 12:06 p.m., during meal observation, Resident 5 was observed in the dining room, lying in a Geri chair (geriatric chair - a recliner chair for individuals with limited mobility). Resident 5 was observed to have his lunch while being fed by Certified Nursing Assistant (CNA) 2. Resident 5 was observed to have a pureed diet (mashed or blended to a smooth, pudding-like consistency). In a concurrent interview with CNA 2, she stated she fed Resident 5 a pureed diet. Resident 5's meal ticket was verified with CNA 2. The laminated meal ticket indicated, .Resident's name.CCHO (Consistent Carbohydrate - diet with consistent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 infection control measures for one of five residents reviewed for infection control (Resident 3) when one staff member was observed providing care for a resident (Resident 3) on Enhanced Barrier Precautions (EBP - measures used to reduce and prevent infections) without wearing recommended Personal Protective Equipment (PPE). This failure had the potential to result in spreading infection to a vulnerable resident population. On September 25, 2025, at 9:04 a.m., Licensed Vocational Nurse (LVN) 3 was observed entering Resident 3's room and handling her feeding tube (a tube inserted in the stomach, used to deliver nutrition for residents who cannot eat). LVN 3 was observed not wearing appropriate PPE (gown) when handling the feeding tube of Resident 3. An isolation cart was observed outside the room of Resident 3, with PPE readily available for staff to use (including gowns), and a posted sign indicating Resident 3 was on EBP.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 interview and record review, the facility failed to ensure wound care treatments were provided to meet the needs of residents when four sampled residents ' (Residents 1, 2, 3, and 4) were not provided wound care treatment in accordance with the physician ' s orders. This failure had the potential for Resident 1, Resident 2, Resident 3, and Resident 4 ' s wounds to worsen and could lead to serious complications. Findings: On June 25, 2025, at 9:37 a.m., Resident 1 ' s admission record indicated resident was admitted to the facility on [DATE], with diagnoses which included diabetes (high blood sugar), hypertension (high blood pressure), osteomyelitis right foot (bone infection), and chronic kidney disease (gradual loss of kidney functions). A review of Resident 1 ' s Order Summary Report from April 1, 2025, to June 25, 2025, indicated the following: a. Clean right foot stump wound with Normal Saline and pat dry apply betadine and cover with kerlix and secure with tape. Change as needed if becomes soiled.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the Office of the State Long-Term Care (LTC) Ombudsman (an advocate for residents of nursing homes) when one of three sampled residents (Resident 1) was transferred to a general acute care hospital. This failure has the potential for the Ombudsman not be able to advocate for the residents in protecting their rights from inappropriate transfer and discharge. Findings: A review of Resident 1 ' s admission record indicated resident was admitted to the facility on [DATE], with diagnoses which included diabetes (high blood sugar), hypertension (high blood pressure), osteomyelitis right foot (bone infection), and chronic kidney disease (gradual loss of kidney functions). Further review of the record indicated the resident was transferred to an acute care hospital on June 10, 2025. A review of Resident 1 ' s Progress Note date June 10, 2025, at 1:45 p.m., indicated .received new orders .Resident sent out to[name of hospital] .gangrene right foot…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 storage practice was followed in accordance with the professional standards of practice when a gallon of chocolate syrup with an open date of October 19, 2023, was found on top of the kitchen overhead counter, readily available for use. This failure had the potential to cause food-borne illnesses in a medically vulnerable population who consumed food in the facility. Findings: On May 12, 2025, at 12:12 p.m., during a brief kitchen tour with the Dietary Manager (DM), a gallon of chocolate syrup with an open date of October 19, 2023, was found on top of the kitchen overhead counter, readily available for use. In a concurrent interview with the DM, he stated the chocolate syrup should have been discarded one year after it was opened on October 19, 2023. He stated the chocolate syrup was only good for one year once opened. The DM stated the chocolate syrup should have been thrown away so the kitchen staff will not use it. He also stated expired food can cause stomach upset or stomach illnesses. On May…

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

Based on observation, interview, and record review, the facility failed to dispose garbage and refuse properly when the dumpster was found overflowing with trash. In addition, the lid of the dumpster was not completely closed. This failure had the potential to attract pests. Findings: On May 12, 2025, at 12:33 p.m., during a garbage disposal inspection with the Dietary Manager (DM), a trash dumpster located outside the building by the parking lot area was observed overflowing with trash. In addition, the lid of the dumpster was not completely closed. In a concurrent interview with the DM, he stated the dumpster should not be overflowing with trash. He also stated, the dumpster lid should be completely closed to prevent attracting pests. On May 12, 2025, at 12:25 p,m, during an interview with the facility owner, he stated the dumpster should not be overflowing and the lid should be completely closed. A review of the facility policy and procedure, titled, Food-Related Garbage and Refuse Disposal, revised October 2017, indicated, .Outside dumpsters provided by garbage pick-up services…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure infection control practice was followed for two of three residents reviewed (Residents 1 and 2) when: 1. For Resident 1, the oxygen (O2) cannula (a flexible tube with two prongs that fit into the nostrils and delivers supplemental O2) was not dated and an undated nebulizer mask (a medical device that fits over the nose and mouth and allows an individual to inhale a mist of medication directly into their lungs) was found on top of Resident 1 ' s nightstand. In addition, the undated nebulizer mask was not stored in a plastic bag and was exposed to the environment; and 2. For Resident 2, the nebulizer mask was not changed since admission. These failures had the potential for Residents 1 and 2 to be exposed to bacterial cross contamination and the development of infection. Findings: 1. On May 12, 2025, at 11:18 a.m., Resident 1 was observed sitting in bed, awake and alert. Resident 1 was receiving O2 at 2 (two) LPM (Liters Per Minute –…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, medical record review, and facility Policy and Procedure (P&P) review, the facility failed to ensure: 1. A system was developed and implemented to accurately track the movement of controlled medications (medications with high potential for abuse or addiction) to prevent and identify loss or potential diversion (illegal distribution or use for purposes not intended by the prescriber) of controlled medications when the facility was unable to account for the missing controlled medications for ten residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10). This failure had resulted in controlled medication abuse or diversion. 2. Accurate accountability of controlled medications. During a random controlled medication audit for four of six sampled residents (Residents 9, 11, 12, and 13), the controlled medications were signed out of the Count Sheet (a controlled medication record, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Records (MAR) to indicate they were administered to the…

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

Based on record review, interview, and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) (a comprehensive assessment used to develop a resident's care plan) to reflect a Preadmission Screening and Resident Review (PASRR) Level II for 3 (Residents #11, #18, and #39) of 15 sampled residents and failed to code a resident with an indwelling catheter for 1 (Resident #26) of 15 sampled residents reviewed for MDS accuracy. Findings included: A facility policy titled, Certifying Accuracy of the Resident Assessment, revised in 12/2009 revealed, All personnel who complete any portion of the Resident Assessment (MDS) must sign and certify the accuracy of that portion of the assessment. The policy revealed, 1. The Assessment Coordinator must sign and certify that an MDS assessment has been completed for each resident. 2. All personnel who complete any portion of the MDS assessment, tracking form, or correction request form must sign a hard copy of such assessment certifying the accuracy of that portion of that assessment. 1. An admission Record revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review, and facility policy review, the facility failed to ensure a privacy bag was used for 1 (Resident #26) of 2 sampled residents reviewed for urinary catheters. Findings included: A facility policy titled, Resident Rights, revised in 12/2016, specified, Federal and state laws guarantee certain basic rights to all resident of this facility. These rights include the resident's right to: a. a dignified existence. An admission Record revealed the facility admitted Resident #26 on 11/04/2023. According to the admission Record, the resident had a medical history that included diagnoses of hemiplegia and hemiparesis (one-sided paralysis) following cerebral infarction (stroke), infection of the skin and subcutaneous tissue, and sepsis (infection of the blood). A significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/21/2024, revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated Resident #26 was always…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review, and facility policy review, the facility failed to ensure a care plan was developed for 2 (Resident #26 and Resident #34) of 2 sampled residents reviewed for urinary catheters. Findings included: A facility policy titled, Care Plans, Comprehensive Person-Centered, revised in 12/2016, specified, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident. The policy also indicated, The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 1. An admission Record revealed the facility admitted Resident #26 on 11/04/2023. According to the admission Record, the resident had a medical history that included diagnoses of hemiplegia and hemiparesis (one-sided paralysis) following cerebral infarction (stroke), infection of the skin and subcutaneous tissue, and sepsis (infection of the blood). A significant change Minimum…

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

Based on observation, interview, record review, and facility policy review, the facility failed to ensure upon admission, that orders were obtained for the placement and ongoing care and maintenance of urinary catheters for 2 (Resident #34 and Resident #26) of 2 sampled residents reviewed for urinary catheters. Findings included: A facility policy titled, Catheter Care, Urinary, revised in 10/2010, revealed, The purpose of this procedure is to prevent catheter-associated urinary tract infections. The policy also revealed, The following information should be recorded in the resident's medical record: 1. The date and time that catheter care was given. 2. the name and title of the individual(s) giving the catheter care. 3. All assessment data obtained when giving catheter care. 4. Character of urine such as color (straw-colored, dark, or red), clarity (cloudy, solid particles, or blood), and odor. 5. Any problems noted at the catheter-urethral junction during perineal care such as drainage, redness, bleeding, irritation, crusting, or pain, and 9. The signature and title of the person…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review, and facility policy review, the facility failed to ensure physician orders were followed for 1 (Resident #17) of 1 resident reviewed for supplemental oxygen use. Findings included: A facility policy titled, Medication and Treatment Orders, revised in 07/2016, specified, Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in the state. A facility policy titled, Oxygen Administration, revised in 10/2010, specified, The purpose of this procedure is to provide guidelines for safe oxygen administration. The policy revealed, Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. An admission Record revealed the facility admitted Resident #17 on 02/22/2020. According to the admission Record, the resident had a medical history that included diagnoses of shortness of breath, acute upper respiratory infection, and dependence of supplemental oxygen. A quarterly Minimum Data Set (MDS),…

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

Based on interview, record review, and facility policy review, the facility failed to ensure staff assessed a resident's condition and monitored for complications before and after dialysis treatments and failed to ensure there was ongoing communication and collaboration with the dialysis center regarding dialysis care and services for 1 (Resident #53) of 1 sampled resident reviewed for dialysis. Findings included: A facility policy titled, Care of Resident on Renal Dialysis, revised in 06/2016, revealed, It is the policy of this facility to provide standards in the care of the residents on renal dialysis and the care of the vascular access site for hemodialysis. The policy revealed, under Documentation, 2. Facility Licensed Nurse will complete the baseline information, pre and post dialysis section of the Nurses Dialysis Communication Record. 3. Dialysis Center Licensed Nurse will complete the dialysis center section of the Nurses Dialysis Communication Record. An admission Record revealed the facility admitted Resident #53 on 04/26/2024. According to the admission Record, 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 residents were free of imposed charges for services required for residents to achieve their goals and needs safely, when the facility developed and implemented a policy to charge residents, and/or their families when facility staff accompanied the resident to an appointment outside of the facility. This failure had the potential for residents to be charged for covered services and for residents of the facility to avoid necessary appointments. Findings: On March 7, 2024, at 9 a.m., an unannounced visit to the facility was conducted to investigate a complaint related to residents' rights. On March 7, 2024, at 10:09 a.m., a concurrent observation and interview was conducted with Resident 1. Resident 1 was in her room, in her bed, and was alert and oriented. Resident 1 stated the facility informed her they will start charging her $25 if she requests a facility staff member to accompany her at outside appointments. Resident 1 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 interview and record review, the facility failed to ensure medications was administered for two of the four sample residents (Residents 3 and 4) in accordance with the physician order. This failure has the potential to negatively affect the health status of Residents 3 and 4. Findings: On March 20, 2024, at 10:00 a.m., an unannounced visit was conducted at the facility to investigate a complaint for quality-of-care issue. 1. A review of Resident 3's admission record indicated Resident 3 was admitted to the facility on [DATE]. Resident 3's diagnoses included Type 2 diabetes ((condition in which body has trouble controlling blood sugar), end stage renal disease (a person's kidneys cease functioning on a permanent basis leading to long-term dialysis), hypertensive heart disease (changes in the heart as a result of chronic blood pressure elevation), and osteoarthritis (occurs when flexible tissue at the ends of bones wears down). A review of Resident 3's Physician orders, indicated the following: a. June 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, for two of three residents reviewed (Residents 1 and 3), to ensure an inventory of the residents ' belongings were completed upon admission. This failure has the potential for the facility to not be able to protect the resident ' s property or personal belongings from loss or theft. Findings: On January 4, 2024, at 9:44 a.m., an unannounced visit was conducted at the facility to investigate a report on missing personal belongings. a. On January 4, 2024, at 11:06 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated Resident 1 was admitted to the facility on [DATE], and was discharged from the facility on December 25, 2023. The DON stated Resident 1 claimed she had personal bank cards and 15 dollars cash in her belongings that she did not receive after her discharge on [DATE]. On January 4, 2024, Resident 1 ' s record was reviewed, Resident 1 was admitted to the facility on [DATE]. There was no documented…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 of a resident's medication that was being taken at home prior to admission, after being notified by a family member (FM), for one of three residents reviewed (Resident 1). This failure resulted in Resident 1 not receiving her Seroquel (an antipsychotic medication used to treat mental disorders) from January 3, 2024 to January 5, 2024, which she had been taking at home. In addition, Resident 1 had shown behavior of being non compliant when redirected during episodes of wandering and had episodes of being aggressive to staff. Findings: On January 24, 2024, at 8:58 a.m., a telephone interview was conducted with Resident 1's family member (FM). The FM stated Resident 1 had been taking Seroquel at home. She stated the medication kept Resident 1 calm and without the Seroquel Resident 1 could get aggressive. She stated she brought the medications to the facility on January 3, 2024, and gave the medications to the licensed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure resident's right leg swelling and active medical diagnoses of deep vein thrombosis (DVT - blood clot) on the right leg were assessed and monitored for one of three residents reviewed (Resident 1). This failure resulted in Resident 1's development of increased edema (swelling) on the right leg with blisters after three days of admission without staff knowledge, leading to Resident 1's transfer to the acute hospital. Findings: On January 24, 2024, at 12:40 p.m., an unannounced visit was conducted at the facility to investigate one complaint related to the quality of care. During a review of Resident 1's record on January 24, 2024, the record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included right leg DVT and dementia (memory loss). Resident 1's assessment from the acute hospital on January 2, 2024, indicated 3+ pitting edema (a condition when excess fluid builds up in the body and when pressure is applied…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three residents reviewed (Resident 1) had a physician order to go out on pass (OOP–temporarily leave the facility for a specific time period) when Resident 1 went OOP for more than 24 hours on December 21, 2023. This failure had the potential for Resident 1 to be at risk for harm, accidents, and/or injury. Findings: On January 4, 2024, at 11:00 a.m., a concurrent interview and record review was conducted with the Administrator. The Administrator stated Resident 1 left the facility OOP on December 21, 2023, early morning with a family member, and returned to the facility on December 23, 2023, at 6:46 p.m. The Administrator stated Resident 1 went OOP for more than 24 hrs. On January 4, 2023, Resident 1 ' s medical record was reviewed. Resident 1 was admitted to the facility on [DATE], with a diagnoses of Diabetes Mellitus (disease that causes high blood sugar), bipolar disorder (a mental illness that causes unusual shifts in a person's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, for one (Resident 1) of four residents, the facility failed to ensure services for skin management and prevention of breakdown was implemented for Resident 1 when the facility did not conduct skin check to identify progression and deterioration of pressure ulcer development to Resident 1 ' s heels and sacro-coccyx (area between the oval surface at the apex of the sacrum, and the base of the coccyx) area. The facility failure had resulted to delayed identification and treatment implementation of pressure ulcer development on Resident 1 ' s bilateral heels on August 15, 2023, and breakdown to sacro-coccyx area the day Resident 1 was discharge on [DATE]. Findings: On September 25, 2023, at 9:35 a.m., an unannounced visit was conducted to investigate complaint for quality of care/treatment issues for allegation the facility had not implemented pressure sore precaution for the prevention of skin breakdown of Resident 1. On September 25, 2023, Resident 1 ' s record was reviewed.…

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

Based on observation, interview, and record review, the facility failed to report an allegation of sexual abuse to the California of Department of Public Health (CDPH - a state department responsible for enforcing some of the laws in the California Health and Safety Codes) for two of three residents reviewed (Residents 1 and 2). This failure had the potential to result in a delay of investigation and reporting of further allegation of abuse. Findings: During an interview on June 7, 2023, at 10:50 a.m., the administrator (ADM) stated, he received a call from Licensed Vocational Nurse (LVN) on June 4, 2023, at about 7 p.m. The ADM stated the LVN said there were signs of inappropriate behavior by Resident 1 towards Resident 2, his roommate. The ADM stated Resident 1 had a tube of A&D ointment (Vitamin A and D ointment - moisturizer to treat rough, scaly, and itchy skin) in his hand and was next to Resident 2. Resident 2's brief was unfastened. The ADM stated there was no room available to transfer Resident 1 and remained on the same room with Resident 2 on June 4, 2023. The ADM 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 the care plan for one of three residents (Resident 1) was implemented when Resident 1 was not placed in a private room after an allegation of inappropriate sexual behavior. This failure placed Resident 1's new roommate at risk of potential inappropriate sexual behavior conducted by Resident 1. Findings: During an interview on June 7, 2023, at 10:50 a.m., the administrator (ADM) stated, he received a call from Licensed Vocational Nurse (LVN) 1 on June 4, 2023, at about 7 p.m. The ADM stated LVN 1 said there were signs of inappropriate behavior by Resident 1 towards Resident 2, his roommate. The ADM stated Resident 1 had a tube of A&D ointment (Vitamin A and D ointment - moisturizer to treat rough, scaly, and itchy skin) in his hand and was next to Resident 2. Resident 2's brief was unfastened. The ADM stated there was no room available to transfer Resident 1 and remained on the same room with Resident 2 on June 4, 2023. The ADM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 supervisory staff carried out the functions of the food and nutrition service, when the Dietary Service Supervisor (DSS) and the facility Registered Dietitian (RD), did not provide management and oversight to ensure food was stored, prepared, and served according to the facility and industry standards. The RD and the DSS did not maintain oversight of the day-to-day operations of the dietetic service. This failure resulted in multiple deficient practices observed in the dietetic service. These deficiencies placed 49 residents, who were on an oral diet, at risk for serious harm from unsafe and unsanitary food handling practices and inadequate nutrition. (Cross reference F803 and F812). Findings: During the standard recertification survey conducted from November 1, through 9, 2021, multiple issues on food safety, food sanitation, food storage, and nutritional needs, were identified. On November 1, 2021, at 10:15 a.m., during a concurrent tour of the facility kitchen and interview with the Dietary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 nutritional needs of the residents were met when the food portion sizes for seven residents (Residents 4, 38, 40, 45, 46, 153, and 154) on the menu, were not followed. This failure had the potential for 49 of 49 residents on oral diets not to receive the adequate nutrition which can further compromise their medical status. Findings: 1. During an observation of lunch on November 1, 2021, at 11: 30 a.m., during meal tray distribution by the facility staff. The food items for all residents were observed to have the following: - tuna salad; - tomato salad; - half slice of bread; - cream of mushroom soup (1 cup) with 1 cracker; - milk (4 oz - ounce - unit of measurement); and -juice (8 oz). A review for the facility's planned menu, Week 2 - Fall Menu indicated the following food items: - baked ham; - baked beans; - wheat bread; - pineapple with mandarin oranges; - coffee or tea; and - milk. On November 1, 2021, at 3:50 p.m., During an interview with the Dietary Service Supervisor (DSS), the DSS stated…

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

Based on observation, interview, and record review, the facility's Administrator and governing body failed to exercise the general policy and operating directions to ensure effective oversight, staff competency, and essential resources were provided in order to sustain the necessary care, services and treatment necessary to maintain the highest level of practicable, physical, mental and psychosocial wellbeing of each resident. This systemic failure resulted in several major deficiencies identified in the course of the facility's Recertification Survey. They are as follows: 1. An Immediate Jeopardy (IJ- represents a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment, or death) was called on November 2, 2021, regarding the facility's use of unpasteurized eggs for vulnerable residents in the facility; 2. Multiple issues were identified in the kitchen as a result of inadequate training, as well as ineffective supervision of dietary staff by the Dietary Services Supervisor (DSS)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 Advance Directive (AD - written instruction related to the provision of health care when the resident is no longer able to make decisions) information were provided to 11 of 14 residents reviewed (Residents 4,10, 24, 27, 28, 30, 35, 38, 44, 47, and 149). This failure had the potential for Residents 4, 10, 24, 27, 28, 30, 35, 38, 44, 47, and 149 not to be able to exercise their rights to formulate an Advance Directive. Findings: 1. On November 3, 2021, Resident 4's record was reviewed. Resident 4 was admitted to the facility on [DATE]. The physician's history and physical dated October 28, 2021, indicated Resident 4 was able to make decisions. Resident 4's Physician Orders for Life-Sustaining Treatment (POLST) form indicated Resident 4 did not have an AD. On November 5, 2021, at 11:27 a.m., an interview was conducted with the Social Service Director (SSD). The SSD stated she did not provide the AD information to Resident 4; 2. On November 4,…

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

Based on observation, interview, and record review, the facility failed to provide a safe, comfortable, and home-like environment for six of seven sampled residents (Residents 2, 4, 28, 29, 30, and 38) when: 1. Inside Residents 2, 4, and 30's, shared bathroom, the following were observed: - The bathroom sink was not fully secured or fully attached to the wall; - The bathroom wall on the right side had faux tiles not fully attached to the wall; and - The shower area water drainage cover was not secured to the floor. 2. Inside Residents 29 and 38's shared bathroom in, the following were observed: - The right-side wall in the shower area had an open area approximately five inches (unit of measurement) wide; - The lower section of the bathrom door had chipping paints; and - The bathroom wall had missing tiles approximately 10 inches wide. 3. Inside Resident 28's room the following were observed: - The corner wall of the room near the bathroom entrance had a severe dry wall damage approximately two feet (unit of measurement) wide. 4. Inside Resident 28's bathroom, the following 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.

Based on observation, interview, and record review, the facility failed to ensure the Emergency Kits (E-Kit - an emergency storage box containing a small quantity of critical medications used in emergency situations) were not expired and were replaced within 72 hours according to the facility's policy and procedure. This failure had the potential to result in a delay in the administration of medications. In addition, this placed the residents at risk for receiving expired medications. Findings: On November 5, 2021, an observation with concurrent interviews were conducted on the following: - At 8:55 a.m., an inspection of the IV (an injection administered through the veins) E-kit in medication room was conducted with the Director of Nursing (DON). The IV E-kit did not have a lock or an indication it was sealed or unused. In a concurrent interview, the DON stated the IV E-Kit was opened and there was no documented evidence when it was opened, by whom, and what medication was used and taken from it. The DON further stated the opened IV E-Kit should have been secured with a zip tie lock…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 were safe to self-administer medications, for two of three residents (Residents 4, and 35), reviewed for self-administration of medications. This failure had the potential for Residents 4 and 35 to self-administer medications unsafely. Findings: 1. On November 1, 2021, at 12:18 p.m., an observation with a concurrent interview was conducted with Resident 4. Resident 4 was observed awake, alert and oriented. Observed on his bedside table was one capsule of fish oil (supplement) on top of a container lid. In a concurrent interview, Resident 4 stated he will take the one fish oil capsule later. On November 4, 2021, Resident 4's record was reviewed. Resident 4 was admitted to the facility on [DATE]. The History and Physical, dated October 28, 2021, indicated Resident 4 was .mentally capable of understanding . The physician's order titled, Order Summary Report for November 2021, indicated Resident 4 had a physician's order…

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

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 two residents reviewed (Resident 22), the cause of an injury of unknown origin (purplish skin discoloration on lateral right forearm) was investigated and reported in a timely manner. This failure had the potential to jeopardize the protection, health, and safety of Resident 22. Findings: On November 2, 2021, at 3:51 p.m., an observation with a concurrent interview was conducted with Resident 22. Resident 22 was observed awake, lying in bed, and watching television. A reddish skin discoloration, approximately 5 inches in length, was observed on Resident 22's lateral right forearm. In a concurrent interview, Resident 22 stated when the facility staff helped her out, They are a little bit rough. On November 3, 2021, at 9:49 a.m., a second observation with a concurrent interview was conducted with Resident 22. The previously reddish skin discoloration on Resident 22's lateral right forearm had developed into purplish…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 their policy and procedure on safe smoking practices for two of four residents (Residents 17 and 27) reviewed for smoking when: 1. There was no staff supervision observed during Residents 17 and 27's smoke breaks; 2. There was no fire extinguisher observed in the smoking area. In addition, the fire blanket (sheet made of fire retardant material placed over a fire to smother it) was outdated, and the plastic covering of the fire blanket was observed to be torn and opened; and 3. Unsecured smoking materials such as cigarettes, loose tobacco and lighters, were observed to be in Residents 17 and 27's possession at all times. These failures had the potential to increase the residents' risks for smoking related injuries and accidental fires. Findings: 1. On November 1, 2021, at 10:15 a.m., Residents 17 and 27 were observed smoking without smoking aprons in the designated smoking area, and without a staff present to supervise them. 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 interview and record review, the facility failed to conduct two Gradual Dose Reduction (GDR - a stepwise tapering of a dose) on psychotropic medications (medication capable of affecting the mind, emotions, and behavior) for two of three residents reviewed for GDR (Residents 35 and 38). This failure had the potential for the residents to have excessive duration, dose, and unnecessary use of the psychotropic medications. Findings: 1. On November 2, 2021, at 2:19 p.m., Resident 35's record was reviewed. Resident 35 was admitted to the facility on [DATE], with diagnoses which included anxiety disorder (a mood disorder), bipolar disorder (a brain disorder), psychosis (a brain disorder), insomnia (inability to sleep), and depression (a mood disorder). The History and Physical, dated September 16, 2020, indicated, Resident 35 was .mentally capable of understanding . The Order Summary Report for November 2021 indicated Resident 35 was on the following medications: - Ambien (a brand name for sleep inducing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based of observation, interview, and record review, the facility failed to ensure medications were properly stored and disposed and/or discarded when: 1. A multi-dose vial of one tuberculin PPD (a test used to detect tuberculosis (TB - an infectious lung disease), was found stored inside the medication refrigerator at the nurse station beyond the discard date. This failure had the potential for the residents to be administered a PPD past the beyond the discard date and could result in an inaccurate TB test results. 2a. Two eardrop medications for Residents 14 and 30 were found stored in the medication cart after the treatments were completed. In addition, a bottle of an opened Milk of Magnesia (MOM - a medication to treat constipation, upset stomach, and heartburn) suspension, labeled for a discharged resident's use, was stored in the medication cart; 2b. Multiple completed, discontinued and/or expired medications were stored in the treatment cart, readily available for use. These failures had the potential for…

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