Huntington Park Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care and services to maintain good grooming and personal hygiene for one of 11 residents (Resident 7) by failing to keep Resident 7's fingernails clean and neat. This failure had the potential to result in a negative impact on Resident 7's quality of life and self-esteem. This failure also had the potential for the development of infection. Findings: During an observation on 5/5/2025 at 11:50 a.m., in the activity room, observed Resident 7's fingernails were long with yellow and brown substance underneath. During an observation on 5/6/2025 at 8:15 a.m., in Resident 7's room, observed Resident 7's fingernails were long with yellow and brown substance underneath. During an observation on 5/7/2025 at 1:31 p.m., in the facility's hallway, observed Resident 7's fingernails long with yellow and brown substance underneath. During a review of Resident 7's admission Record, the admission Record indicated Resident 7 was originally admitted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 physician order for physical therapy ([PT]- healthcare specialty focuses on restoring, maintaining, and improving a resident ability to move and function) and occupational therapy ([OT]- a healthcare specialty that helps a resident improve the ability to perform daily activities) services were implemented timely for one of six sampled residents (Resident 72). This deficient practice had the potential to result in a significant decline in Resident 72's functional status, including total dependency for mobility, and increased dependency in activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing, and toileting a person performs daily to care for themselves). Findings: During a review of Resident admission Record (Face Sheet), the Face Sheet indicated Resident 72 was admitted to the facility on [DATE]. Resident 72's diagnoses included dementia, Alzheimer's disease (a disease characterized by a progressive decline in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two-person assist when utilizing the electric stand-up lift (battery-powered device to provide assistance from a sitting to standing position) for one of two sampled residents (Resident 64). This deficient practice had the potential to result in Resident 64 becoming unsteady on the electronic stand-up lift resulting in a fall and/or injury. Findings: During an observation on 5/5/2025 at 1:27 p.m., inside Resident 64's room, Certified Nursing Assistant (CNA) 4 entered Resident 64's room with the electric stand-up lift. CNA 4 did not have another staff member in Resident 64's room to operate the electronic stand-up lift. CNA 4 transferred Resident 64 from the wheelchair to the bed using the electronic stand-up lift alone. During a review of Resident 64's admission Record (Face Sheet), the Face Sheet indicated Resident 64 was admitted to the facility on [DATE]. Resident 64's diagnoses included multiple sclerosis (a disease that…

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

Based on observation, interview, and record review, the facility failed to provide one of two residents (Resident 80), who required hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), a dialysis emergency kit (e-kit) at bedside. This failure had the potential for Resident 80 to receive delayed intervention in managing dialysis site complications such as bleeding. Findings: During a review of Resident 80's admission Record, dated 1/15/2025, the admission record indicated the facility admitted Resident 80 on 1/15/2025 with diagnoses including, but not limited to, chronic kidney disease (CKD - a condition that causes gradual loss of kidney function over a period of time) with dependence on hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), anemia (a condition where the body does not have enough healthy red blood cells), and hypertension (HTN - high blood pressure). During a review of Resident 80's Minimum Data Set…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's physician (Physician 1) conducted an initial comprehensive assessment (a thorough evaluation of person's health, including their physical, mental, and social factors) for one of six sampled residents (Resident 45) after Resident 45 was readmitted to the facility. This deficient practice resulted in the delay of a comprehensive assessment of Resident 45's health and status, which could negatively affect the delivery of necessary care and services for Resident 45. Findings: During a review of Resident 45's admission Record (Face Sheet), the Face Sheet indicated Resident 45 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 45's diagnoses included cognitive communication deficit (difficulties with communication due to problems with thinking and processing information, rather than just speech or language issues), generalized muscle weakness (feeling weak throughout the body), and dementia (a progressive…

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

Based on interview and record review, the facility failed to follow up on an order for consultation with an Ear, Nose, and Throat (ENT - medical doctor who specializes in the medical and surgical treatment of conditions affecting the ears, nose, throat, head, and neck region) doctor for Resident 82. This failure had the potential to result in worsening left ear pain and left ear hearing loss for Resident 82. Findings: During a review of Resident 82's admission Record, dated 1/22/2025, the admission record indicated the facility admitted Resident 82 on 1/22/2025 with diagnoses including, but not limited to, end stage renal disease (ESRD - irreversible kidney failure), anemia (a condition where the body does not have enough healthy red blood cells), hypertension (HTN - high blood pressure), diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), and peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs). During an interview on 5/5/2025 at 10:55 a.m., with Resident 82, in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents' food preferences were respected and alternatives were provided for one of six sampled residents (Resident 42). This deficient practice had the potential to result in decreased meal intake, and alter Resident 42's nutritional status. Findings: During a review of Resident 42's admission Record (Face Sheet), the Face Sheet indicated Resident 42 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia (a progressive state of decline in mental abilities), ([DM]- a disorder characterized by difficulty in blood sugar control and poor wound healing), and dysphagia (difficulty swallowing), and muscle weakness (loss of muscle strength). During a review of Resident 42's Minimum Data Set ([MDS] - a resident assessment tool), dated 4/15/2025, the MDS indicated Resident 42's cognitive (the ability to think and process information) skills for daily decision making was intact. 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 follow the renal diet (specialized diet designed to help people with kidney disease or kidney failure to manage their condition) menu for one of four sampled residents (Resident 21). This deficient practice had the potential to result in the buildup of waste products that Resident 21's kidneys could not filter. Findings: During a review of Resident 21's admission Record (Face Sheet), the Face Sheet indicated Resident 21 was admitted to the facility on [DATE]. Resident 21's diagnoses included spina bifida (a condition that occurs when the spine and spinal column do not form properly), end stage renal disease ([ESRD], irreversible kidney failure), and neuromuscular dysfunction of the bladder (also known as neurogenic bladder, when damage to the brain, spinal cord, or nerves disrupts the communication between the brain and the bladder, leading to a loss of bladder control). During a review of Resident 21's Minimum Data Set ([MDS], a resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to label and properly store food brought by family/ visitors for three out of three residents (Residents 40, 66, and 52) in accordance with the facility's Policy and Procedure (P&P) titled, Use and storage for foods brought in by family or visitors. These deficient practices had the potential to result in food borne illnesses (any illness resulting from eating contaminated/spoiled foods) for Residents 40, 66, and 52, with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and could lead to other serious medical complications and hospitalization. Findings: 1. During a review of Resident 40's admission Record, the admission record indicated Resident 40 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 40's diagnoses included diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) and end stage renal disease (ESRD…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 physician order for physical therapy ([PT]- healthcare specialty focuses on restoring, maintaining, and improving a resident ability to move and function) and occupational therapy ([OT]-a healthcare specialty that helps a resident improve the ability to perform daily activities) evaluation and a wheelchair was carried out for one of six sampled residents (Resident 72). This deficient practice resulted in delayed treatment and services for Resident 72 and placed the resident at higher risk for further functional and mobility decline. Cross Reference F688 Findings: During a review of Resident admission Record (Face Sheet), the Face Sheet indicated Resident 72 was admitted to the facility on [DATE] with diagnoses which included dementia, Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), and muscle…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of 3 sampled residents ' (Resident 1) personal wheelchair was accounted for, in the resident ' s inventory list (a document where a resident ' s personal belongings are listed/ added when received), as indicated in the facility ' s policy and procedure (P&P) titled, Inventory List, Resident ' s Personal. This failure had the potential to result in Resident 1 ' s wheelchair lost or stolen. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) following cerebral infarction (stroke, loss of blood flow to a part of the brain). During a review of Resident 1 ' s History and Physical (H&P), dated 9/26/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a concurrent observation and interview 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 interview, and record review, the facility failed to ensure a comprehensive, resident-centered care plan was developed for one of three sampled residents (Resident 1), who was admitted high risk for fall. This failure resulted in a total of three falls (2/20/2024, 3/25/2024 and 7/16/2024) within 5 months and had the potential to cause harm and injury to Resident 1. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including history of falls and muscle weakness. During a review of Resident 1 ' s Fall Risk assessment dated [DATE], the fall risk assessmentindicated Resident 1was admitted with history of falls. The fall risk assessment indicated Resident 1 had impaired gait (a person's manner of walking) and overestimates (misjudge) and was forgetful of limitations. The fall risk assessment indicated Resident 1 was a high fall risk. During a review of Resident 1 ' s…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure the call light was in reach for five of 92 facility residents (Resident 27, 70, 7, 9, and 79). This deficient practice increased the risk for residents to be unable to call for staff assistance or express their needs. Findings: 1. A review of Resident 27's admission Record indicated Resident 27 was admitted to the facility on [DATE]. Resident 27's admitting diagnoses included generalized muscle weakness and osteoarthritis (when flexible tissue at the ends of bones wears down). A review of Resident 27's Minimum Data Set (MDS, a standardized assessment and care screening/planning tool), dated 2/13/2024, indicated Resident 27 required partial to moderate assistance with personal hygiene and dressing, required substantial to maximal assistance with toileting, and was dependent on staff for showering and bathing. The MDS indicated Resident 27 required partial to moderate assistance with rolling left to right in the bed, and required…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 treatments and services to prevent and/or limit a decline in range of motion (ROM, full movement potential of a joint [where two bones meet]) and mobility (ability to move) for two of six sampled residents (Residents 78 and 29) with identified ROM and mobility concerns by failing to: a. Provide treatment and services to maintain and prevent a decline in mobility and ROM of Resident 78's legs. b. Provide a right knee extension splint (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) to Resident 78's right leg in accordance with Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) recommendations on 2/14/2023. c. Implement the Restorative Nursing Program (RNP, nursing program that uses restorative nursing aides [RNAs] to help residents maintain their function and joint mobility) for ambulation (to walk), five times a week, as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 37) did not receive unnecessary psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) when: 1. Lorazepam (brand name Ativan, used to act on the brain and nerves to produce a calming effect) was administered for behaviors not indicated in the physician order or resident's care plan. 2. Certified Nursing Assistant (CNA) observations were used for clinical justification in determining whether to attempt a gradual dose reduction (GDR, the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) for Resident 37's lorazepam order. 3. Resident 37's attending physician did not document the risk benefit analysis for continued administration of lorazepam beyond 14 days. These deficient practices placed Residents 37 at risk for avoidable harm from unwanted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Ensure expired Ozempic (once-weekly injection to manage blood glucose levels) was removed and discarded for one out of three residents (Resident 51) medications reviewed in two of two inspected medication carts (Middle Station Medication Cart). 2. Ensure medication remaining at the facility after two of two residents (Resident 55 and 88) was discharged from the facility was removed from active supply, marked discontinued and securely stored until destroyed in accordance with the facility's Policy and Procedure (P&P) titled, Discontinued Medications, dated 8/2019. These deficient practices increased the risk that Residents 51 could have received medication that had become ineffective or toxic due to improper storage or labeling, which had the potential to lead to health complications related to Diabetes (a group of disease that result in too much sugar in the blood), hospitalization or death. For Resident 55 and Resident 88, these…

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

Based on observation and interview, the facility failed to ensure all food items stored in the kitchen and dry food storage room were labeled and dated, and failed to ensure safe food preparation practices in the kitchen were followed. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness for residents who received food from kitchen. Findings: During the initial tour of the facility's kitchen on 4/29/2024 at 8:30 a.m., the following was observed: 1. In the refrigerator, there were 10 glasses of milk,10 glasses of juice, one medium sized plastic container of cooked beans, and one medium sized container of apple sauce without a date, and three cartons of milk open without a date. 2. In the refrigerator, there was one large size box of margarine and three plastic bags of uncooked sausages without a date. 3. On top of the kitchen table, there was two medium sized containers with previously cooked rice without a date. 4. In the dry storage room,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not ensure enhanced barrier precautions (EBPs, an infection control intervention used to reduce transmission of multidrug-resistant organisms [MDROs, organisms resistant to at least one or more classes of antimicrobial agents]) were implemented for 16 of 16 sampled residents (Residents 59, 70, 94, 46, 25, 74, 92, 71, 48, 38, 40, 69, 26, 2, 62, 247). This deficient practice increased the risk for spread of MDROs to vulnerable facility residents, and the potential incidence of preventable infection. Findings: 1. A review of Resident 59's admission Record indicated Resident 59 was originally admitted to the facility on [DATE], and most recently readmitted Resident 59 on 7/13/2023. Resident 59's admitting diagnoses included cellulitis (a common and potentially serious bacterial skin infection) of the right lower leg and a pressure ulcer (PU, injury to skin and underlying tissue resulting from prolonged pressure) above the tailbone. 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 offer advance directives for one of three residents (Resident 44). This deficient practice had the potential to cause conflict with Resident 44's wishes regarding health care. Findings: A review of Resident 44's admission Record indicated Resident 44 was admitted to the facility on [DATE]. Resident 44's diagnoses included metabolic encephalopathy (a problem with the metabolism causing brain dysfunction) and dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of Resident 44's History and Physical (H&P), undated, indicated Resident 44 did not have capacity to understand and make decisions. A review of Resident 44's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 3/12/2024, indicated Resident 44 was severely cognitively impaired (ability to think and reason). The MDS indicated Resident 44 required substantial…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of 92 resident's (Resident 37 and 41) beds were not positioned against the wall. This deficient practice reduced the residents' ability to get out of bed freely and also increased the risk for entrapment and subsequent injury. Findings: 1. A review of Resident 37's admission Record indicated Resident 37 was admitted to the facility on [DATE]. Resident 37's admitting diagnoses included generalized muscle weakness and a history of falling. A review of Resident 37's Minimum Data Set (MDS, a standardized assessment and care screening/planning tool), dated 4/2/2024, indicated Resident 37 had severe cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated Resident 37 required maximal assistance from or full dependence on staff for repositioning herself in bed. During a concurrent interview and record review on 5/1/2024 at 12:02 p.m., with Registered Nurse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop and implement an individualized care plan with measurable objectives, timeframes, and interventions to improve, maintain, or prevent a further decline in range of motion (ROM, full movement potential of a joint) and mobility for one of six sampled residents (Resident 78) who was identified as having decreased mobility and ROM limitations in the right leg. This deficient practice had the potential to negatively affect the delivery of necessary care and services for Resident 78, and had the potential to lead to contracture (loss of motion of a joint) development and a decline in overall physical functioning. Findings: A review of Resident 78's admission Record indicated Resident 78 was admitted to the facility on [DATE] with diagnoses including an acquired absence of the right leg below the knee (amputation of the right leg below the level of the knee), right knee contracture, and chronic left ankle ulcer (sore that forms on 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 accurately monitor and record the total amount of calories received via enteral feeding (nutrition that bypasses the mouth and delivers via the stomach) for one of three residents (Resident 2). This deficient practice had the potential to result in Resident 2 not receiving an adequate amount of calories which could potentially lead to weight loss. Findings: A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 2's diagnoses included dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), gastrostomy ([g-tube] the creation of an artificial external opening into the stomach for nutritional support), and dysphagia (difficulty swallowing). A review of Resident 2's History and Physical (H&P), dated 1/5/2023, indicated Resident 2 did not have capacity to understand…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to honor one out of three residents' food preferences (Resident 65). This deficient practice had the potential for Resident 65 experience discomfort due to indigestion. Findings: A review of Resident 65's admission Record indicated Resident 65 was admitted to the facility on [DATE]. Resident 65's diagnoses included gastro-esophageal reflux disease ([GERD] a digestive disease in which the stomach acid or bile irritates the food pipe lining), constipation, and nausea with vomiting. A review of Resident 65's History and Physical (H&P), dated 1/10/2023, indicated Resident 65 had the capacity to understand and make decisions. A review of Resident 65's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 3/6/2024, indicated Resident 65 was cognitively intact (ability to think and reason). A review of Resident 65's GERD care plan, dated 1/27/2023, indicated Resident 65's health goals was to remain free from discomfort…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Occupational Therapy (OT, provides services to increase and/or maintain a person's capability to participate in everyday life activities) services to one of six sampled residents (Resident 78) who had activities of daily living (ADL, basic activities such as eating, dressing, toileting) and functional mobility (ability to move around and perform daily tasks) concerns. This deficient practice prevented Resident 78 from receiving skilled therapy services to maintain or achieve the highest practicable level of function. Findings: A review of Resident 78's admission Record indicated Resident 78 was admitted to the facility on [DATE] with diagnoses including an acquired absence of the right leg below the knee (amputation of the right leg below the level of the knee), right knee contracture (shortening and hardening of muscles, tendons, or other tissue leading to deformity and rigidity of joints), and chronic left ankle ulcer (sore that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one out of three Residents (Resident 74) understood and received the arbitration agreement in a language (Spanish) Resident 74 could understand when entering a binding contract. This deficient practice had the potential to result in harm for Resident 74 by waiving his right to a jury trial when taking legal action without his knowledge. Findings: A review of Resident 74's admission Record indicated Resident 74 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 74's diagnoses included stage renal disease (is the final, permanent stage of kidney disease, where kidney function has declined to the point that the kidneys can no longer function on their own) and dependence on renal dialysis (is the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). A review of Resident 74's History and Physical (H&P), dated 12/5/2023,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide privacy to one of five sampled residents (Resident 2), when providing right foot wound care. This deficient practice violated the resident's right to privacy and had the potential to affect the psychosocial well-being of the resident. Findings: A review of Resident 2's admission record indicated Resident 2 was admitted to the facility on [DATE], with a diagnosis that included encounter for change or removal of surgical wound dressing, diabetes (abnormal blood sugar levels), and encounter for orthopedic aftercare following surgical amputation (aftercare following surgical amputation) A review of Resident 2's history and physical (H&P) dated 3/16/2004, indicated Resident 2 had the mental capacity to understand and make medical decisions. A review of Resident 2's minimum data set ([MDS] a standardized care assessment and care screening tool), dated 3/20/2024, indicated Resident 2's cognitive skills (thought process) was independent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 revise the care plan to reflect safety measures in caring for one of five sampled residents (Resident 1), who was at risk for spontaneous fractures (broken bone) due to brittle bones. This deficient practice had the potential to place Resident 1 at risk for further injuries. Findings: A review of Resident 1's admission record, indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis that included dementia (impairment of memory and abstract thinking), age-related osteoporosis (a condition in which bones become weak and brittle), and unilateral primary osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wears down) of right knee. A review of Resident 1's history and physical (H&P) dated 4/18/2023, indicated Resident 1 does not have the mental capacity to understand and make medical decisions. A review of Resident 1's minimum data set ([MDS] a standardized care assessment and care screening tool),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurate assessment was conducted on the lower extremities for one of three sampled residents (Resident 1). This failure had the potential that proper interventions necessary for an individualized care plan will not be identified and had the potential to provide poor quality care to the affected resident. Findings During a review of Resident 1's admission record, dated 3/28/2024, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including fracture (broken bone) of lower end of left femur (thigh), fracture of lower end of right femur, and osteoporosis (a condition in which bones become weak and brittle). During a review of Resident 1's History and Physical (H&P), dated 8/26/2023, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 9/5/2023, the MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an accurate documentation was available in the medical record for 1 of 4 sampled residents, Resident 1. Resident 1 who had an insurance managed by a Health Management Organization (HMO, a health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO), and was changed to Medicare (united states federal health insurance program for people aged 65 years or older and people with certain disabilities). This failure resulted in Resident 1 ' s family member verbalizing feelings of mistrust, accusations of false documentation and doubting the care the facility staff provided. Findings: During an interview on 2/7/24 at 8:30 a.m., with Family Member 1 (FM 1), FM 1 stated facility staff changed Resident 1 ' s health insurance coverage from an HMO to Medicare to extend Resident 1 ' s stay at the facility without his consent. During an interview on 2/20/24 at 12:55 p.m., with the business office manager, 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 Certified Nurse Assistant (CNA) 2 monitored and supervised one of three sampled residents (Resident 1) after being medicated and agitated 10 minutes prior to the incident. As a result of this failure, Resident 1 suffered a fall to the ground from a wheelchair and sustained a subdural hematoma (a type of brain bleed), subarachnoid hemorrhage (bleeding in the space that surrounds the brain), compression fracture of the fourth lumbar vertebra (a type of break in bones to the back that stack up on from the spine), right eleventh rib fracture (break in bone of the rib), and right temporal bone fracture (break in bone that forms part of the side and base of the skull). Findings: During a review of Residents 1's Face Sheet (admission record), the face sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 1's diagnoses included generalized muscle weakness, Alzheimer's disease…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the call light was within reach and accessible for one of three sampled residents (Resident 3). This deficient practice had the potential to result in a fall, accidents and delay in meeting the needs for Resident 3. Findings: During a review of Residents 3 ' s Face Sheet (admission record), the Face Sheet indicated Resident 3 was originally admitted to the facility on [DATE], with diagnoses including muscle weakness, hypertension (high blood pressure) and diabetes (abnormal blood sugar). During a review of Resident 3 ' s History and Physical (H/P), dated 12/13/2022, the H/P indicated Resident 3 had the capacity to understand and make decisions. During a review of Resident 3 ' s care plan titled, High Risk for Falls and Injuries, dated 12/13/2022, the staff's interventions included to place the resident ' s call light within reach and to encourage the use of the call light. During a review of Resident 3's Minimum Data Set ([MDS] a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility staff failed to provide reasonable accommodation to meet the resident's needs by not ensuring: A. the resident's call lights were within reach for Five of Five sampled residents (Residents 56, 67, 2, 41 and 35) B. ensure bed's are working properly for one of three sampled residents (Resident 20). These deficient practicse had the potential to negatively impact the psychosocial well-being of the residents or result in delayed provision of services. Findings: A1.During a review of Resident 56's admission Record, the admission record indicated the resident was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses of, but not limited to hypertension (a common condition in which the long-term force of the blood against artery walls is high enough that it may eventually cause health problems, such as heart disease), diabetes mellitus (refers to a group of diseases that affect how your body uses blood sugar), kidney transplant status…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of two sampled Residents (#56 and # 269), received the professional standard of care and services to maintain good grooming and personal hygiene. This deficient practice resulted in Resident 56 and Resident 269 not receiving fingernail care and had the potential to negatively impact Resident 56's and Resident 269's quality of life and self-esteem. Findings: a.During a review of Resident 56's admission Record indicated Resident 56 was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses of, but not limited to hypertension (a common condition in which the long-term force of the blood against your artery walls is high enough that it may eventually cause health problems, such as heart disease), diabetes mellitus (refers to a group of diseases that affect how your body uses blood sugar), kidney transplant status (surgical procedure to place a healthy kidney from a living or deceased donor into a person whose…

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

Based on observation, interview, and record review the facility failed to: 1. Label four insulin pens with a pharmacy label for Resident 23, in accordance with medication labeling requirements, in one of 2 inspected medication room (Medication Room Miles Station). 2. Indicate open date on a multi-dose Tuberculin Purified Protein Derivative (Mantoux) Tubersol Vaccine, Gabapentin Solution, Albuterol Sulfate in one of two inspected medication room (Medication Room Miles Station). 3. Indicate an open date on Morphine Sulfate concentrate, Geri-tussin DM, 5 dietary supplements, multi-dose Heparin vial and Breo Ellipta, in accordance with medication labeling requirements and manufacturers' requirements and facility policies, in one of two inspected medication carts (Medication Cart Miles in Yellow zone). 4. Remove and discard from use one expired multi-dose Influenza Vaccine, one insulin vial with no identifier, one suppository with no identifier, one Intravenous antibiotic, Nystatin oral suspension, in accordance with manufacturers' requirements and facility policies in one of two…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations, interviews, and record reviews, the facility failed to store and prepare food under sanitary conditions in one (1) of 1 kitchen, by failing to: A. Ensure the facility used pasteurized ( have gone through a process that kills germs in foods and drinks ) eggs when preparing fried over-easy eggs( (egg gets fried on both sides, but it's not cooked for very long on the second side, so the yolk remains runny and uncooked) egg for 6 of 6 residents sampled, B. Ensure the jelly sandwiches were not stored in the dry storage area. These deficient practices had the potential to result in contamination of food items placing residents at a high risk for food borne illness that can lead to a decline in health, hospitalization and death. Findings: A.During an observation and interview with the dietary supervisor (DS) on 1/19/2022 at 9:27 a.m., DS confirmed that the eggs did not have P stamped on them to indicate the eggs were pasturized. Per DS, fried over easy-eggs were not on the regular menu, however fried-over easy eggs were regularly served due to residents requests. Per…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement interventions to prevent and control the spread of infections for two of two sampled residents (29, 1 and 17) by failing to: a.Ensure treatment nurse 1 (TN 1) performed hand hygiene and used clean gloves while rendering wound care treatment for Resident 29 and Resident 1. b. Staff covered Resident 17's toothbrush before storing it on top of the bathroom sink for Resident 17 These deficient practices placed Residents17 and 29 at risk for contracting an infectious disease that could lead to illness and hospitalization. Findings: a. During a review of Resident 29's admission record (face sheet) , the face sheet indicated the facility admitted Resident 29 on 8/20/2021. Resident 29's diagnoses included Alzheimer's disease (progressive disease that destroys memory and other important mental functions), type 2 diabetes (body unable to regulate blood sugar [glucose]) , peripheral vascular disease (a condition that causes poor blood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1 out of 7 residents (Resident 23), and or their responsible parties, with written information on how to formulate an Advanced Directive (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor). This deficient practice had the potential for violating Resident 23 choices about their medical care. Findings: During a review of Resident's medical records, the following information was missing: Resident 23 (admitted on [DATE], readmitted on [DATE]) did not have an advanced directive or a signature declining information on how to obtain an advanced directive. During a concurrent interview with Social Services Director (SSD) and record review of Resident 23's medical record on 01/20/2022 at 03:34 p.m., there was no advance directive form in Resident 23's chart. SSD stated that the advance directives…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 protect resident's belongings, update inventory list, and verify missing items for one of two sampled residents (Resident 6), resulted in Resident 6 feeling uncomfortable wearing clothes that do not belong to him. This deficient practice resulted in violating Resident 6's rights and has the potential to cause negative effect on resident's quality of life. Findings: A review of admission record, Resident 6 was originally admitted on [DATE] with medical diagnoses that included obesity (excessive amount of body fat), arthritis (swelling and tenderness of one or more joints), joint replacement surgery of the left knee. A review of Resident 6's Minimum Data Set (MDS- a comprehensive assessment and care screening tool) dated 08/19/2021 indicated Resident 6 has intact cognition, with clear speech. Resident 6 required one person assist in transferring, dressing, and grooming. During an observation rounds on 01/20/22 at 08:50 a.m., Resident 6 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 develop and/or implement an individualized resident-centered plan of care with measurable objectives, timeframe, and interventions to meet Resident 56 who has pacemaker (a small device that is implanted in the chest to help control heartbeat) needs. Findings: During a review of Resident 56's admission Record, the record indicated the resident was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses of, but not limited to hypertension (a common condition in which the long-term force of the blood against your artery walls is high enough that it may eventually cause health problems, such as heart disease), diabetes mellitus (refers to a group of diseases that affect how your body uses blood sugar), kidney transplant status (surgical procedure to place a healthy kidney from a living or deceased donor into a person whose kidneys no longer function properly), peripheral vascular disease (a circulatory condition in which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure Resident 8 received the necessary care and services needed to attain the highest practicable level of physical, mental, and psychosocial well-being, by not ensuring facility staff tended to Resident 8's needs. This deficient practice had the potential to result in Residents 8 not receiving the care that was needed to maintain Resident 8's physical and psychosocial well-being. Findings: A review of Resident 8's Face Sheet (admission record) indicated Resident 8 was admitted to the facility on [DATE]. Resident 8's diagnoses included essential hypertension (high blood pressure), history of falling, dizziness and giddiness (the feeling if being unbalanced and lightheaded), ataxia following cerebral infarction (without coordination and can occur after stroke and may affect various body parts including the eyes, hands, arms, legs, body or trunk, and speech, following injury to the brain), hyperlipidemia (high level of fat particles in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 received treatment and care in accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial needs, for three of three sampled residents, as evidenced by: a. Failing to properly implement safety precaution for Resident 10 who needed proper positioning and suctioning. This deficient practice has the potential to result in aspiration (inhalation of foreign materials) and resident choking on her saliva. b. Failing to provide proper turning for a Resident 1who needed assistance with repositioning and care. This deficient practice resulted in worsening of the left hip wound. Findings: A review of the admission record (Face sheet) indicated Resident 10 originally admitted on [DATE] and was re-admitted to the facility on [DATE] with diagnoses including but not limited to dependence to supplemental oxygen, muscle weakness, Dysphagia (difficulty swallowing) and Alzheimer's disease (progressive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one of one sampled residents (Resident 268) was assessed upon arrival to the facility when she returned from outpatient dialysis (procedure to remove waste products and excess fluid from the blood). This deficient practice resulted in a delay in addressing Resident 268's complaint of dizziness, and this could have been detrimental to her health and well-being. Findings: During a review of Resident 268's admission record (face sheet) , the face sheet indicated the facility admitted Resident 268 on 1/10/2022. Resident 268's diagnoses included; multiple fracture (broken) ribs , type 2 diabetes (body unable to process blood sugar [glucose]), end stage renal disease (kidney [organ that filters waste from the blood] ceases to function thus needing dialysis to live), cardiomegaly (enlarged heart), sepsis (blood infection), encephalopathy (disease or damaged brain and person has a declined ability to think, reason, concentrate). During a review of Resident 268's Minimum Data Set (MDS), a standardized 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.

Based on observation, interview and record review, the facility staff failed to follow policy for count of controlled substances on change-of-shift documentation in the medication cart in the red zone. This deficient practice has the potential for the facility staff to not secure and safeguard-controlled medications as well as not be able to monitor those medications were administered to the residents safely and accurately. Findings: During a concurrent inspection of the controlled substances in the medication cart, and interview with assistant director of nursing (ADON) on January 20, 2022, at 11:32 a.m.; ADON, acknowledged that the Controlled count verification form, indicated the box designated for the on-coming nurse on January 20, 2022, was blank. ADON stated that both on-coming and outgoing licensed nurses need to complete and sign the form indicating that a narcotic count was performed and reconciled at the start and end of the shifts. ADON stated this was important in order to track all medications for accountability. During an interview on January 21, 2022, at 4:09 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 interview and record review, the facility failed to act on the consultant pharmacist's recommendation in the Medication Regimen Review (MRR- a thorough evaluation of the medication regimen of a resident with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) in a timely manner for three out of nine sampled residents (Residents 13, 45, and 53). This deficient practice resulted in recommended blood test not performed on time for Residents 13, 45, and 53, with potential for adverse drug reaction for the following: a. Resident 13- Digoxin (medication to treat heart failure) level for the months of November and December b. Resident 45- Liver Function Test (blood test to diagnose and monitor liver disease) for the month of December c. Resident 53- TSAT (Transferrin Saturation- measures how much of stored iron can be used to make new red blood) and Ferritin (measures how much iron is stored in your body) for the months of November 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.