Centinela Skilled Nursing & Wellness Centre West

Based on observation and interviews the facility failed to: 1. Ensure an unopened prefilled pen of Lantus (a long-lasting insulin [a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication]) was stored inside the refrigerator per manufacturer's guidelines instead of storing inside Medication Cart Westback. This deficient practice had the potential to result in the deterioration and loss of effectiveness for insulin Lantus' improper storage and potential for ineffective management of the residents' diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). Findings: During a concurrent observation and interview on 11/20/2025 at 12:35 p.m. with Registered Nurse (RN) 1 at medication cart westback, an unopened prefilled pen of Lantus was observed in the medication cart. RN 1 acknowledged that the insulin was stored in the cart unopened. RN 1 stated that all unopened insulin prefilled pens and vials should be stored in the refrigerator until they are opened. RN 1 stated once an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the correct information was provided to one of three sampled residents (Resident 7) prior to asking him to enter into a binding arbitration agreement (the resolution of a dispute where both parties waive their right to a trial). This deficient practice resulted in Resident 7 unknowingly forfeiting his right to resolve any disputes with the facility in court, alongside a judge and/or jury.Findings: During a review of Resident 7's admission Record, the admission Record indicated Resident 7 was initially admitted to the facility on [DATE]. Resident 7's diagnoses included surgical aftercare for amputation of both legs below the knee and polyneuropathy (nerve damage). During a review of Resident 7's History and Physical (H&P), dated 9/25/2025, the H&P indicated Resident 7 had the capacity to understand and make decisions. During a review of Resident 7's record titled Arbitration Agreement, dated 9/25/2025, the record indicated Resident 7's daughter…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain infection control for all facility residents when: 1. Resident 48 was not tested for Covid-19 (an infectious disease caused by the SARS-CoV-2 virus) after first exhibiting symptoms on 11/12/2025. 2. The facility failed to ensure there was warm running water in the handwashing sink located in the soiled laundry sorting area. These deficient practices created the potential for the transmission and spread of infection to all facility residents. Findings: 1. During a review of Resident 48's admission Record, the admission Record indicated Resident 49 was initially admitted to the facility on [DATE], and most recently readmitted on [DATE]. Resident 48's admitting diagnoses included sepsis (a life-threatening blood infection). During a review of Resident 48's Minimum Data Set (MDS, a resident assessment tool), dated 9/14/2025, the MDS indicated Resident 48 did not have cognitive impairments (ability to think and reason). The MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two out of six sampled residents (Resident 27 and 24) were dressed appropriately. This deficient practice of the Residents 24 and 27 not wearing their own clothes had the potential to make the residents feel left out from socialization (activities that contributes to the integrity of an individual's health and wellness). Findings: a. During a review of Resident 27's admission Record (Face Sheet), the Face Sheet indicated Resident 27 was admitted to the facility on [DATE]. Resident 27's diagnoses included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), chronic kidney disease (a condition where the kidneys do not work as well as they should), and aphasia (a disorder that makes it difficult to speak). During a review of Resident 27's History and Physical (H&P), dated 6/12/2024, the H&P indicated Resident 27 could make needs known but could not make medical decisions. During a review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one out six sampled residents (Resident 24) was offered his dentures before eating. This deficient practice of not offering Resident 24 his dentures while eating had the potential to not be able to chew food effectively. Findings: During a review of Resident 24's admission Record (Face Sheet), the Face Sheet indicated Resident 24 was initially admitted to the facility on [DATE]. Resident 24's diagnoses included heart failure (a condition in which the heart does not pump blood as well as it should), dysphasia (difficulty swallowing), and aphasia (a disorder that makes it difficult to speak). During a review of Resident 24's History and Physical (H&P), dated 8/26/2024, the H&P indicated Resident 24 had fluctuating capacity to understand and make decisions. During a review of Resident 24s Minimum Data Set ([MDS] a federally mandated assessment tool), dated 7/1/2024 the MDS indicated, Resident 24's cognition (ability to learn, reason,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 six sampled residents (Resident 27) had the appropriate call light device to call for assistance. This deficient practice of not having the appropriate call light device had the potential for Resident 27 to not get assistance in a timely manner. Findings: During a review of Resident 27's admission Record (Face Sheet), the Face Sheet indicated Resident 27 was admitted to the facility on [DATE]. Resident 27's diagnoses included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), chronic kidney disease (a condition where the kidneys do not work as well as they should), and aphasia (a disorder that makes it difficult to speak). During a review of Resident 27's History and Physical (H&P), dated 6/12/2024, the H&P indicated Resident 27 could make needs known but could not make medical decisions. During a review of Resident 27's Minimum Data Set ([MDS] a federally mandated assessment 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 inform and provide the Notice of Medicare Non-Coverage (NOMNC) form 48 hours prior to the end of skilled nursing services for one of three sampled residents (Resident 205). This deficient practice had the potential to result in the resident not being able to exercise his right to file an appeal and unknowingly paying for non-covered care expenses. Findings: During a review of Resident 205's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 205 was admitted to the facility on [DATE]. Resident 205's diagnoses included chronic obstructive pulmonary disease ([COPD] a chronic lung disease causing difficulty in breathing), alcoholic liver disease (damage to the liver and its function due to alcohol abuse), and diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 205's 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.

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 six sampled residents (Resident 34) was provided a homelike environment and did not have chipped paint on the wall next to the resident's bed. This deficient practice of not providing a homelike environment for Resident 34 had the potential to negatively impact the resident quality of life. Findings: During a review of Resident 34's admission Record (Face Sheet), the Face Sheet indicated Resident 34 was initially admitted to the facility on [DATE] and last readmitted [DATE]. Resident 34's diagnoses included aphasia (a disorder that makes it difficult to speak), chronic kidney disease (a condition where the kidneys do not work as well as they should), and atherosclerotic hearth disease (a chronic inflammatory disease that causes plaque buildup in the walls of arteries, narrowing them and restricting blood flow). During a review of Resident 34's History and Physical (H&P), dated 8/29/2024, the H&P indicated Resident 34 did…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one out of six sampled residents (Resident 2) had a care plan (a communication tool for patient care between nurses) for the refusal of dental services. This deficient practice of not having a care plan for refusal of dental services had the potential to place Resident 2 at risk for not receiving the appropriate interventions to prevent discomfort when eating. Findings: During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses included chronic kidney disease (damage to kidneys and can't filter blood the way they should), dysphagia (difficulty swallowing), and aortic aneurysm (a bulge in the wall of an artery). During a review of Resident 2's History and Physical (H&P), dated 7/22/2024, the H&P indicated Resident 2 had fluctuating capacity to understand and make decisions. During a review of Resident 2s Minimum Data Set ([MDS] a federally…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, by failing to measure the abdominal girth (the measurement of the distance around the abdomen at a specific point, usually at the level of the belly button) weekly per the physician's order for one of one sampled resident (Resident 45) who had a diagnosis of ascites (a condition where fluid builds up in the abdomen). This deficient practice would put Resident 45 at risk for abdominal pain and shortness of breath possibly leading to medical complications requiring hospitalization. Findings: During a review of Resident 45's admission Record, the admission Record indicated, Resident 45 was admitted to the facility on [DATE]. Resident 45's diagnoses included ascites, chronic kidney disease (kidneys are damaged and can't filter blood they way they should), and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 low air loss mattress ([LALM] a mattress designed to prevent and treat pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) was set and maintained at the correct setting for one of three sampled residents (Resident 6). This deficient practice placed Resident 6 at risk for worsening of pressure ulcer/injury ([PU] localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) and further skin breakdown. Findings: During a review of Resident 6's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 6 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 6's diagnoses included PU Stage 3 (Full-thickness loss of skin. Dead and black tissue may be visible) on the sacral (large triangular bone at the base of the spine)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident who received hemodialysis ([HD]) a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed) treatment received care in accordance with standards of practice for one of two sampled residents (Resident 204) by failing to monitor and record the resident's daily fluid restriction (medical treatment that limits the amount of fluids a person can consume each day). This deficient practice placed Resident 204 at risk for swelling, discomfort, and shortness of breath. Findings: During a review of Resident 204's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 204 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 204's diagnoses included end stage renal disease ([ESRD] irreversible kidney failure) and heart failure (a heart disorder which causes the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure a resident with a diagnosis of dementia was free from the use of antipsychotic medication (class of drug to treat mental illness) for one out of five sampled residents (Resident 49). This deficient practice had the potential to result in use of unnecessary psychotropic drugs (drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) for Resident 49. Findings: During a review of Resident 49's admission record (face sheet), the admission record indicated Resident 49 was admitted to the facility on [DATE]. Resident 49's diagnoses included dementia (a decline in mental functioning, such as thinking, remembering, and reasoning, to the point that it interferes with daily life), urinary tract infection (a bacterial infection that occurs when bacteria enter the urinary tract and multiply), cerebral ischemia (a condition that occurs when there isn't enough blood flow to the brain)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure a dental services follow-up was completed for one of five sampled residents (Resident 17). This deficient practice had the potential to result in a decreased appetite and weight loss for Resident 17. Findings: During a review of Resident 17's admission record (face sheet), the admission record indicated Resident 17 was admitted to the facility on [DATE]. Resident 17's diagnoses included metabolic encephalopathy (a brain disorder caused by a chemical imbalance in the blood that affects brain function), dysphagia (difficulty swallowing), protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), and iron deficiency (a condition where the body's total iron content decreases). During a review of Resident 17's Minimum Data Set Assessment (MDS- a federally mandated resident assessment tool), dated 7/19/2024, the MDS indicated Resident 17 was cognitively intact…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive (complete; including all or nearly all elements or aspects of something) and patient-centered care plan for one out of four sampled residents (Resident 1) following allegations of financial abuse and Resident 1 missing $ 11,000. This failure had the potential to result in Resident 1 repeatedly being placed at risk for financial abuse. Findings: During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including hypertensive (high blood pressure) heart disease without heart failure, peripheral vascular disease (a reduced blood flow to a body part, other than the brain or heart, due to a narrowed or blocked blood vessel), and chronic obstructive pulmonary disease (COPD, a lung disease causing restricted airflow and breathing problems). During a review of Resident 1's Minimum Data Set (Minimum Data Set [MDS] a standardized…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to: 1). Implement its policy and procedure (P&P) titled Theft and Loss, which indicated residents ' personal property will be safeguarded and when a resident ' s property was missing, the facility will investigate and document the incident on a theft and loss log. 2. Implement its P&P titled Abuse Prevention, Screening, and Training Program, which indicated misappropriation of resident property and financial abuse were the deliberate misplacement, exploitation, or wrongful use of a resident ' s belongings or money without the resident ' s consent. As a result, Resident 1 and other residents in the facility were placed at risk. Findings: A review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 ' s diagnoses included chronic kidney disease ([CKD], condition which the kidneys are damaged and cannot filter blood as well as they should), chronic obstructive pulmonary disease (COPD, lung 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen were followed when: 1. Three bags of breaded potato hash browns were stored in the reach-in freezer with no date label. One large container of apple sauce was store in the reach-in refrigerator with no date. 2. Personal water bottles were stored in the facility two door reach-in refrigerator. 3. Nutritional supplement labeled store frozen, with manufactures instruction to use within 14 days of thawing, were not monitored for the date they were thawed to ensure expired shakes were discarded after this time frame. 30 strawberry flavored nutrition supplements were stored in the reach in refrigerator with no thaw date. This deficient practice had the potential to result in food borne illness (food poisoning caused by consuming contaminated food, beverages, or water) in 9 residents who are on nutrition supplements at the facility. 4. Juice machine tubing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Skilled Nursing Facility (SNF) Advance Beneficiary Notice of Non-coverage form (SNFABN, a document issued by medical providers to Medicare recipients, warning that services might not be covered; formally and legally transfers liability for payment of services to the Medicare recipient instead of Medicare) was completely filled out, by having one of three residents (Residents 256), chose one of the options for billing the anticipated non-covered inpatient skilled nursing facility (an in-patient rehabilitation and medical treatment center staffed with trained medical professionals) stay. This deficient practice had the potential to affect the skilled nursing services needed to progress and achieve the highest practicable physical, mental, and psychosocial wellbeing of the affected resident (Resident 256). Findings: During a review of the admission record indicated Resident 256 was originally admitted to the facility on [DATE] and an initial…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Minimum Data Set (MDS) assessment, a comprehensive assessment and care planning tool, regarding the pneumococcal vaccination (vaccine to prevent pneumococcal disease), was conducted for one of two sampled residents (Resident 3). This deficient practice had the potential for a poor care planning which can affect the health and safety of the affected resident (Resident 3). Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnosis that included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), dysphagia (difficulty of swallowing), aphasia (loss of ability to understand or express speech, caused by brain damage) and dementia (the loss of thinking, remembering, and reasoning). During a review of Resident 3's Minimum Data Set (MDS), a comprehensive assessment and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow its policy and procedure by ensuring one of one sampled resident (Resident 42), had a titration order (order to adjust flow of oxygen to achieve target oxygen level range in the system) for oxygen use, and ensuring the oxygen tubing was changed and labeled every seven days per policy. The deficient practice had the potential to cause respiratory complications and had the potential for facility acquired respiratory infections associated with oxygen therapy. Findings: During an observation on 10/10/2023 at 10:10 a.m., Resident 42 was receiving oxygen at two (2) liters per minute (LPM) via nasal cannula (a small flexible tube that has two open prongs that sit inside the nostrils used to deliver oxygen). The oxygen regulator (regulator that controls the flow of oxygen) was set at 2 LPM. During an observation on 10/12/2023 at 7:57 a.m. at Resident 42's room, Resident 42 was receiving oxygen at three (3) LPM via nasal cannula. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two insulin pens (a type of medication used to treat high blood sugar) requiring refrigeration were stored according to the manufacturer's requirements affecting Residents 10 and 21, in one of two inspected medication carts (West Back Medication Cart 1.) The deficient practices of failing to store medications per the manufacturers' requirements increased the risk that Residents 10 and 21 could have received medication that had become ineffective or toxic due to improper storage possibly leading to health complications resulting in hospitalization. Findings: During a concurrent observation and interview on [DATE] at 2:10 p.m. of the [NAME] Back Medication Cart 1 with the Licensed Vocational Nurse 1 ( LVN), the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date, as required by their respective manufacturer's specifications: 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.

Based on observation, interview and record review, the facility failed to prepare food by methods that conserved flavor, texture, and appearance for one of one puree food test-tray. The texture of the pureed diet was sticky and gummy with glossy and shiny appearance. When tasted the food was sticky to palate and gums and difficult to swallow and the flavor was bland. This deficient practice had the potential to result in meal dissatisfaction, decreased intake and placed Four resident on the puree diet at risk for unplanned weight loss. Findings: During initial facility tour on 10/10/2023 at 9:00 a.m., complaints about the temperature and flavor of the food were identified. During an observation and interview in the kitchen on 10/10/2023 at 10:00 a.m., Cook1 was preparing the lunch menu. Cook1 said the lunch includes chicken, creamy pasta, and spinach. Cook1 was cooking the chicken in the oven, she had prepared the creamy sauce for the pasta and was steaming the spinach on the stove. Cook1 stated, once food is cooked will take a portion and will blend for the residents on the pureed…

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