Inglewood Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Social Services Director (SSD) acted in accordance with the professional standards when interacting to one of three sampled residents, (Resident 1). This failure had the potential to affect the resident's psychosocial well-being, leading to emotional harm.Findings: 1). During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included morbid (severe) obesity due to excess calories (chronic disease characterized by having excessive body fat that poses an immediate, serious risk to health, resulting from consistently consuming more energy than the body burns) and hypertension (high blood pressure). During a review of Resident 1's History and Physical (H&P) dated 8/20/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated…

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 honor one of two residents (Resident 1) request, not to have a male Certified Nurse Assistant (CNA) assigned to provide care for activities of daily living (ADLs -routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). This deficient practice violated resident's rights and had the potential to affect the resident's psychosocial well-being. 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]. Resident 1's diagnoses included cerebral infarction (loss of blood flow to part of the brain), Diabetes Mellitus Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Care Plan titled, Resident Refuses Male CNA Care, dated 8/30/2025, 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 report Influenza A (viral infection that attacks the respiratory system, including the nose, throat, and lungs) outbreak on 2/2/2026, for two of eight residents (Residents 1 and 8), to the California Department of Public Health (CDPH) within 24 hours, as indicated in the facility's policy and procedure (P&P) titled Unusual Occurrence Reporting. This failure resulted in delayed investigation by the CDPH.Findings: 1). During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted on [DATE]. Resident 1's diagnoses included heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), stage four chronic kidney disease (severe kidney impairment), and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). The admission record indicated Resident 1 was self-responsible. During a review of Resident 1's History…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Nurse Practitioner's (NP) verbal order of Tamiflu (medication to treat the Influenza [viral infection that attacks the respiratory system, including the nose, throat, and lungs]) for one of three residents (Resident 1), was transcribed to a telephone order form, the Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) and notify the pharmacy, as indicated in the facility's policy and procedure titled Physician Orders.This failure resulted in Resident 1 missing two doses of Tamiflu on 2/2/2026 and 2/3/2026.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted on [DATE]. Resident 1's diagnoses included heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), stage four chronic kidney disease (severe kidney…

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 five sampled residents (Resident 1) was free from abuse when a Certified Nurse Assistant (CNA 1) kicked Resident 1's right shin (the front of the leg below the knee). This deficient practice resulted in Resident 1 sustaining pain and a purplish discoloration to the right shin. This deficient practice had to potential to cause Resident 1 to not feel safe in the facility. Findings:During a review of Resident 1's Face Sheet, the face sheet indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included metabolic encephalopathy (a problem in the brain, when the imbalance affects the brain, it can lead to personality change), osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D), and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's History and Physical (H&P), dated 5/28/2025, the H&P indicated Resident 1 did not have the…

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

Based on interview and record review, the facility failed to:1. Maintain the COVID vaccination status for 19 employees.This deficient practice had to the potential to cause a delay in response in the event of an outbreak, since the unvaccinated staff cannot be easily identified.During a concurrent interview and record review on 12/4/2025 at 8:00 a.m. with the Infection Prevention Nurse (IPN), a binder titled Staff Vaccination 2025 was reviewed. The binder indicated 19 employees declined to receive a COVID vaccine. The IPN stated she cannot show documentation of what staff are vaccinated. The IPN stated she is supposed to offer the vaccine to all staff. The IPN further stated it is important to know who is or is not vaccinated in case there is an outbreak. It will be easier to track where the outbreak may have started if you know who is not vaccinated.During a review of the facility's policy and procedure (P&P) titled, COVID-19 Vaccination-Staff, (no date), the P&P indicated the infection preventionist maintains a tracking worksheet of staff members and their vaccination status.

Based on observation, interview, and record review, the facility failed to maintain a safe, clean, and sanitary environment when an air filter in the hallway for four of four sampled Residents (Residents 13, Resident 33, Resident 67, and Resident 99) was full of dust and gray, fuzzy substance accumulation.This deficient practice had the potential to exposing residents to an environment that was unclean, and negatively impacting residents' comfort, safety, and quality of life.Findings:a. During a review of Resident 13's admission Record (Face sheet), the admission Record indicated the facility admitted Resident 13 on 12/3/2024 with diagnoses including acute respiratory failure with hypoxia (a life-threatening condition where the lungs cannot get enough oxygen into the blood), shortness of breath, heat failure, and sepsis (a life-threatening blood infection).During a review of Resident 13's History and Physical (H&P) dated 1/15/2025, the H&P indicated the resident was alert, cooperative, had normal affect (a person shows a healthy, appropriate, and varied range of emotional…

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. Ensure linen was folded using proper technique to prevent recontamination.This deficient practice put residents at risk of infection if they came in contact with the contaminated linen.2. Ensure the Laundry Aide did not pour a chemical into a new unlabeled/uncovered container in the laundry room.3. Ensure air purifier filter in the hallway was maintained in a clean condition for four of four sampled Residents (Residents 13, Resident 33, Resident 67, and Resident 99) when the air filter was full of dust and fuzzy, grey buildup accumulation.This deficient practice had the potential to increase the risk of airborne particle (tiny solid or liquid particles in the air) accumulation in the hallway, which could contribute to the spread of infection among residents.4. Ensure the ice machine in the kitchen was maintained in a clean and sanitary condition. This deficient practice had the potential to expose residents to contaminated ice, increasing the risk of foodborne illness. 1. During a concurrent observation…

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 two of five sampled residents (Resident 78 and Resident 98) was provided with goods and services when1.Resident 98 had notified staff he would like to retrieve his vehicle.2. Staff were standing over Resident 78 while assisting with eating lunch.These deficient practices of not providing goods and services for Resident 98 to escort him to retrieve his vehicle had the potential for him to feel unacknowledged of his needs and placed Resident 78 at increased risk for choking, aspiration, or inadequate monitoring of the resident's tolerance during meals.1.During a review of Resident 98's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 98 was initially admitted to the facility on [DATE]. Resident 98's diagnoses included respiratory failure (the lungs can't adequately oxygenate the blood or remove carbon dioxide), osteoarthritis (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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure one of five sampled residents (Resident 98) walking cane was located when Resident 98 notified Social Worker Director (SSD) the walking cane was missing.This deficient practice of not promptly resolving Resident 98's grievance of the missing walking cane had the potential for Resident 98 to feel the SSD did not want to help him replace the walking cane. During a review of Resident 98's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 98 was initially admitted to the facility on [DATE]. Resident 98's diagnoses included respiratory failure (the lungs can't adequately oxygenate the blood or remove carbon dioxide), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and heart failure (the heart can't pump enough blood to meet the body's needs). During a review of Resident 98's History and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one of five sampled residents (Resident 10) Minimum Data Set ([MDS] a resident assessment tool) was filled out accurately.This deficient practice of not accurately completing the MDS had the potential for Resident 10 goods and services not to be met while residing at the facility. During a review of Resident 10 's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 10 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 10's diagnoses included chronic obstructive pulmonary disease ([COPD]- a chronic lung disease causing difficulty in breathing), respiratory failure (when the body's respiratory system is unable to exchange oxygen and carbon dioxide properly), and heart failure (heart muscle can't pump enough blood to meet the body's needs). During a review of Resident 10's History and Physical (H&P), dated…

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 Preadmission Screening and Resident Review (PASRR- a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) was completed for one of one resident (Resident 2).This failure had the potential to result in an inappropriate placement and delay in needed services for Resident 2.Findings:During a review of Resident 2's Face Sheet (admission Record), the Face Sheet indicated the facility admitted Resident 2 on 8/13/2025 and was readmitted on [DATE] with diagnoses psychosis (when a person has trouble telling the difference between what is real and what is not real not) due to substance or known physiological (normal, healthy functioning of a living body) condition.During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool) dated 8/19/2025, the MDS indicated Resident 2 was taking antipsychotic (a type of medicine used to treat symptoms of mental disorder)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure one of five sample residents (Resident 4) meal tray was properly set up with containers unopened and within reach for Resident 4 to eat breakfast. This deficient practice of not setting up Resident 4's meal tray had the potential for delay in Resident 4's ability to eat his food and placed him at risk for inadequate nutrition and compromised dignity. Findings:During a review of Resident 4's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 4 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 4's diagnoses contractures (painful, permanent tightening and shortening of muscles causing joints to become stiff and their lose their normal range of motion), protein-calorie malnutrition ( a severe form of undernutrition from insufficient intake of protein and calories), and adult failure to thrive (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.

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 residents (Resident 18 and Resident 52) was supervised by staff while smoking. This failure had the potential to result to resident injury.Findings: a. During a review of Resident 52's Face Sheet (admission Record), the Face Sheet indicated the facility admitted Resident 52 on 9/26/2025 with diagnoses including acute respiratory failure, systemic lupus erythematosus (lupus - an ongoing disease where the body's immune system gets confused and attacks its own healthy tissues and organs by mistake), obstructive and reflux uropathy (when urine flows backward from the bladder up toward the kidneys), acute kidney failure, and benign prostatic hyperplasia (enlarged prostate gland). During a review of Resident 52's History and Physical (H&P) dated 9/27/2025, indicated Resident 52 had the capacity to understand and make decisions. During a review of Resident 52's Minimum Data Set (MDS – a resident assessment tool) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure one of one resident's (Resident 8) oxygen tubing was labeled with the date the tubing was last changed. This failure had the potential for Resident 8 to receive oxygen through compromised oxygen tubing and increasing the risk of infection while receiving oxygen therapy.Findings:During a review of Resident 8's Face Sheet (admission Record), the Face Sheet indicated the facility admitted the Resident 8 on 9/22/2025 and was readmitted on [DATE] with diagnoses including metabolic encephalopathy (a brain problem where the brain has trouble working correctly because of a chemical imbalance in the body), anemia (a condition where the body does not have enough healthy red blood cells), and acute respiratory failure with hypoxia (a medical condition where the body's tissues and cells do not get enough oxygen to function correctly).During a review of Resident 8's History and Physical (H&P) dated 10/28/2025, the H&P indicated the resident does not have 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 one of five sampled residents (Resident 57) was monitored for pain. This deficient practice of not monitoring for pain had to potential for Resident 57 to have discomfort.During a review of Resident 57's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 57 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 57's diagnoses included conversion disorder with motor deficit (a condition where psychological distress manifests as real, physical systems affecting movement), headache (pain in the head), and encephalopathy (a general brain disorder from injury, disease toxins, or metabolic issues, causing altered brain function). During a review of Resident 57's History and Physical (H&P), dated 5/27/2025, the H&P indicated, Resident 57 did not have the capacity to understand and make decisions. During 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.

Based on observation, interview, and record review, the facility failed to ensure one of one resident (Resident 108) had a hemodialysis (HD - a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidneys have failed) emergency kit (e-kit) at bedside.This failure had the potential to result in a delayed emergency interventions during a life-threatening dialysis complications.Findings:During a review of Resident 108's Face Sheet (admission Record), the Face Sheet indicated the facility admitted Resident 108 on 11/26/2025 with diagnoses including acute and chronic respiratory failure with hypoxia (a medical condition where the body's tissues and cells do not get enough oxygen to function correctly), dependence on renal dialysis (a medical treatment that takes over the job of cleaning the blood when a person's kidneys stop working properly), and myocardial infarction (heart attack).During a review of Resident 108's History and Physical (H&P) dated 11/29/2025, the H&P indicated Resident 108 had the capacity to understand and make…

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

Based on observation, interview, and record review, the facility failed to ensure three of three sampled Residents (Resident 7, Resident 48, and Resident 111) opened medication boxes and a medication bottle were labeled with the date opened.This failure had the potential to result in the use of medications past their stability period, reducing efficacy and compromising resident's health and safety.Findings:1. During a concurrent observation and interview on 12/3/2025 at 3:20 p.m. with the Infection Preventions Nurse (IPN), for medication cart 3 located in station 2, the following medications boxes were inside medication cart 3 without opened date labels: a. Lidocaine Patch (medication used for pain) and Albuterol Sulfate Inhalation (medication used to treat lung diseases) for Resident 48b. Lovenox injections (medication used to treat blood clots) for Resident 111During an interview on 12/3/2025 at 3:20 p.m. with IPN, the IPN stated it was important to have open date labels to know when medications expire. The IPN stated labeling medications with opened dates was important to prevent…

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 chocolate frosting, flour, and starch stored in the kitchen were not expired.This failure had the potential to result in unsafe food preparation practices and increased risk of residents consuming foods made with expired ingredients, leading to decreased food quality or foodborne illness.Findings:During an observation on 12/2/2025 at 8:55 a.m. in the kitchen food storage room, chocolate frosting in a plastic tub was observed with an expiry date on 11/19/2025, starch stored in a grey circular bin with lid had an expiry date on 11/24/2025, and flour in a grey circular bin with lid had an expiry date on 11/24/2025.During an interview on 12/2/2025 at 8:57 a.m. with Dietary Aid (DA) 1, DA 1 stated the chocolate frosting, starch, and flour were expired and expired foods in storage must be thrown away as it may be used for foods served to the residents. DA 1 stated the residents may get severely sick from eating foods that were made with expired ingredients.During an interview on 12/3/2025 at 12:44 p.m. with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain a television in a safe and operating condition for one of 42 resident rooms' (room [ROOM NUMBER]B), when an uncovered and unsecured cable electrical wire was hanging underneath the television and not having a system in place to timely take care of equipment repairs.This deficiency had the potential to cause injury from electrical hazards.Findings:During an observation on 12/4/2025 at 1:28 p.m. in room [ROOM NUMBER]B, a wall-mounted television had an uncovered wire hanging from the cable at the bottom of the television.During a concurrent observation, and interview on 12/5/2025 at 10:27 a.m. in room [ROOM NUMBER]B, the Housekeeping Supervisor (HS) stated the television cable wire was exposed and should not be exposed because the wires could be dangerous to the residents. During a concurrent interview and record review on 12/5/2025 at 10:35 a.m., the HS indicated the facility's Preventative Maintenance Monthly Checklist, dated 2025,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure one of five sampled residents (Resident 23) the licensed staff had turned off the oxygen when Resident 23 was not in the room and not in use. This deficient practice of not turning off the oxygen while the resident was not in the room had the potential for hazardous conditions.During a review of Resident 23's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 23 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 23's diagnoses included chronic obstructive pulmonary disease ([COPD]- a chronic lung disease causing difficulty in breathing), respiratory failure (when the body's respiratory system is unable to exchange oxygen and carbon dioxide properly), and dementia (a progressive state of decline in mental abilities). During a review of Resident 23's History and Physical (H&P), dated 8/13/2025,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 2) had a functioning television (TV) to watch. This deficient practice resulted in not being able to watch TV clearly when she wanted to.Findings: During a review of Resident 2's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 2 was admitted on [DATE]. During a review of Resident 2's Activity assessment dated [DATE], the Activity Assessment indicated Resident 2 enjoyed music, exercise, hand massage, music programs and watching TV, and enjoyed these activities in her own room or the activities room.During a review of Resident 2's Care Plan dated 5/14/2025, the Care Plan indicated Resident 2 is interested in independent and self-directed activities and had goals to maintain interest or pleasure in doing daily activities of preference. During a review of Resident 2'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 ensure one out of three sampled residents (Resident 1) resident rights were accommodated when Resident 1 refused a blood draw. This deficient practice of not allowing Resident 1 to refuse blood draw had the potential for the resident to feel discomfort when the staff attempted to draw the blood. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 1 diagnoses included dementia (a serious disturbance in a person's metal abilities that results in a decreased awareness of one's environment and confused thinking), anxiety (a feeling of worry, nervousness, or unease), and osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time). During a review of Resident 1's History and Physical (H&P), dated 6/20/2024, the H&P indicated Resident 1 did not have the capacity to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide dental services when one of three residents (Resident 1) did not receive follow up care for partial dentures as requested by the resident. This failure resulted in Resident 1 feeling embarrassed and had the potential to result in the resident having difficulty chewing and eating which could lead to weight loss and aspiration (accidental inhalation of food into the lungs). Findings: During a concurrent observation and interview on 6/5/2025 at 10:20 a.m. with Resident 1, Resident 1 smiled and was observed with a large gap along the top row of the resident's teeth. Resident 1 stated, she had requested partial dentures from the facility's dentist (date unknown) and had not received them. Resident 1 stated she felt embarrassed, self-conscious to smile and talk due to her missing teeth. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted on [DATE] with diagnoses including…

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

Based on observation, interview and record review, the facility failed to ensure one of three sampled (Resident 3) incontinence brief were changed in a timely manner. This failure had the potential for Resident 3 to develop a skin rash, infection and skin breakdown. Findings: During a review of Resident 3's admission Record (Face Sheet), the admission Record indicated the facility admitted Resident 3 on 10/28/2024 with diagnoses including Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities) and anxiety (a feeling of worry or unease). During a review of Resident 3 ' s Minimum Data Set (MDS-a resident assessment tool) dated 2/07/2025, the MDS indicated Resident 3 was severely cognitively impaired(never/rarely made decisions) and was dependent( helper does all of the effort) on the staff for eating, oral hygiene, personal hygiene, toileting, bathing, upper/lower body dressing, always incontinent(no control) of bladder or bowel movements and at risk for developing a pressure ulcer injury(localized, pressure-related damage to the skin and/or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide a pain management evaluation for one of three sampled residents (Resident 1). This failure had the potential to result in Resident 1 experience pain that was not controlled. Findings: During a review of Resident 1's Face Sheet, the Face Sheet indicated the facility admitted Resident 1 on 10/12/2022, and readmitted on [DATE]/2024 with diagnoses including unspecified dementia (a progressive state of decline in mental abilities), unspecified severity, without behavioral disturbance, anxiety (a feeling of worry or unease), primary osteoarthritis(a progressive disorder of the joints, caused by a gradual loss of cartilage) of both knees, and hypertension(high blood pressure). During a review of Resident 1 ' s Minimum Data Set (MDS-a resident assessment tool) dated 4/21/2025, the MDS indicated Resident 1 had moderate cognitive impairment, and was dependent( helper does all of the effort) on the staff for toileting hygiene, lower body…

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

Based on observation, interview and record review, the facility failed to provide a safe, sanitary environment for one of three sampled residents (Resident 3) by not having a soap dispenser in resident ' s bathroom. This failure had the potential to result in the spread of disease and Resident 3 developing an infection. Findings: During a review of Resident 3's admission Record (Face Sheet), the admission Record indicated the facility admitted Resident 3 on 10/28/2024 with diagnoses including Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities) and anxiety (a feeling of worry or unease). During a review of Resident 3 ' s Minimum Data Set (MDS-a resident assessment tool) dated 2/7/2025, the MDS indicated Resident 3 was severely cognitively impaired (never/rarely made decisions) and was dependent (helper does all of the effort) on the staff for eating, oral hygiene, personal hygiene, toileting, bathing, upper/lower body dressing, always incontinent(no episodes of continent with voiding or bowel movements) and at risk for developing a pressure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure transportation was arranged on 2/11/2025, for 1 of 4 residents, Resident 1, who had a follow up appointment with the Surgeon regarding the Jackson Pratt (a surgical suction drain that gently draws fluid from a wound to help recover after surgery) drain. This failure had the potential to affect the care the resident need post (after) operation, and placed the resident at risk for complications, like infections. 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 encounter for surgical aftercare following surgery on the digestive system ( the organs that take in food and liquids and break them down into substances that the body can use for energy, growth, and tissue repair), left bundle branch block (blockage or disruption of electrical impulses that causes heart to beat) and acute on chronic systolic heart failure (a sudden worsening…

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 infection prevention and control practices during wound care, for 3 of five sampled residents (Residents 2, 3, and 4.) This deficient practice had the potential to cause wound infections and delay wound healing process. Findings: a). During an observation on 11/12/2024 at 9:30 a.m. with Licensed Vocational Nurses (LVN) 1 in Resident 2 ' s room, LVN 1 cleaned the bedside table and applied plastic cover. LVN 1 washed hands, applied gloves and removed soiled dressing from Resident 2 ' s right heel. LVN 1 applied new pair of gloves and cleansed the right heel wound with normal saline ([NS] a cleansing solution). LVN 1 applied new pair of gloves and applied collagenase santyl ointment (wound ointment to remove damaged tissue from chronic skin ulcers) and covered the wound with gauze. LVN 1 applied vitamin A&D ointment (moisturizer to treat or prevent dry, rough) to Resident 2 ' s left heel and applied Resident 2 ' s bilateral heel…

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 recheck the blood pressure, of one of three sampled residents, (Resident 1). Resident 1 had a physician ' s order of no Cardiopulmonary Resuscitation (a procedure to restore normal breathing after cardiac arrest that includes the clearance of air passages to the lungs, mouth-to-mouth method of artificial respiration, and heart massage by the exertion of pressure on the chest) and had a low blood pressure reading. This failure had the potential Resident 1 ' s medical condition not monitored and get worse. 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]. Resident 1 ' s diagnoses included acute (sudden) osteomyelitis (inflammation of bone or bone marrow, usually due to infection) on the right ankle and foot and end stage renal disease (a terminal illness that occurs when kidneys can no longer function properly). During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 2), was provided a safe environment when providing wound care. This failure had the potential for Resident 2 to fall and sustain injuries. Findings: During a review of Resident 2 ' s admission Record, the admission Record indicated, Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2 ' s diagnoses included pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) of sacral region (area relating to sacrum, [the large, triangle-shaped bone in the lower spine that forms part of the pelvis]). During a review of Resident 2 ' s History and Physical (H&P) dated 11/3/2023, the H&P indicated Resident 2 did not have the capacity (ability to) to understand and make decisions. During a review of Resident 2 ' s Minimum Data Set ([MDS], a federally mandated resident assessment tool), dated 9/6/2024,…

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

Based on interview and record review, the facility failed to ensure a competency assessment skills check (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics in performing that an individual need to perform work roles or occupational functions successfully) was performed upon hire and annually for two out of five randomly selected staff. This deficient practice had the potential for the facility to not be able to assess the skills necessary to provide nursing services while assuring resident safety and attaining or maintaining the highest practicable physical, mental, and psychosocial well-being of each resident within the acceptable standards of practice. Findings: During a concurrent interview and record review on 10/17/2024 at 8:45 a.m., with the Director of Staff Development (DSD), Registered Nurse (RN 1), Certified Nurse Assistant (CNA 1), CNA 2, CNA 3, and CNA 4's employee files were reviewed. The DSD stated RN 1, CNA 1, CNA 2, CNA 3, and CNA 4 did not have an annual skills competency assessment check on file. The DSD stated a skills…

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 b. During an interview with Resident 33 on 10/15/2024, at 10:18 a.m., Resident 33 stated she was a vegetarian but the facility serves her meals that include meat dishes. A review of Resident 33's diet order indicated a regular diet, no added salt (NAS), reduced concentrated sweets (RCS), jello with all meals, small portion only, salad for lunch [NAME] at patient's request. During an observation of 10/16/2024, at 12:40 p.m., Resident 33 was served a plate of food with a hamburger bun with a slice of orange cheese and a meat patty on it. During an interview on 10/16/2024, at 11:40 a.m. with Certified Nursing Assistant (CNA) 8, CNA 8 stated she was aware Resident 33 was a vegetarian. During an interview on 10/16/2024, at 4:30 pm, with the Director of Dietary Services (DDS), the DDS stated was new to the facility and had not spoken with Resident 33 about her preferences but will interview do so as well as other residents. During a review of the facility's policy and procedure titled, Nutrition Care, dated 2018,…

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

Based on observation, interview, record review, the facility failed to ensure safe and proper storage of items in the refrigerator when : 1. One frozen bottled water was found not labelled in the freezer. 2. Undated, opened food items were found in the refrigerator and under the food preparation counter. 3. The internal refrigerator fan which was blowing air over uncovered fresh produce had black substances on the fan blades. These deficient practices of not dating and labelling opened food, improper sanitation of equipment for food storage, and food stored in open containers without covers had the potential for harmful bacteria growth and cross-contamination (transfer of harmful bacteria from one place to another) that could lead to food -borne illness. Findings: During an observation on 10/15/2024 at 8:15 a.m., in the kitchen, the following was observed: 1. In freezer #3, a water bottle was on shelf without a label , 2. In refrigerator #1 a bag of white sliced bread loaf, no open date, no use by date 3. Under the food preparation counter, stored foods were observed: Oatmeal,…

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 revise and provide an updated accurate resident census in the Facility's Assessment (a process for evaluating a facility's resident population and identifying the resources needed to provide care and services). This deficient practice had the potential to place residents at risk for delay of care and treatment services. Findings: During a review of the facility census for 10/15/2024, indicated 94 residents were residing in the facility. During a concurrent interview and record review on 10/18/2024 at 8:13 a.m., with the Administrator (ADM), the Facility's Assessment was reviewed. The ADM stated the Facility's Assessment was last updated on 9/7/2024. The ADM stated the assessment provided was an average daily census of 88 to 91 residents. The ADM stated the census recorded on the Facility Assessment did not match with the current census. The ADM stated the Facility Assessment did not match the census number and for section for Assistance with Activities of Daily Living ([ADL's] - routine tasks/activities such as bathing,…

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 implement the antibiotic stewardship program (coordinated program that promotes the appropriate use of antibiotics by clinicians) by failing to monitor and address antibiotic (a substance used to kill bacteria or to treat infection) use for one of one sampled resident (Resident 20) who was on antibiotics for urinary tract infection [(UTI) an infection in the bladder/urinary tract] was not evaluated when the resident returned from the hospital. The failure had the potential for Resident 20 to receive an inappropriate antibiotic and develop antibiotic resistance. Findings: During a record review of Resident 20 ' s admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included UTI, sepsis (a life-threatening blood infection) and diabetes mellitus [(DM) a disorder characterized by difficulty in blood sugar control and poor wound healing]. During a record review…

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 5 (CNA 5) was not assigned to one out of five sampled residents (Resident 195) after the resident's family member (FM 1) filed a grievance regarding CNA 5's loud and rude behavior. This deficient practice had the potential to affect Resident 195's sense of self-worth and self-esteem. Findings: During a review of Resident 195's face sheet (front page of the chart that contains a summary of basic information about the resident), the admission record indicated Resident 195 was admitted to the facility on [DATE]. The face sheet indicated Resident 195's diagnoses included displaced fracture of the upper end of the left humerus (a broken left upper arm bone), displaced fracture of the lower end of right humerus (a broken right upper portion of the elbow), displaced intertrochanteric fracture of the left femur (a broken thigh bone), and unspecified fracture of the left patella (a break in the kneecap). During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one out of five sampled residents (Resident 81) was notified her missing Electronic Benefit Transfer ([EBT]- to access benefits for food and cash aid) card was found. This deficient practice of not notifying Resident 81 the EBT card was found had the potential to cause distress for Resident 81. Findings: During a review of Resident 81's admission Record (Face Sheet), the Face Sheet indicated Resident 81 was admitted to the facility on [DATE]. Resident 81's diagnoses included metabolic encephalopathy (a brain dysfunction caused by a chemical imbalance in the blood that affects the brain), chronic kidney disease (a condition where the kidneys do not work as well as they should), and dementia (a progressive state of decline in mental abilities). During a review of Resident 81's History and Physical (H&P), dated 9/11/2024, the H&P indicated Resident 81 had fluctuating capacity to understand and make decisions. During a review of Resident 81's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one out of five sampled residents (Resident 81) was offered an opportunity to file a grievance (a complaint) for a missing Electronic Benefit Transfer ([EBT]- to access benefits for food and cash aid) card. This deficient practice of not allowing Resident 81 to file a grievance for missing the EBT card had the potential to cause distress for Resident 81. Findings: During a review of Resident 81's admission Record (Face Sheet), the Face Sheet indicated Resident 81 was admitted to the facility on [DATE]. Resident 81's diagnoses included metabolic encephalopathy (a brain dysfunction caused by a chemical imbalance in the blood that affects the brain), chronic kidney disease (a condition where the kidneys do not work as well as they should), and dementia (a progressive state of decline in mental abilities). During a review of Resident 81's History and Physical (H&P), dated 9/11/2024, the H&P indicated Resident 81 had fluctuating capacity to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately complete the Minimum Data Set ([MDS]- a federally mandated resident assessment tool) Section A for the level II Preadmission Screening and Resident Review ([PASRR] a tool to determine if the person had or was suspected of having a mental illness or intellectual disability) condition for two out of five sampled residents (Resident 42 and 85). This deficient practice resulted in incorrect data transmitted to the Centers for Medicare and Medicaid Services (CMS) and had the potential to result in inaccurate care and services for Resident 42 and 85. Cross Reference F644. Findings: a. During a review of Resident 42's admission Record (Face Sheet - front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 42 was admitted to the facility on [DATE]. The admission record indicated Resident 42's diagnoses included schizophrenia (a mental illness that is characterized by disturbances 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 a Preadmission Screening and Resident Review ([PASRR] a tool to determine if the person had or was suspected of having a mental illness or intellectual disability) was resubmitted for two out of five sampled residents (Resident 42 and 85). This deficient practice had the potential to result in Residents 42 and 85 not receiving the necessary mental health care and services needed. Cross Reference F641. Findings: a. During a review of Resident 42's admission record (face sheet), the admission record indicated Resident 42 was admitted to the facility on [DATE]. The admission record indicated Resident 42's diagnoses included schizophrenia (a chronic mental disorder that affects how people think, feel, and behave), dementia (a group of thinking and social symptoms that interferes with daily functioning), osteoarthritis (a chronic degenerative joint disease that occurs when the cartilage in a joint breaks down and becomes rough) of the left shoulder,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a person-centered care plan for two of five sampled residents (Resident 83 and Resident 195) by failing to: 1. Develop a comprehensive care plan addressing Resident 83's smoking. 2. Develop a care plan after Resident 195 filing of two grievances (a wrong or hardship suffered, real or supposed, which forms legitimate grounds of complaint). These deficient practices had the potential to negatively affect the delivery of necessary care and services for Resident 83 and Resident 195. Findings: a. During a review of Resident 83's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated, Resident 83 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 83's diagnoses included major depressive disorder (a mental health condition characterized by a depressed mood or loss of interest in activities for a prolonged period of time), anxiety disorder (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one out of six sampled residents (Resident 32) dentures were cleaned daily. This deficient practice of not cleaning Resident 32s dentures daily made Resident 32 feel frustrated. Findings: During a review of Resident 32's admission Record (Face Sheet), the Face Sheet indicated Resident 32 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 32's diagnoses included chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), heart failure (a heart disorder which causes the heart to no pump the blood efficiently, sometimes resulting in leg swelling), and blindness (the inability to see or a lack of vision). During a review of Resident 32's History and Physical (H&P), dated 11/10/2023, the H&P indicated Resident 32 had fluctuating capacity to understand and make decisions. During a review of Resident 32's Minimum Data Set ([MDS] a federally mandated assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a follow-up cataract (a medical condition in which the lens of the eye becomes cloudy) and glaucoma (group of eye conditions that can cause blindness and gradual loss of sight) appointment was scheduled for one of three sampled residents (Resident 85). This deficient practice had the potential to result in Resident 85's worsening vision that would negatively affect his quality of life. Findings: During a review of Resident 85's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 85 was admitted to the facility on [DATE]. Resident 85's diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), chronic kidney disease ([CKD]- a condition where the kidneys are damaged and can't filter blood properly), and dysphagia (difficulty of swallowing). During a review of Resident 85's History and Physical (H&P), dated 6/6/2024,…

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 residents (Resident 84) had the correct low air loss (LAL) mattress (an air mattress with small holes that helps prevent pressure wounds and keeps the skin dry and cool) setting to prevent pressure ulcer development (localized injuries to the skin and soft tissue caused by prolonged pressure on the skin). This deficient practice of not having the correct LAL mattress settings had the potential for Resident 84 to develop a pressure ulcer. Findings: During a review of Resident 84's admission Record (Face Sheet), the Face Sheet indicated Resident 84 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 84's diagnoses included failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity), dementia (a progressive state of decline in mental abilities), and chronic obstructive pulmonary…

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 32) had the correct diet texture when not wearing dentures. This deficient practice of not providing the correct diet texture had the potential for Resident 32 to not properly chew his food. Findings: During a review of Resident 32's admission Record (Face Sheet), the Face Sheet indicated Resident 32 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 32's diagnoses included chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), heart failure (a heart disorder which causes the heart to no pump the blood efficiently, sometimes resulting in leg swelling), and blindness (the inability to see or a lack of vision). During a review of Resident 32's History and Physical (H&P), dated 11/10/2023, the H&P indicated Resident 32 had fluctuating capacity to understand and make decisions. During a review of Resident 32's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sample resident (Resident 83) with post traumatic stress disorder ([PTSD] - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event) received informed trauma care ([TIC] - an intervention and approach that focuses on how trauma may affect an individual's life and his or her response to behavioral health) per their policy. This deficient practice had the potential for the staff's inability to identify possible triggers that could result in re-traumatization (the reactivation of trauma symptoms via thoughts, memories, or feelings related to the past traumatic experience) for Resident 83. Cross Reference F745. Findings: During a review of Resident 83's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated, Resident 83 was initially admitted to the facility on [DATE] and readmitted on [DATE]. 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 the staff was following the physician orders for the correct oxygen settings for one out five sampled Residents (Resident 12). This deficient practice of not following the physician orders had the potential to worsen Resident 12's health. Findings: During a review of Resident 12's admission Record (Face Sheet), the Face Sheet indicated Resident 12 was admitted to the facility on [DATE]. Resident 12's diagnoses included emphysema (a chronic lung disease that damages the air sacs in the lungs, making it hard to breathe), end stage renal disease (irreversible kidney failure), and heart failure (a heart disorder which causes the heart to no pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 12's History and Physical (H&P), dated 8/17/2024, the H&P indicated Resident 12 did not have the capacity to understand and make decisions. During a review of Resident 12'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 failed to ensure a resident was provided with medically related social services and emotional support while grieving for one of one sampled resident (Resident 83). This deficient practice placed Resident 83 at risk for further depression (a serious mental illness that can affect how a person feels, thinks, and acts) and ineffective coping ability. Cross Reference F699 Findings: During a review of Resident 83's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 83 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 83's diagnoses included major depressive disorder (a mental health condition characterized by a depressed mood or loss of interest in activities for a prolonged period of time), anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness) and mental disorder (a condition…

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 pharmacy consultant (a professional responsible for reviewing each resident's medication profile monthly to identify and report changes) recommendation to consider a trial reduction of psychotropic medication (drug that affects behavior, mood, thoughts, or perception) was acknowledged and acted upon for one out of five sampled residents (Resident 83). This deficient practice had the potential to result in Resident 83 receiving unnecessary medication. Findings: During a review of Resident 83's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated, Resident 83 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 83's diagnoses included major depressive disorder (a mental health condition characterized by a depressed mood or loss of interest in activities for a prolonged period of time), anxiety disorder (a condition in which a person has…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure an opened multi-dose tuberculin (a sterile liquid that contains substances taken from the bacterium that causes tuberculosis and is used in the diagnosis of the disease) vial was labeled with an expiration date in the medication storage room. This deficient practice had the potential to result in a medication error and/or administering expired medication. Findings: During a concurrent observation and interview, on [DATE], at 8:53 a.m., with Registered Nurse 1 (RN 1), a multidose vial of tuberculin purified protein derivative vial was observed in the refrigerator with a date of [DATE] and no expiration date. RN 1 stated the vial was just opened and was to be labelled with an expiration date. RN 1 stated the date written on the vial box also could have been confusing and taken as an expiration date instead of an open date. RN 1 stated the risk of not labeling an expiration date on a medication could result in giving expired…

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 oxygen humidifier (a device that adds moisture to prevent dryness) was dated and labeled for one out of five sampled residents (Resident 12). This deficient practice of not dating and labeling the oxygen humidifier had the potential to cause respiratory infection to Resident 12. Findings: During a review of Resident 12's admission Record (Face Sheet), the Face Sheet indicated Resident 12 was admitted to the facility on [DATE]. Resident 12's diagnoses included emphysema (a chronic lung disease that damages the air sacs in the lungs, making it hard to breathe), end stage renal disease (irreversible kidney failure), and heart failure (a heart disorder which causes the heart to no pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 12's History and Physical (H&P), dated 8/17/2024, the H&P indicated Resident 12 did not have the capacity to understand and make decisions. During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Care Plan for two of four sampled residents (Resident 1 and Resident 3) who were at risk for fall, were revised and individualized to include the level of staff assistance needed for the safe transfer and mobility (ability to move) of the residents. This deficient practice had the potential to result in unidentified nursing interventions and recurrent falls for Residents 1 and 3. Findings: a) During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including left thigh osteopenia (low bone density), bradycardia (heart beats slower than 60 beats per minute), and syncope (fainting or passing out). During a review of Resident 1 ' s Care Plan, dated 3/15/2024, the care plan indicated Resident 1 was a high risk for fall that may result to physical harm due to: history of falls and syncope. The Care Plan indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide needed assistance for one of four sampled Residents (Resident 3), who was assessed as needing partial/moderate assistance (resident could perform half of the mobility task while staff assisted with 50%) after toileting and while ambulating (walking). This failure resulted in Resident 3 sustaining a fall and placed the resident at risk for injuries and hospitalization from a fall. Findings: During a review of Resident 3 ' s admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including radiculopathy lumbar region (disease or damage of the nerve roots in the lower back), spinal stenosis (spinal canal narrows), and neuralgia (nerve pain). During a review of Resident 3 ' s History and Physical (H&P) dated 8/1/2024, the H&P indicated Resident 3 had the capacity to make medical decisions. During a review of Resident 3 ' s Fall Care Plan, dated 8/1/2024, The Care Plan Indicated Resident 3…

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 two sampled residents (Resident 2) was free from physical abuse by Resident 1 by failing to: 1. Follow Resident 2 ' s Care Plan and physician ' s order to monitor and address episodes of aggressive and abusive behaviors. 2. Revise and individualize (tailoring to the resident) the Care Plan for Resident 2 who had a history of altercations and aggressive behaviors. 3. Ensure Residents 1 and 2 who had prior resident-to resident altercation on 7/29/2024, were separated. 4. Follow the facility ' s Policy and Procedure titled, Abuse Prevention Program which indicates the facility would protect residents from abuse. These deficient practices resulted in Resident 1 being physically abused by Resident 2 on 8/18/2024, sustained a hematoma to the forehead (collection of blood that forms outside of the blood vessel) and had the potential to other injuries including intracranial hemorrhage (bleeding within the skull) and fractures (broken bones).…

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 reviews, the facility failed to: 1. Follow their policy and procedure (P&P) titled, Resident Elopement (an instance of a patient or person in care leaving a care facility, or safe area independently without notifying anyone), which indicated, the facility will provide a safe environment and preventive measures for elopement. 2. Follow their policy and procedure (P&P) titled, Safety Supervision of Residents, which indicated, resident supervision is a core component of the systems approach to safety. As a result, one of three resdients, Resident 1, left the facility unsupervised. Findings: A review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated, Resident 1 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's diagnoses included dementia (loss of the ability to think, remember, and reason to levels that affect daily life and activities), anxiety disorder (persistent and excessive worry that interferes with daily…

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 obtain a physician order to allow 1 of 5 sampled residents (Resident 1), to leave the facility on out on pass . This failure had the potential to jeoaprdize resident's safety and may result to bodily injuries. Findings: A review of Resident 1's admission record indicated Resident 1 was originally admitted to the facility on [DATE] and was re-admitted to the facility on [DATE] with diagnosis of acute kidney failure (kidneys unable to filter waste products from blood), presence of automatic cardiac defibrillator (preprogramed device implanted in the chest to automatically detect cardiac arrest or a life-threatening irregular rhythms) and hypertension (high blood pressure). A review of Resident 1's Minimum Data Set (MDS-an assessment and care planning tool), dated 3/5/2024 indicated Resident 1 had clear speech, ability to express ideas and wants, and understands. The MDS indicated Resident 1 was independent with eating, toileting hygiene, and personal…

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 medication was administered as ordered, for one of three sampled residents (Resident 1). This deficient practice had the potential to a poor healing process of Resident 1 ' s vaginal condition. Findings: During a review of Resident 1 ' s admission Record, the admission record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including muscle weakness and urinary tract infection. During a review of Resident 1 ' s History and Physical (H/P), dated 1/17/2024, 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 care assessment and care screening tool), dated 2/11/2024, the MDS indicated Resident 1 required substantial assistance for personal hygiene. During a review of Resident 1 ' s Order Summary Report (physician orders), dated 1/19/24, the physician order indicated estrace…

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 implement its infection prevention and control policy and procedure (P&P) by failing to report the facility ' s Coronavirus ([Covid-19] a highly contagious infection caused by a virus that could easily spread from person to person) outbreak (at least one confirmed case of Covid-19 who had resided for at least 7 days in the facility) to the California Department of Public Health (CDPH) District Office (DO). This deficient practice had the potential to result in a delay in the investigation by the DO and the spread of Covid-19. Findings: During a review of Resident 1 ' s admission record (Face sheet), the face sheet indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including anemia (low blood iron), and alcohol abuse. During review of Resident 1 ' s history and physical (H&P) dated 10/11/2023, the H&P indicated, Resident 1 had the capacity to understand and make decisions. During a review of Resident 1 ' s Covid-19 Antigen Test…

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 follow physician orders and care plan interventions by ensuring the nursing staff turned on a wheelchair pad alarm (a weight-sensitive sensor pad that is connected to a monitor unit and activates an alarm if a resident leaves the chair or the bed) to ensure its working properly and alerts staff of a potential fall for one of three sampled residents, (Resident 2). This failure had the potential to increase Resident 2 ' s risk of falling and sustaining injuries. Findings: During a concurrent observation and interview on 1/3/2024 at 11:55 a.m., Resident 2 sat in a wheelchair with a wheelchair pad alarm on the back of his wheelchair. The pad alarm did not show a red flashing light indicating the pad was working. Licensed Vocational Nurse (LVN) 1 assisted Resident 2 to a standing position, but the pad alarm did not sound. LVN 1 then turned the pad alarm on, and the alarm sound and red flashing light activated. LVN 1 stated the pad alarm was off and staff members would not hear the alarm if Resident 2 tried to stand…

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 eight of 20 sampled residents' (Residents 18, 35, 3, 25, 41, 45, 53 and 72) medical records were updated to show documentation that advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes were carried out should the person be unable to communicate them to a doctor) were discussed and written information provided to the residents and/or their responsible parties. This deficient practice violated the residents' and/or the responsible parties' rights to be fully informed of the option to formulate their advance directives and had the potential to cause conflict with the residents' health care wishes. Findings: A. During a review of Resident 18's Face Sheet, dated 10/26/2023, the Face Sheet indicated Resident 86 was initially admitted to the facility on [DATE], and readmitted on [DATE], with the diagnoses including glaucoma (a condition of increased pressure within the eyeball, causing…

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 the Lorazepam oral solution (a medication used to treat mental illness) was stored in one of one inspected medication rooms, (Station 1 Medication Room), and ensure the 29.5 milliliters (ml - a unit of measure for volume) of lorazepam was accounted for and was maintained for Resident 60's use. 2. Reorder Lactulose solution (a medication used to maintain regular bowel movements) for one of three residents (Resident 1), from the facility's contracted pharmacy, to ensure the medication supply was available between 6/13/2023 and 10/26/2023 and was available during the observed medication administration for Resident 1. (cross-refer F842) The deficient practice of failing to maintain accountability of Resident 60's Lorazepam oral solution increased the risk of diversion (the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) of medications, staff working in an impaired state,…

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 licensed staff checked the expiration date of Humalog insulin (a medication used to treat high blood sugar) before administering 36 doses between 10/14/23 and 10/25/2023 to one randomly observed resident (Resident 61.) (cross-refer F761) The deficient practice of failing to check the expiration date of insulin prior to administration increased the risk that Resident 61 could have experience medical complications such as poor blood sugar control or injection site infections which may have resulted in hospitalization and a decreased quality of life. Findings: A review of Resident 61's Face Sheet (a document containing demographic and diagnostic resident information), dated 10/26/23, indicated Resident 61 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses including type 2 diabetes mellitus (a medical condition characterized by a loss of blood sugar control.) 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 licensed staff did not falsify the Medication Administration Record (MAR - the record of all medications administered to a resident) by documenting the administration of lactulose (a medication used to maintain regular bowel movements) 267 times when the product was unavailable in the facility between 6/13/23 and 10/26/2023, for one of three residents observed for medication administration (Resident 1). (cross-refer F755) The deficient practice of failing to ensure the medical records accurately reflect care delivered to the resident increased the risk that Resident 1 may not have received her lactulose as ordered and may have received unnecessary dosage adjustments possibly resulting in medical complications leading to an overall diminished quality of life. Findings: A review of Resident 1's Face Sheet (a document containing demographic and diagnostic resident information), dated 10/26/23, indicated she was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to assist and document grievance for missing personal clothing for one of one sampled resident (Resident 57). This deficient practice violated the resident's right to have his grievance addressed. Findings: During a review of Resident 57's Face Sheet, the Face Sheet indicated the facility originally admitted Resident 57 on 6/30/2021 and was readmitted on [DATE] with diagnoses including cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), mild protein calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), and epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures). During a review of Resident 57's History and Physical (H&P), dated 8/28/2023, the H&P, indicated Resident 57 has fluctuating capacity to understand and make decisions. During a review of Resident 57's 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 ensure the Minimum Data Set (MDS), a standardized assessment and care screening tool, for Significant Change in Status Assessment (SCSA), is a comprehensive assessment that must be completed when the Interdisciplinary Team (IDT) has determined that a resident meets the significant change guidelines for either improvement or decline, was completed within the time frame for one of one sampled resident (Resident 25). This deficient practice had the potential to result inaccurate care and services due to inappropriate MDS care screening and assessment tool practices. Findings: During a review of Resident 25's Face Sheet, the Face Sheet indicated the facility originally admitted Resident 25 on 3/25/2016 and was readmitted on [DATE] with diagnoses including cerebrovascular disease (group of disorders of the heart and blood vessels), obstructive uropathy (a condition in which the flow of urine is blocked) and renal calculi (kidney stone). During 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 correctly fill out the Preadmission Screening and Resident Review (PASRR, a tool to determine if the person had, or was suspected of having, a mental illness, intellectual disability, or related condition) level one screening and refer one of three sampled residents (Resident 15) who had a diagnosis of schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves) to the appropriate state-designated authority for PASRR level two evaluation and determination. This failure had the potential to result in Resident 15 not receiving appropriate treatment recommendations for schizophrenia. Findings: During a record review of Resident 15's Face Sheet, dated 10/26/2023, the Face Sheet indicated, Resident 15 was originally admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses of metabolic encephalopathy (a chemical imbalance in the blood that affects the brain) and schizophrenia. The MDS Coordinator…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a comprehensive care plan for physical therapy (the treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise rather than by drugs or surgery) and occupational therapy (a form of therapy for those recuperating from physical or mental illness that encourages rehabilitation through the performance of activities required in daily life) for one of one sampled resident (Resident 25). This deficient practice had the potential to negatively affect the delivery of care and services to Resident 25. Findings: During a review of Resident 25's Face Sheet, the Face Sheet indicated the facility originally admitted Resident 25 on 3/25/2016 and was readmitted on [DATE] with diagnoses including cerebrovascular disease (group of disorders of the heart and blood vessels), right hip contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity 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 update and revise a comprehensive care plan to include the new physician's order for wound care treatment for one of one sampled resident (Resident 33). This deficient practice had the potential to place Resident 33 to not receive appropriate care and/or services. Findings: During a review of Resident 33's Face Sheet, the Face Sheet indicated Resident 33 was admitted to the facility on [DATE] with diagnoses including anemia (a condition in which the blood does not have enough healthy red blood cells) in chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), and atherosclerosis of extremities (a disease of the peripheral blood vessels that is characterized by narrowing and hardening of the arteries that supply the legs and feet) with gangrene (dead tissue caused by an infection or lack of blood flow). During a review of Resident 33's History and Physical (H&P), dated 8/4/2023, the H&P,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of six sampled residents (Resident 18), who was assessed at risk for weight loss received High Protein Nutrition (HPN) as indicated in the physician orders and nutritional assessment. This deficient practice had the potential for further weight loss to Resident 18 by not providing the HPN as ordered. Findings: During a review of Resident 18's Face Sheet, dated 10/26/2023, the Face Sheet indicated Resident 18 was initially admitted to the facility on [DATE], and readmitted on [DATE] with the diagnoses that include glaucoma (a condition of increased pressure within the eyeball, causing gradual loss of sight), legal blindness, dementia (loss of the ability to think, remember, and reason to levels that affect daily life and activities) with behavioral disturbance, and type 2 diabetes mellitus (high level of sugar in the blood). During a review of Resident 18's History and Physical (H&P), dated 4/21/2023, the H&P indicated 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 interview and record review, the facility failed to act on one recommendation from the pharmacy consultant (a professional responsible for reviewing each resident's medication profile monthly to identify and report changes) from September 2023 for routine lab works, the Complete Metabolic Panel (CMP) (a test that measures different substances in the blood, and provides important information of your body's chemical balance and how it uses food and energy), Complete Blood Count (CBC) (a blood test used to look at overall health conditions and blood disorders), lipid panel (a blood test used to monitor and screen your risk for heart disease), Hemoglobin A1c (HBA1c) (average level of blood sugar over the past two to three months) and magnesium levels (a test measuring the amount of mineral you get from foods you eat for high or low levels), in one of five sampled residents, (Resident 6). The deficient practice of failing to respond to recommendations from the consultant pharmacist had the potential to…

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

Based on observations, interviews, and record review, the facility failed to discard a bottle of Humalog insulin (a fast-acting medication used to treat high blood sugar) with an opened date of 9/16/23 according to the manufacturer's requirements affecting Resident 61 in one of two medication carts inspected (Station 2 Medication Cart). (cross-refer F760) The deficient practice of failing to discard opened bottle of Humalog insulin within the date recommended by manufacturer resulted in Resident 61 received 36 doses between 10/14/23 and 10/25/23 per medication administration record (MAR) (important information about someone's medication, time, date, and amount taking). Findings: During a concurrent observation and interview on 10/25/23 at 1:45 PM of Station 2 Medication Cart with Licensed Vocational Nurse (LVN 1), the following medication was found expired: 1. One opened vial (a small container made of glass for holding liquid medications) of Humalog insulin for Resident 61 was found labeled with an open date of 9/16/23. According to manufacturer's product labeling, opened Humalog…

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 document and provide education regarding the benefits and risks of immunization and administration of influenza (a contagious respiratory illness) vaccine and pneumonia ([PNA] infection of the lungs) vaccine (medication to prevent a particular disease) to residents or resident's responsible party for four of five sampled residents (Residents 13, 18, 38, and 80). This deficient practice resulted in incomplete resident's medical records. Findings: 1. During a review of Resident 18's Face Sheet, dated 10/26/2023, the Face Sheet indicated Resident 18 was initially admitted to the facility on [DATE], and readmitted on [DATE] with the diagnoses that include glaucoma (a condition of increased pressure within the eyeball, causing gradual loss of sight), legal blindness, dementia (loss of the ability to think, remember, and reason to levels that affect daily life and activities) with behavioral disturbance, and type 2 diabetes mellitus (high level of sugar 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.