Primrose Post-Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review, the facility failed to ensure the call light was within reach for one of four sampled residents (Resident 7). This failure had the potential for increased risk of falls, delayed response to emergencies, and unmet basic needs for Resident 7. Findings: During a review of Resident 7's record titled, Face Sheet (front page of the chart that contains a summary of basic information about the resident), dated 5/22/25, the Face Sheet indicated Resident 7 was admitted on [DATE] with diagnoses of dementia (a progressive state of decline in mental abilities), cerebral vascular accident (CVA - stroke, loss of blood flow to a part of the brain), hypertension (high blood pressure), and generalized muscle weakness. During a review of Resident 7's record titled, Minimum Data Sheet (MDS - a resident assessment tool), dated 3/19/2025, the MDS indicated Resident 7 was dependent on staff for all activities. During a review of Resident 7's records, titled Care Plan Report (CP), 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: 1. Implement its abuse prevention and reporting policy by failing to submit the results of the investigation of an allegation of financial abuse to the state agency (California Department of Public Health) within five working days of the incident for one of one sampled resident (Resident 52). This deficient practice delayed the investigation by the CDPH and placed Resident 52 at risk for further abuse. Findings: During a review of Resident 52's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 52 was admitted to the facility on [DATE]. Resident 52's diagnoses included dementia (a progressive state of decline in mental abilities), osteoarthritis (a progressive disorder of the joints, caused by gradual loss of cartilage) of knee, and acute kidney failure (a sudden and often temporary loss of the kidneys ability to function properly). 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: 1. Complete and re-submit the Preadmission Screening and Resident Review ([PASARR - a tool to determine if the person had, or was suspected of having a mental illness, intellectual disability, or related condition) Level one (I) screening and refer one of two sampled residents (Resident 45) who had a diagnosis of major depressive disorder ([MDD] - a mood disorder that causes a persistent feelings of sadness and loss of interest) to the appropriate state-designated authority for PASARR Level two (II) evaluation and determination. This deficient practice had the potential to result in Resident 45 to not receive the appropriate medical treatments for mental illness diagnosis. Findings: During a review of Resident 45's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 45 was admitted to the facility on [DATE]. Resident 45's diagnoses included MDD,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to: 1. Ensure one of seven sampled residents (Resident 39) received a Pre-admission Screening and Resident Review ([PASRR] - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) level II assessment. This deficient practice had the potential to result in Resident 39 not receiving the required services for his mental health condition. Findings: During a review of Resident 39's admission Record, the admission Record indicated Resident 39 was admitted to the facility on [DATE] with diagnoses including hypertension (HTN-high blood pressure), bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional highs), and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 39's History and Physical (H&P), dated 4/9/2025, 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 interview and record review, the facility failed to: 1. Ensure one of seven sampled residents (Resident 63) had the battery changed in her Life Vest (device that monitors the heart to correct dangerous rhythms) per physician's order. This deficient practice had the potential to result in the battery running out which would prevent monitoring of the resident's heart rhythm. Findings: During a review of Resident 63's admission Record, the admission Record indicated Resident 63 was initially admitted to facility on 3/21/2025, with a readmission on [DATE]. Resident 63's diagnoses included hypertension (HTN-high blood pressure), diabetes mellitus ((DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently). During a review of Resident 63's History and Physical (H&P), dated 3/22/2025, the H&P indicated Resident 63 had the capacity for medical decision making. 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.

Based on observation, interview, and record review, the facility failed to ensure the resident's bed was in the low position for one of four sampled residents (Resident 6). This failure had the potential for an increased risk of falls and injuries. Findings: During a review of Resident 6's record titled, Face Sheet (front page of the chart that contains a summary of basic information about the resident), dated 5/22/25, the Face Sheet indicated the facility admitted Resident 6 on 12/18/24 with a diagnoses of dementia (a progressive state of decline in mental abilities), epilepsy (brain disorder that causes a person to have seizures, a sudden surge of electrical activity in the brain that can cause convulsions and a loss of consciousness), unspecified immunodeficiency (condition where the immune system is unable to effectively fight off infections and diseases), dysphagia (difficulty swallowing), repeated falls, and muscle weakness. During a review of the Resident 6's record, titled Physician Order's, dated 5/22/25, the Physician Order's indicated, Fall Precautions (strategies 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: 1. Ensure one of seven sampled residents (Resident 42) food was at an appetizing temperature for consumption. This deficient practice resulted in Resident 42 not being able to eat the hard-boiled eggs she requested for breakfast. Findings: During a review of Resident 42's admission Record, the admission Record indicated Resident 42 was admitted to the facility on [DATE]. Resident 42's diagnoses included hypertension (HTN-high blood pressure), diabetes mellitus ((DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and hyperlipidemia (condition where there is high levels of fat in the blood). During a review of Resident 42's History and Physical (H&P), dated 4/4/2025, the H&P indicated Resident 42 had the capacity for medical decision making. During a review of Resident 42's Minimum Data Set (MDS - a resident assessment tool), dated 4/8/2025, the MDS indicated Resident 42's cognition (ability to think and reason)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to: 1. Ensure one of seven sampled residents (Resident 65) preferences to accommodate her lactose intolerance (digestive issue that results in difficulty digesting the sugar in milk) was honored. This deficient practice resulted in Resident 65 not being able to enjoy milk with her meals. This practice also had the potential to result in Resident 65 experiencing diarrhea, belly pain, or nausea if she consumed the milk that was provided. Findings: During a review of Resident 65's admission Record, the admission Record indicated Resident 65 was admitted to the facility on [DATE]. Resident 65's diagnoses included diabetes mellitus ((DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN-high blood pressure), and hyperlipidemia (condition where there is high levels of fat in the blood). During a review of Resident 65's History and Physical (H&P), dated 3/30/2025, the H&P indicated Resident 65…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. Follow enhanced barrier precautions (EBP - an infection control intervention designed to reduce transmission of multidrug-resistant organisms) for one of four sampled residents (Resident 6). 2. Ensure Certified Nursing Assistant 1 (CNA 1) performed hand hygiene (the act of cleaning one's hands with soap and water or using an alcohol-based hand sanitizer to remove germs, dirt, and other unwanted substances) before and after performing care for one of four sampled residents (Resident 16). This failure had the potential for an increased risk of developing and spreading life threatening infections to Resident 6, Resident 16, as well as other residents and staff in the facility. Findings: 1.During a review of Resident 6's record titled, Face Sheet (front page of the chart that contains a summary of basic information about the resident), dated 5/22/25, the Face Sheet indicated the facility admitted Resident 6 on 12/18/24 with a diagnoses of dementia (a progressive state of decline in mental abilities), epilepsy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review. The facility failed to: 1. Complete the McGeer Criteria (minimum set of signs and symptoms which when met, indicated that a resident likely has an infection and that an antibiotic (a drug used to treat infections caused by bacteria) might be needed) for Infection Screening Evaluation for one of two sampled residents (Resident 13). This deficient practice had the potential to result in the development of multi-drug-resistant organisms ([MDRO] - microorganisms, predominantly bacteria that are resistant to one or more classes of antimicrobial agents) from inappropriate antibiotic use. Findings: During a review of Resident 13's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 13 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 13's diagnoses included cerebrovascular accident ([CVA] - stroke, loss of blood flow to a part of the brain) 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 interview and record review, the facility failed to ensure resident who was admitted to the facility with intact skin did not develop a pressure ulcer ([PU] - injury to skin and underlying tissue resulting from prolonged pressure on the skin or bony prominences) for one of four sampled residents (Resident 120) by failing to: 1. Ensure nursing staff implemented Resident 120's care plan titled Resident is at risk for skin breakdown to apply barrier cream and to check resident's skin daily. This deficient practice resulted in Resident 120 acquiring a PU stage 2 (Partial-thickness loss of skin, presenting as a shallow open sore or wound) on sacral (a triangular-shaped bone located at the base of the spine) area. Findings: During a review of Resident 120's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 120 was admitted to the facility on [DATE]. Resident 120's diagnoses included cerebrovascular accident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensur e an inventory of personal belongings was completed upon transfer to General Acute Care Hospital (GACH) for one of one sampled resident (Resident 120). This deficient practice had the potential for not having proper accountability of Resident 120's personal belongings. Findings: During a review of Resident 120's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 120 was admitted to the facility on [DATE]. Resident 120's diagnoses included , cerebrovascular accident ([CVA] - stroke, loss of blood flow to a part of the brain) with hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), left elbow contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion), and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 120'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: 1. Implement its Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy and procedure (P&P) by not reporting within two (2) hours of an allegation of physical abuse, for one of three sampled residents (Resident 1) to the California Department of Public Health ([CDPH] – state licensing and certification agency) and the Ombudsman (an agency who investigates, reports on, and helps settle complaints against the facility), after Resident 2 allegedly hit Resident 1 on 12/5/2024. This deficient practice resulted in the delay of investigation by the CDPH and had the potential to place Resident 1 for further abuse. Findings: During a review of Resident 1's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to install floor mats (a cushioned floor pad designed to help prevent injury should a resident falls) for one of three residents (Resident 1) who was a high risk for fall, as indicated on the resident ' s Care Plan. This failure had the potential to result in Resident 1 sustaining injuries such as fractures (broken bones) and brain hemorrhage (bleeding in the brain) from a fall. 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]. The admission Record indicated Resident 1 ' s diagnoses included metabolic encephalopathy (a disorder that affects brain function), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), dementia (a progressive state of decline in mental abilities) and cerebral infarction (loss of blood flow to the brain). During a review of Resident 1 ' s History and Physical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Report an allegation of abuse to the State agency (Department of Public Health) within 24 hours for one of 3 sampled residents (Resident 1). This deficient practice had the potential to result in further abuse for Resident 1. Findings: During a review of Resident 1 ' s face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 1 was admitted to the facility on [DATE]. The face sheet indicated Resident 1 ' s diagnoses included dementia (a progressive state of decline in mental abilities), urinary tract infection (UTI- an infection in the bladder/urinary tract), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and cerebral infarction (when the blood supply to part of the brain is blocked or reduced). During a review of Resident 1 ' s Minimum Data Set (MDS- a federally mandated resident assessment tool), the MDS indicated Resident 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1.Implement its abuse Policy and Procedure (P&P) titled, Abuse Investigation and Reporting which indicated an allegation of abuse would be reported immediately to the State Licensing/Certification Agency immediately, but no later than two hours. This deficient practice had the potential for a delay in the investigation of the state agency and placed Resident 1 and other residents at risk for further abuse. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including heart failure (heart disorder which causes the heart to not pump the blood efficiently), end stage renal disease ([ESRD] irreversible kidney failure), and hypertension ([HTN] high blood pressure). During a review of Resident 1 ' s History and Physical (H&P) dated 3/1/2024, 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.

Based on interview and record review, the facility failed to revise and provide an updated accurate resident census in the Facility's Assessment. This deficient practice had the potential to place residents at risk for lack or delay of care and treatment services. Findings: A review of the facility census for 5/7/2024, indicated 64 residents were in the facility. A review of the Facility's Assessment on 5/10/2024 at 2:10 p.m., indicated the Facility Assessment was last revised for the period of 1/1/2024. The assessment provided was for a census of 52-53 residents. A record review of the Facility Assessment, on 5/10/24 at 02:12 PM, the Facility Assessment did not match the census number for provision of Activities of Daily Living (ADL). During a concurrent interview and record review, on 5/10/2024 at 2:47 p.m., with the DON, the DON stated the census recorded on the facility assessment did not match with the current census. DON stated there were residents who were not accounted for on the Facility Assessment. DON stated the residents who weren't accounted for on the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure adequate space to access the room's restroom for two out of 7 sampled residents (Resident 28 and Resident 39). This deficient practice resulted in psychological harm from the shame of possibly soiling themselves while sitting in their wheelchairs. Findings: a. A review of Resident 28's admission record indicated Resident 28 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included falls, dementia (a group of thinking and social symptoms that interferes with daily functioning), polyneuropathy (damage to multiple brain and spinal cord nerves), and gait/mobility abnormalities (an unusual walking pattern). A review of Resident 28's Minimum Data Set (MDS- an assessment and care screening tool) assessment, dated 4/4/2024, indicated Resident 28's cognitive patterns were moderately impaired and was dependent on staff members with toileting, showering and upper/lower body dressing. b. A 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 develop a care plan (the process of identifying a patient's needs and facilitating care and ensures collaboration among nurses, patients, and other healthcare providers) for three of 18 sampled residents (Residents 44, 16, and 53). This deficient practice had the potential for Resident 44, Resident 16, and Resident 53 to not receive the care and services needed. Findings: a. A review of Resident 44's admission Record indicated, Resident 44 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 44's diagnoses included multiple sclerosis (a potentially disabling disease of the brain and spinal cord), Huntington's disease (a condition that damages nerve cells in the brain causing them to stop working properly), and insomnia (inability to fall asleep). A review of Resident 44's Minimum Data Set ([MDS], a standardized assessment and care planning tool), dated 2/21/2024, indicated the resident was assessed to have no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, staff interviews, and record review, the facility failed to ensure expired and discontinued medications were discarded and disposed in accordance with the regulatory requirement: 1. The facility failed to label medications in accordance with the facility's medication disposition policy for one of three residents (Resident 53) who was discharged from the facility 2. The facility failed to label multi-dose medications with an open date for two of two residents (Residents 1 and 17). This failure had the potential to result in the loss of medication potency and for residents to receive ineffective medication dosages. Findings: A. During review of Resident 53's admission Record (facesheet), the record indicated the resident was initially admitted to the facility on [DATE], and the most recent re-admission was on [DATE]. Resident 53's diagnoses included hypertension (high blood pressure), hyperlipidemia (high cholesterol), malnutrition, venous thrombosis and embolism (blood clots in veins), 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.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Several food items were not dated and labeled in the dry storage area, reach in Refrigerator 1, Freezer 1, Freezer 2, and Freezer 3. 2. Dietary Aide 1 (DA 1) did not perform handwashing or wear gloves when cleaning the stainless-steel table. 3. [NAME] 1 did not perform handwashing or wear gloves when handling the scooper. 4. DA 2 did not perform handwashing after picking up a dirty towel on the kitchen floor. These failures had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness in 59 out of 64 residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview on 5/7/2024 at 8:45 a.m., with the Dietary Service Supervisor (DSS), in the dry storage area, four cans of evaporated milk were not labeled. The DSS stated all the food items in the dry storage should be…

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

Based on observation, interview, and record review, the facility failed to ensure the trash stored in the dumpster area was maintained in a sanitary manner when one out of one garbage bin was overfilled with the lid open. This deficient practice had the potential for harboring mice and other pest. Findings: During a concurrent observation and interview on 5/9/2024 at 1:00 p.m., with the Dietary Service Supervisor (DSS), in the outside kitchen area, found one garbage dumpster overfilled with the lid open. The DSS stated the lid was unable to close due to overfilling trash. The DSS stated trash bins that were open attracted unwanted pests to the area. A review of the 2022 U.S. Food and Drug Administration Food Code, code number 5-501.116 Cleaning Receptacles indicated, Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. A review of the facility's policy and procedure (P&P) titled, Food-Related Garbage and Refuse Disposal, revised 2017, the P&P indicate,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to: 1. Ensure a change of condition was formulated and responsible party notified for one of 18 sampled residents (Residents 55). This deficient practice violated the responsible party's right to be informed of the care services provided, violated the resident's rights of notification to the resident's representative (family member) and hand the potential to result in lack of proper care and treatment. Findings: A review of Resident 55's admission Record indicated, Resident 55 was initially admitted to the facility on [DATE]. Resident 55's diagnoses included acute kidney failure (sudden loss of the ability of the kidneys to function), cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), dementia (loss of the ability to think, remember, and reason to levels that affect daily life and activities), and hypertension (when the pressure in your blood vessels is too high). A review of Resident 55's History and Physical (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 interview and record review, the facility failed to ensure an accurate Minimum Data Set ([MDS] assessment and care screening tool), regarding functional limitation in range of motion, was conducted for one of 18 sampled residents (Resident 47). This deficient practice had the potential to result inaccurate care and services for Resident 47 due to inappropriate MDS care screening and tool assessment practices. Findings: A review of Resident 47's admission Record Resident 47 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 47's diagnosis included osteoarthritis (a degenerative joint disease in which the tissues in the joint break down over time) and contractures (chronic loss of joint mobility) on right elbow, right knee, and left knee. A review of Resident 47's History and Physical (H&P), dated 8/7/2023, the H&P indicated Resident 47 had the capacity to understand and make decisions. A review of Resident 47's Rehab Joint Mobility Screen Assessment (a form used 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: 1. Ensure g-tube residuals were checked for one of one sampled residents (Resident 8). 2. Ensure a clean stirring utensil was used when diluting the medications for one of one sampled residents (Resident 8). 3. Ensure physician orders were followed to place floor mats for one of 18 sampled residents (Residents 44). This deficient practice had the potential for the affected resident not to receive the care and services needed and the provision of a poor-quality care. Findings: a. A review of Resident 44's admission Record indicated, Resident 44 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 44's diagnoses included multiple sclerosis (a potentially disabling disease of the brain and spinal cord), Huntington's disease (a condition that damages nerve cells in the brain causing them to stop working properly. The damage can affect movement, cognition (perception, awareness, thinking, judgement) and mental health.),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 respiratory care was consistent with professional standards of practice when there was no physician order to administer oxygen for one of 7 sampled residents (Resident 16). This deficient practice had the potential to result in unsafe use of oxygen equipment, respiratory infection, unable to breathe comfortably, and/or hospitalization for Resident 16. Findings: A review of Resident 16's admission record indicated Resident 16 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included epilepsy (seizures), dyspnea (difficulty breathing), hemiplegia (muscle weakness or paralysis on one side of the body), and encephalopathy (a brain disease in which the brain is affected by an infection or toxins). A review of Resident 16's Minimum Data Set (MDS- an assessment and care screening tool) assessment, dated 3/20/2024, indicated Resident 16's was dependent on staff members with toileting,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident who received hemodialysis ([HD]) process of removing waste products and excess fluids from the body) received treatments in accordance with standards of practice for one of three sampled residents (Resident 216) by failing to communicate to physician and implement the fluid restrictions (certain amount of liquid each day) as recommended by hemodialysis. This deficient practice placed Resident 216 at risk for fluid overload, swelling, shortness of breath and discomfort. Findings: A review of Resident 216's admission Record, indicated, Resident 216 was admitted to the facility on [DATE] with diagnoses including end stage renal disease (a life-threatening condition when the kidneys fail to filter the blood) and hyperkalemia (too much potassium in the blood). A review of Resident 216's History and Physical (H&P), dated 4/30/2024, indicated, Resident 216 had the capacity for medical decision making. A review of Resident 216's Minimum Data…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that licensed nurses have the specific competencies and skill sets necessary to provide emergency care for one of 8 sampled residents (Resident 65) by: 1. Failing to call 911 after initiating CPR. This deficient practice resulted in Resident 65's death. Findings A review of Resident 65's closed record (face sheet), indicated Resident 65 was initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included encephalopathy (a broad term for any brain disease that alters brain function or structure), sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death), acute respiratory failure (the inability of the respiratory system to meet the oxygenation, ventilation, or metabolic requirements needed of the body), and pneumonia (an infection that…

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

Based on observation, interviews, and record review, the facility failed to document quality control checks for two of two medication carts in Nursing Station 1. This deficient practice had the potential to result in inaccurate blood sugar measurements for residents requiring blood sugar checks and can lead to uncontrolled blood sugar. Findings: During concurrent observation and interview on 5/10/2024 at 3:15 p.m. with Licensed Vocational Nurse (LVN) 5, at Medication Carts 1 and 2 in Nursing Station 1, the glucometer (a hand-held device that measures blood sugar) test solutions were not found in two of two medication carts. LVN 5 was unable to find the test solutions. LVN 5 stated the glucometer's results could be inaccurate if the glucometer was not calibrated at least once per day. LVN 5 stated the calibration was done by the night shift. During concurrent interview and record review on 5/10/2024 at 3:18 p.m. with LVN 5, the Quality Control Record, dated May 2024, in Cart 1 and Cart 2 for Station 1 were reviewed. The records indicated there was no documentation for blood sugar…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 laboratory test of Comprehensive Metabolic Panel ([CMP] a test that measures different substances in the blood and provides important information of the body's chemical balance and how it uses food and energy) results for one of 18 sampled residents (Resident 216) was reported to the physician in a timely manner. This deficient practice had the potential to result in Resident 216 experiencing preventable complications from abnormal lab values and possibly leading to medical complications requiring hospitalization. Findings: A review of Resident 216's admission Record, indicated, Resident 216 was admitted to the facility on [DATE] with diagnoses including end stage renal disease (a life-threatening condition when the kidneys fail to filter the blood) and hyperkalemia (too much potassium in the blood). A review of Resident 216's History and Physical (H&P), dated 4/30/2024, indicated Resident 47 had the capacity for medical decision making. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of four residents (Resident 2 and Resident 3) were assisted with Activities of Daily Living ([ADL's] activities related to personal care) in a timely manner. This deficient practice resulted in Resident 2 feeling upset, Resident 3 feeling frustrated and ignored, and had the potential to result in skin breakdown and falls for Residents 2 and 3. Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted on [DATE], with a diagnoses that included Hemiplegia (paralysis one side of the body) and Hemiparesis (muscle weakness or paralysis on one side of the body) following cerebral infarction (occurs as a result of disrupted blood flow due to the brain), other abnormalities of gait (manner of walking) and mobility, and other lack of coordination (having problems with movement). During a review of Resident 2's History and Physical (H&P) dated 3/11/2024, the H&P indicated Resident 2 had the…

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

Based on observation and interview, the facility failed to provide a clean and safe environment for residents by failing to ensure the activity room and hallway near the exit door (#3) were free of clutter. This deficient practice had the potential to result in accidents, fall and injuries for residents in the facility. Findings: During an observation on 1/10/2024 at 10:20 a.m. in the activity room, cardboard boxes piled against the wall next to the activity desk, 2 cardboard boxes at the back of the activity room and 1 cardboard box open behind the door were observed. Residents were observed propelling in their wheelchairs next to the boxes as they were going in and out of the activity room. During an observation on 1/10/2024 at 10:30 a.m., six plastic bags and six boxes piled up with resident's belongings, one linen cart and 2 wheelchairs were observed at the back hallway near the exit door to the smoking patio. Residents were observed propelling their wheelchair through this hallway to go in and out of the smoking patio. During an interview on 1/10/2024 at 12:03 p.m. with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to meet professional standards of quality for one of one sampled resident (Resident 2) by failing to contact the physician and obtain orders for blood glucose (BG blood sugar level) checks for Resident 2 who had a history of Diabetes Mellitus ([DM] a chronic condition that affected the way the body processes blood glucose). This deficient practice increased the risk of Resident 2 having adverse effects (unwanted effects) related to hyperglycemia (high BG) or hypoglycemia (low BG) which could result in medical complications including hospitalization or death. Findings: During a review of Resident 2 ' s admission Record (Face Sheet), the admission Record indicated Resident 2 was admitted on [DATE], with diagnoses including Type 2 DM, End Stage Renal Disease (a medical condition in which a person's kidneys stop functioning properly) and hypertension ([HTN] high blood pressure). During a review of Resident 2 ' s History and Physical (H&P) dated 12/17/2023,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility staff failed to follow its infection control policy and procedure (P&P) for one of five sampled residents (Resident 5) by failing to use the appropriate measures to rinse and clean the resident ' s bedpan (shallow vessel used for urination or defecation) after use. This deficient practice had the potential to for cross contamination (transfer of harmful bacteria from one place to another), transmit infectious microorganisms and increase the risk of infection for Resident 5. Findings: During a review of Resident 5 ' s admission Record (Face Sheet), the admission Record indicated Resident 5 was admitted on [DATE], with diagnoses including pneumothorax (collection of air outside the lung but within the pleural cavity), osteoarthritis (wearing down of the protective tissue at the ends of bones), and hypertension ([HTN] high blood pressure). During a review of Resident 5 ' s History and Physical (H&P) dated 1/3/2024, the H&P indicated Resident 5 had the mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow it's Infection prevention and Control Policy and Procedure (P&P) during wound care for three of 3 of 4 sampled residents (Residents 2, 3 and 4) by failing to ensure facility staff performed hand hygiene (cleaning hands by handwashing or using an alcohol-based hand sanitizer) after removing soiled dressing, doffing (removing) soiled gloves and donning (putting on) clean gloves. This deficient practice had the potential to result in cross contamination (transfer of harmful bacteria from one place to another), infection and delay in the wound healing process for Residents 2, 3 and 4. Findings: a.During a review of Resident 2's admission record, the admission record indicated Resident 2 was admitted on [DATE], with diagnoses including transient ischemic attack (temporary blockage of blood flow to the brain), diabetes ([DM] high blood sugar), and hypertension ([HTN] high blood pressure). During a review of Resident 2'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 controlled narcotic drugs (strong pain medicine) for two of three sampled residents (Resident 1 and Resident 2) were accurately accounted for. This deficient practice resulted in Resident 1 missing 30 tablets of Norco (strong pain medicine) and Resident 2 missing 30 tablets of oxycodone (medication to treat severe pain). It also had the potential of preventing Resident 1 and Resident 2 from getting pain medications and exposed staff and others to drug misuse. Finding: 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 hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body), hypertension (high blood pressure) and obesity (excess body fat). During a review of Resident 1 ' s Minimum Data Set (MDS – a standardized assessment and care screening tool), dated 7/20/2023, indicated Resident 1 was able 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 d. During a review of Resident 12's Facesheet (admisson record) indicated Resident 12 was admitted to the facility on [DATE] with diagnoses including urinary tract infection (an infection in any party of the urinary system, the kidneys, bladder, or urethra), lack of coordination (inability to coordinate body movements), transient ischemic attack (a temporary period of symptoms like those of a stroke). During a review of Resident 12's History and Physical record dated 8/24/2021, indicated the resident's judgement/insight was appropriate and cooperative. During a review of Resident 12's Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 11/19/2021, the MDS indicated Resident 12 required extensive assistance (resident involved in activity, staff provide weight-bearing support) for transfer, locomotion on unit, locomotion off unit, toilet use, and personal hygiene. During an interview with a group of alert and oriented residents on 2/9/2022, Resident 12 stated, It takes them (the staff)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents' medical records were updated to show documentation that advance directives (written statements of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person unable to communicate them to a doctor) were discussed and formulated, and written information were provided to the residents and/or responsible parties for seven of 14 residents (Resident 2, 15, 22, 23, 49, 200 and 202). These deficient practices violated the residents' and/or the resident representatives' right to be fully informed of the option to formulate their advance directives and had the potential to cause conflict with the residents' wishes regarding alternatives in the provision of health care. Findings: a. A review of Resident 200's Face Sheet (admission Record), indicated the resident was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (diffuse disease of the brain that changes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 system implemented for grievances to be addressed and resolved of one of 14 residents (Resident 14). This deficient practice resulted in the resident feeling upset and had the potential for other residents' grievances to not be addrressed in a timely manner. Findings: During an interview with Resident 14 on 2/9/22 at 11:09 a.m., during a group meeting of alert and oriented residents, the resident stated the Social Services Director (Social Service Director) does not follow up on transportation requests and lost items. A review of Resident 14's medical record the resident was admitted to the facility on [DATE] with diagnoses including sepsis (presence of harmful microorganisms in the blood) with escherichia coli (a bacteria that causes infection in the intestines), anemia ( low red blood cells in the blood) unspecified, hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone) unspecified, Type 2 diabetes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assessment entries on the Minimum Data Set (MDS, an assessment and care screening tool) related to bladder (body organ that stores urine) were accurately documented to reflect the resident's incontinence status for one of six residents (Resident 8). This deficient practice had the potential to negatively affect Resident 8's plan of care and delivery of necessary care and services. Findings: A review of Resident 8's Facesheet (admisson record) indicated the resident was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis after cerebral infarction (inability to move or weakness of one side of the body after a stroke), hypertension (high blood pressure), dysphagia (difficulty swallowing), and benign prostatic hyperplasia (overgrowth of prostate tissue). A review of Resident 8's MDS dated [DATE] under Section H Bladder and Bowel, indicated that the resident had an indwelling catheter. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a baseline care plan for one of four residents (Resident 200) within 48 hours of resident's admission. This deficient practice placed Resident 200 at risk for not receiving necessary care and services. Findings: A review of Resident 200's Face Sheet (admission Record), indicated the resident was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (diffuse disease of the brain that changes brain function), muscle weakness, end stage renal disease(when kidneys no longer function to meet body's demands), depression, chronic viral hepatitis C (an infection caused by a virus that attacks the liver and leads to inflammation), diabetes mellitus (abnormal blood sugar), malnutrition (lack of proper nutrition), acidosis (an excessively acid condition of the body fluids or tissues), and gout (a disease marked by a painful inflammation of the joints). A review of Resident 200's Resident Progress Notes, dated 2/4/22…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure resident care met professional standards for two of 46 residents (Resident 15 and Resident 43) by: a. Not following wound care procedures during treatment for Resident 15. b. Failing to assess and change the dressing of a midline catheter for Resident 43. These deficient practices placed Resident 43 at risk for accidental removal of the midline catheter and placed both residents at risk for infection. Findings: a. A review of the Resident 15's Facesheet (admssion record) indicated the resident was admitted to the facility on [DATE] with diagnoses including dementia (the loss of cognitive functioning, thinking, remembering, and reasoning), hyperlipidemia (high cholesterol), hypertension (high blood pressure) and adult failure to thrive. During an observation in Resident 15's room on 2/10/22 at 10:00 a.m., Licensed Vocational Nurse (LVN 6) was preforming wound care and dressing change on th resident. During the observation, LVN 6…

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

Based on observations, interviews, and record reviews, the facility failed to: 1. Ensure that one (1) licensed nurse administered the correct formulations of two (2) medications to two (2) out of four (4) residents observed during the morning medication administration. This deficient practice had the potential for harm to the residents receiving medication formulations not ordered by the physician. 2. Ensure that one (1) licensed nurse accurately documented the narcotics count of one (1) resident's narcotics record, which did not match the actual physical count, at one (1) out of two (2) total medication carts at the facility. This deficient practice had the potential for loss of accountability, which affected the controls against drug loss, diversion, or theft. 3. Ensure that the change of shift narcotics reconciliation record, for one (1) out of two (2) total medication carts at the facility, was not missing one (1) licensed nurse signature in the designated nurse signature space, over a nine (9) day period. This deficient practice had the potential for loss of accountability,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that the medication error rate of less than five (5) percent, due to two (2) medication administration errors out of twenty-six (26) opportunities involving two (2) out of four (4) residents observed during medication administration (med pass). This deficient practice of a medication administration error rate of seven and sixty-nine hundredths percent (7.69 %) exceeded the five percent (5%) threshold. Findings: 1a. During an observation, on 2/9/22, at 8:22 a.m., the morning medication administration (med pass) for Resident 39, at the Station 2 medication cart, indicated, Oyster Shell Calcium (calcium carbonate from the shell of an oyster used to treat low calcium levels in the body, necessary for normal functioning of nerves, cells, muscle, and bone) 500 mg (strength in milligram units) Tablet, take two (2) tablets by mouth. During an interview, on 2/9/22, at 11:49 a.m., the licensed vocational nurse/director of staff development (DSD), stated that when she receives telephone orders, We put it directly…

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

Based on observations, interviews, and record reviews, the facility failed to: 1. Ensure that a room thermometer was in place for routine monitoring of medications requiring storage at room temperature, in one (1) of two (2) medication storage rooms, out of three (3) total medication storage rooms at the facility. This deficient practice had the potential for harm to residents due to the potential loss of strength of the medications, and the potential for the residents to receive ineffective medication dosages. 2. Ensure that eleven (11) containers of six (6) over-the-counter medications were not expired, in one (1) out of two (2) total medication carts at the facility, and in one (1) out of three (3) total medication storage rooms at the facility. This deficient practice had the potential for harm to residents due to the potential loss of strength of the medications, and the potential for the residents to receive ineffective medication dosages. Findings: 1. During an observation, on 2/10/22, at 10:15 a.m., an inspection of the Central Supply medication closet indicated no room…

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

Based on observation, interview, and record review, the facility failed to follow menu as written for 26 out of 26 residents on regular diet. The 26 residents on regular diet received an incorrect portion size for skillet fried potatoes and seas greens. This failure had the potential for residents to receive the wrong caloric intake when not following the menu, which could result in over nutrition or under nutrition and further compromise the medical status of the 26 residents who received food from the kitchen. Findings: During an observation on 02/09/22 at 12:12 PM of the tray line, the [NAME] was using a green handle ladle for large portions, white handle ladle for small portion, white and black scoop for the mechanical diet, a navy blue, green and white handled ladles for regular. During a concurrent observation and interview on 02/09/22 at 12:30 PM with the Cook, scoops numbers and ladle sizes were reviewed. The following ladle and/or scoop size were used: 1. For regular diet, ladle size 6 ounce (oz, unit of measure) used for seasoned beans/ham, for the fried potatoes an 8 oz…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews, and record review, the facility failed to store food in accordance with professional standards for food service safety when: 1. Several food items were not dated and labeled after being placed in the reach-in freezer. 2. Multiple containers of unlabeled and not dated small bowls of ice cream in the reach in freezer. 3. Ground beef and chicken thawing in separate plastic containers noted at the bottom of the Refrigerator #1 were unlabeled with date. 4. Bulk container of thickener had scoop stored in container. 5. Several items were not dated and labeled after being place in Resident Refrigerator. 6. Staff were placing food items in Resident Refrigerator. These failures have the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food, as well as toxins) which can lead to other serious medical complications and hospitalization for 55 out 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 staff failed to ensure medical records were accurately labeled to correspond with the correct room number for four of 14 residents (Resident 23, 28, 49, 400). This deficient practice had the potential for delay in finding records during an emergency and errors in resident care. Findings: a. During a review of Resident 23's Face Sheet (admission record) indicated Resident 23 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease (most common cause of dementia, a general term for memory loss and other cognitive abilities serious enough to deal with daily life), muscle weakness (when your full effort doesn't produce a normal muscle contraction or movement), hemiplegia (paralysis of one side of the body). During a review of Resident 23's Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 12/28/2021, indicated Resident 23 had intact cognition (ability to think, understand and make daily decisions). b. 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 provide a functioning call light for two of 14 sampled residents (Resident 23 and Resident 28). This deficient practice had the potential for delay in providing the resident's needs in a timely manner and resulted in Resident 23 and Resident 28 feelings of helplessness. Findings: a. During a review of Resident 23's Face Sheet (admission record) indicated Resident 23 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease (most common cause of dementia, a general term for memory loss and other cognitive abilities serious enough to deal with daily life), muscle weakness (when your full effort doesn't produce a normal muscle contraction or movement), hemiplegia (paralysis of one side of the body). During a review of Resident 23's Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 12/28/2021, the MDS indicated Resident 23 had intact cognition (ability to think, undertsand and make 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 did not ensure a written notice of room change was provided for one of two residents (Resident 38). This failure resulted in Resident 38 feeling frustrated by the changing of rooms. Findings: A review of Resident 38's Facesheet (admission record) indicated the resident was admitted to the facility on [DATE] with diagnoses including heart failure, diabetes mellitus (high blood sugar), atrial fibrillation (irregular heartbeat), hyperlipidemia (high cholesterol), and functional quadriplegia (loss of ability to move due to severe disability or frailty). A review of Resident 38's Minimum Data Set (MDS), a standardized assessment and care screening tool dated 1/12/22, indicated that Resident 38 has intact cognition (ability to think, undertsand and make daily decisions), required extensive assistance with one person for personal hygiene concerns, toileting, and dressing and was frequently incontinent of bowel and bladder (loss of control of bowel and bladder…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 to ensure Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN, provides information to the beneficiary so that s/he can decide whether or not to get the care that may not be paid for by Medicare) was provided to two out of three residents (Resident 19 and Resident 28) who were discharged from Medicare part A services (covers payment for skilled nursing care). This deficient practice has the potential for Resident 19 and Resident 28 and/or their responsible parties not having the information to make an informed decision regarding continuing to receive skilled services not covered by Medicare. Findings: a. A review of Resident 19's SNF Beneficiary Protection Notification Review form indicated the resident's last day Medicare Part A Skilled Services was 8/24/21. A review of Resident 19's SNF Beneficiary Protection Notification Review form filled out by the Social Sevices Director (SSD) indicated that Resident 19 did not receive SNFABN because the form was not issued. b. A review of Resident 28's Beneficiary Protection…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were provided a safe, clean, comfortable, and homelike environment for four of 14 sampled residents by: a. Storing belongings (clothing) in boxes on the floor for Resident 9, 16 and 49. b. The floor of Resident 22's room was soiled with yellow fluid and black substance leading from the foot of Resident 22's bed to the bathroom. This deficient practice had the potential for resident falls due to clutter at the bedside and wet substance on the floor, cross contamination, infection, and negatively affect the resident's quality of life. Findings: a. During a review of Resident 9's Face Sheet (admissio record) indicated Resident 9 was admitted to the facility on [DATE] with diagnoses including osteoporosis with current pathological fracture of right forearm (decreased bone density which can lead to a break in the bone), muscle weakness (when your full effort doesn't produce a normal muscle contraction or movement). 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.

Based on interview and record review, the facility failed to follow and implement the facility's written abuse policy and procedure for one of two residents (Resident 34) by failing to investigate an allegation where the welfare and safety of the resident was involved. This failure resulted in Resident 34 feeling distressed. Findings: A review of Resident 34's Facesheet (admission reocrd) indicated the resident was admitted to the faciliyu on 11/16/22 with diagnoses including paraplegia (partial or complete paralysis of the lower half of the body with involvement of both legs), osteoarthritis (inflammation and breakdown of the cartilage in the joints), hyperlipidemia (high cholesterol), and generalized muscle weakness. A review of Resident 34's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 1/14/22, indicated that the resident was cognitively intact (ability to think, understand and make daily decisions), required extensive assistance for toileting needs and was always incontinent (loss of control) of bowel and bladder. During an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents nails were kept clean and neat for three of 14 residents (Resident 12, 13, 25). This deficient practice had the potential for Resident 12, 13 and 25 having feelings of low self-worth and self-esteem. Findings: a. During a review of Resident 12's Face Sheet (admission record) indicated Resident 12 was admitted to the facility on [DATE] with diagnoses including urinary tract infection (an infection in any party of the urinary system, the kidneys, bladder, or urethra), lack of coordination (inability to coordinate body movements) and transient ischemic attack (a temporary period of symptoms like those of a stroke). During a review of Resident 12's History and Physical (H/P) record, dated 8/24/2021, the H/P indicated the resident's judgement/insight was appropriate and cooperative. During a review of Resident 12's Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 11/19/2021, indicated Resident 12…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 social services was provided to four of 14 sampled residents (Resident 2, 22, 23, 49) in assisting residents with advance care planning and providing a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN, provides information to the beneficiary so that s/he can decide whether or not to get the care that may not be paid for by Medicare) for two of three residents (Resident 19 and Resident 28) who were discharged from Medicare part A services (covers payment for skilled nursing care). This deficient practices had the potential to cause conflict with resident's wishes regarding health care needs, and/or delay in the delivery and care of service and not having information to make an informed decision regarding continuing to receive skilled services not covered by Medicare. Findings: a. During a review of Resident 2's Face Sheet (admission record), indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including chronic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two out of four dietary staff (Dietary [NAME] and Dietary Aide) were competent, and had the skills sets to prepare therapeutic diet portion sizes and correct use of scoops for 26 residents. This deficient practice caused 26 residents on a regular diet to receive the incorrect food portions. Findings: During an observation on 2/09/22 at 12:12 PM of the tray line, the [NAME] was using a green handle ladle for large portions, white handle ladle for small portion, white and black scoop for the mechanical diet, a navy blue, green and white handled ladles for regular. During a concurrent observation and interview on 2/09/22 at 12:30 PM with the Cook, scoops numbers and ladle sizes were reviewed. The following ladle and/or scoop size were used: 1. For regular diet, ladle size 6 ounces (oz , a unit of measure) used for seasoned beans/ham, for the fried potatoes an 8 oz ladle was used, for greens 4 oz and 3 oz ladle were used. A review of the menu spreadsheet for a regular diet on Wednesday 2/9/22 indicates for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement their policy for offering and administering influenza (viral infection) and pnuemococcal (bacterial infection) vaccines two of 14 residents (Resident 22 and Resident 8). This deficient practice placed the residents at increased risk of acquiring, transmiting and experiencing complications from an influenza and pneumococcal infection. Findings: During an interview with the Minimum Data Set [(MDS), a standardized assessment and care planning tool] Coordinator on 2/11/2022 at 10:54 a.m., who works as the back up Infection Preventionist (IP) stated Resident 22 was not offered the pneumococcal vaccine (immunization to prevent bacterial infection of the lungs) and Resident 8 was not offered the influenza vaccine (immunization to prevent viral flu infection). A concurrent review of Resident 22's electronic chart ([NAME] record) indicated there was no documentation of pneumococcal vaccine (immunization to prevent bacterial infection of the lungs)…

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