Hi-Desert Medical Center D/P SNF

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that oxygen therapy was administered in accordance with physician's order for three of six residents (Resident 92, Resident 90 and Resident 30) while receiving oxygen. This failure had the potential for placing Resident 30, Resident 92 and Resident 25 at risk for inappropriate treatment and altered oxygen saturation (how well oxygen is being delivered to the body) levels.Findings: 1. During a review of Resident 92 face sheet (clinical record with demographic information), undated, the face sheet indicated, Resident 92 was admitted on [DATE], with diagnosis that included Bilateral (both) Humerus (arm bone) Fracture (broken). During an observation on March 16, 2026, at 12:08 PM, in Resident 92's room, Resident 92 is in bed sitting with oxygen (O2) at 2 liters per minute (L/min-unit of flow rate) via nasal cannula (tube that contains two open prongs intended to deliver oxygen into the nose). During a concurrent interview and record…

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 recommendations made by the pharmacist for one of two sampled residents. (Resident 2). This failure had the potential for unnecessary medication to cause harm to Resident 2. Findings: During a record review of Resident 2's admission Record (contains demographic and medical information), undated, the admission Record indicated, Resident 2 was admitted to the facility on [DATE], with diagnoses which included hypertension (high blood pressure, a chronic condition where the force of blood against artery walls is consistently too high), and dementia ( a general term for a decline in mental ability-such as memory, thinking, or behavior-severe enough to interfere with daily life). During a record review of Resident 2's physician's order, dated on July 17, 2025, the physician's orders indicated, seroquel (medication-treat mood and behavioral disorder) 25 mg (milligram- unit of measurement) = 1 tab (tablet), Oral (by mouth) BID (twice a day), start date…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure medications were administered in accordance with physician orders for one of 23 sampled residents (Resident 67), when Resident 67 received an antibiotic (medication that treats bacterial infections) intravenous (IV - administered through the vein) at an incorrect rate. This failure resulted in medication error and had the potential to result in ineffective treatment and adverse clinical outcomes such as antibiotic resistance (a condition that bacteria have evolved and difficult to kill).Findings: During a record review of Resident 67's admission History & [and] Physical (H&P-document by a physician to evaluate resident's health status), dated September 10, 2025, the H&P indicated, Resident 67 was admitted to the facility on [DATE], with diagnoses including heart failure (heart cannot pump well enough to meet the body's needs), quadriplegia (paralysis of all four limbs-both arms and legs), and recurrent urinary tract infection (UTI-…

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 investigate and monitor the use of illegal substances (drug or chemical that the government has made against the law to have, use, or sell) for one of three sampled residents (Resident 1), when Resident 1 tested positive for marijuana (most common name of the cannabis plant, widely used either for its mind-altering effect or for medical purposes). This failure had the potential to pose a safety hazard to Resident 1 and other residents in the facility.Findings: During a review of Resident 1's face sheet (which contains demographic and medical information) indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included paraplegia (paralysis of the lower half of the body), and multiple sclerosis (a condition where the body mistakenly attacks the nerves, making it harder for the brain to send messages to the rest of the body). During a review of Resident 1 ' s Minimum Data Set (facility assessment tool), dated January 12, 2026,…

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 protect two of three sampled residents (Resident 1 and 3) from verbal abuse (suing negative words and language that cause harm) from Registered Nurse (RN 1). This failure had the potential to contribute to Resident 1 and 3 distrust in the healthcare team which could negatively affect Resident 1 and 3 participating in their care that could lead to actual harm and worsen their condition.Findings: During a review of Resident 1's History and Physical (H&P), dated July 15, 2025, the H&P indicated that Resident 1 was admitted with a diagnosis of multiple sclerosis (a disease that causes breakdown of the protective covering of nerves which can cause numbness, weakness, pain, trouble walking, weakness, vision changes, fatigue, mood changes and other symptoms). During a review of Resident 1's Brief Interview Mental Status (BIMS - test used in nursing homes and hospitals to measure a person's memory and thinking skills where a score of 13 to 15 is considered normal), dated January 24, 2026, the BIMS indicated that his…

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 report an allegation of abuse within 24 hours for one of three sampled residents (Resident 1). This failure prevented the appropriate state agencies from ensuring that the facility was taking the necessary actions to protect Resident 1 and other residents from actual or potential harm.Findings: During of a review of the facility's Report of Suspected Dependent Adult/Elder Abuse (SOC 341, in California, it is a confidential form used to report suspected abuse or neglect of seniors or dependent adults. Mandated reporters must submit this form to local authorities within two working days of witnessing or suspecting harm), dated January 21, 2026, the SOC 341 indicated the allegation of Psychological/Mental (mind, emotion, and behavior) abuse toward Resident 1 was identified on January 13, 2026, and was reported to the Ombudsman (a state-certified advocate dedicated to protecting the rights, safety, and quality of life of the residents) and the California Department of Public Health (CDPH) on January 21, 2026 (8 days after 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 three sampled residents (Resident 1) received enteral nutrition (tube feeding - a delivery of liquid nutrition directly into the stomach through a percutaneous endoscopic gastrostomy (PEG - a feeding tube that is place through the stomach used for a person who cannot eat or swallow safely)) according to the physician's order, when Resident 1 did not receive the calculated amount of feeding for approximately two days. This failure had the potential to compromise Resident 1's nutritional status placing him at risk for weight loss, dehydration, and decline in condition.Findings: During a review of Resident 1's Face Sheet (FS- a document containing patient demographics) the FS indicated, Resident 1 was admitted to the facility on [DATE]. During a review of Patient 1's History and Physical (H&P- a document containing demographic information), dated January 15, 2026, at 5:18 PM, the H&P indicated, Patient 1 was admitted to the facility with 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 interviews, Record Review and observation, the facility failed to follow policy and procedure to provide services in a timely manner to 1 out of 4 residents to avoid physical harm, pain, mental anguish and emotional distress.This failure had the potential to compromise the residents' health, safety, psychosocial wellbeing and overall quality of care, when the resident was left soiled, and their activities of daily living were not met in a timely manner. Based on interviews, Record Review and observation, the facility failed to follow its policy and procedure to provide services in a timely manner to 1 out of 4 residents to avoid physical harm, pain, mental anguish and emotional distress.This failure had the potential to compromise the residents' health, safety, psychosocial wellbeing and overall quality of care, when the resident was left soiled, and their activities of daily living were not met in a timely manner.FINDINGS:During a record review of Resident's 1's admission record (general Demographics),…

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 in response to safety concerns with suspected abuse for one of three sampled Residents (Resident 1) when the facility reported the suspected abuse to the California Department of Public Health (CDPH) on August 20, 2025, or five (5) days after the suspected abuse incident. This failure had the potential to result in a delay of an investigation to determine abuse which could continue or become more severe, other vulnerable Residents to be put at risk for abuse, worsen long-term psychological and physical effects, delay timely access to medical, psychological, and other services for healing for Resident 1.Findings: During a review of the facility's SOC 341 (California form used by specific people, called mandated reporters, to report suspected abuse or neglect of elders and dependent adults), dated August 20, 2025, at 1:00 PM, the SOC 341 indicated that Licensed Vocation Nurse (LVN2) reported on Friday (August 15, 2025, at 1:00 PM), (Visitor) friend 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 follow their policy and procedure (P&P) for resident abuse for one of three sampled residents (Resident 1) when Resident 1's care plan (an individualize treatment plan) was not updated or revised and enhanced monitoring was not implemented. This failure had the potential to result in Resident 1 having psychosocial (affecting person's feelings, emotions, relationships, and sense of well-being) harm to residents such as fear, anxiety and loss of trust in staff.Findings: An unannounced visit was conducted to the facility on August 5, 2025, for an investigation of a facility reported incident of abuse. During a review of Resident 1's Face Sheet (FS- a document containing patient demographics), the FS indicated, Resident 1 was admitted to the facility on [DATE]. A review of Resident 1's History and Physical (H&P - a document containing demographic information), dated January 8, 2025, indicated Resident 1 has a history of depression (feeling sad, hopeless…

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 follow their policy and procedure (P&P) for resident documentation of care plan for one of three sampled residents (Resident 2) when Resident 2's care plan (an individualize treatment plan) was not updated with description of changes in Resident 2's condition and behaviors. This failure had the potential to result in Resident 2 deterioration, emotional distress and an increase in the risk of injury to self, other residents, and staff.Findings: An unannounced visit was conducted to the facility on August 6, 2025, for an investigation of a facility reported incident of resident abuse. A review of Resident 1's Face Sheet (FS- a document containing patient demographics), the FS indicated, Resident 1 was admitted to the facility on [DATE]. A review of Resident 1's History and Physical (H&P - a document containing demographic information), dated March 2, 2025, indicated, Resident 1 has a history of depression (feeling sad, hopeless for long period),…

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, record review the facility failed to develop and implement a comprehensive person-center care plan (a document that outlines a patient's care, including their diagnosis, treatment goals, and nursing orders) that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs for four of five sampled residents (Resident 24, 61, 67, and 50). This failure had the potential to result in person-centered care not being provided which may lead to negative physical, mental, and psychosocial impact upon the resident's function, mood, and cognition. Findings: 1. During an observation on December 4, 2024, at 9:20 AM, on the sub-acute unit (a specialized unit where the resident breathes with the help of a medical device and need close monitoring, rehabilitation, nursing and respiratory care), Resident 24 was observed lying in bed, supine (lying on the back, face up) with eyes closed; on ventilator (a medical device that helps 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 ensure the nursing staff administered medication as ordered for 23 residents of 41 sampled residents (Residents 2, 4, 8, 9, 20, 28, 41, 42, 45, 49, 53, 55, 56, 57, 58, 59, 60, 64, 65, 71, 74, 147 and 295) when: 1.) The nursing staff did not give medications to 22 residents (Residents 2, 4, 8, 9, 20, 28, 41, 42, 45, 49, 53, 55, 56, 57, 58, 59, 60, 64, 65, 71, 74 and 295) on December 1, 2024, as ordered and did not notify a responsible physician or a pharmacist for not giving the medications. 2.) The nursing staff did not administer Resident 147's medication by mouth as ordered and did not verify with a physician for using a percutaneous endoscopic gastrostomy (PEG-a feeding tube surgically inserted directly to the stomach wall to use for food and medication) tube for medication administration. These failures had resulted in unsafe medication administration and could cause adverse health outcomes from the inconsistency of medication dosage…

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 family or emergency contact person were notified appropriately of resident transfer for one of 22 sampled residents (Resident 1) when there was no documented evidence that Resident 1's family was notified before Resident 1 was transferred to the acute care hospital for suprapubic catheter (a surgically created tube that drains urine from the bladder when other methods are not possible) exchange. This failure resulted in no communication between Resident 1's family and the healthcare team and had the potential to interfere with Resident 1's family ability to follow and participate in Resident 1's transfer process and care. Finding: During a review of resident 1's Emergency department Physician note, dated September 30, 2024, the Emergency Department Physician note indicated, resident is [AGE] year-old male with history of quadriplegia (a condition that causes a person to lose all or most motor function in their arms, hands, trunk, legs, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, the facility failed to ensure Passive Range of Motion (PROM - the movement of a joint from staff or therapist with no effort from the resident) services were provided for two of five sampled residents (Resident 61 and 67) when there was no documented evidence that the Range of Motion (ROM-extent or limit to which joint can be moved around) was completed as ordered. This failure has the potential to result in further decline in physical, mental, and/or psychosocial aspects of the resident's ability to maintain and improve range of motion and mobility. Findings: 1. During an observation on December 3, 2024, at 2:03 PM, on the sub-acute unit (a specialized unit where the resident breathes with the help of a medical device and need close monitoring, rehabilitation, nursing, and respiratory care), Resident 61 was observed lying in bed, supine (lying on the back, face up) with eyes closed and the head of bed elevated. Feeding pump was infusing. Resident 61 was noted 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 ensure call lights were answered in a timely manner to provide care and services for two of three residents (Resident 1 and Resident 2). This failure has the potential to jeopardize the health and safety of clinically compromised Residents (Resident 1 and Resident 2) when their requests for assistance with activities of daily living were not responded to promptly. Findings: During a concurrent observation and interview on August 29, 2024, at 1:50 PM. Resident 1 was found seated in a wheelchair in his room, it was noted that Resident 1 relied solely on the wheelchair for mobility. Resident 1 stated, It takes a long time, sometimes up to two hours for staff to answer the calls for help. During a review of Resident 1's clinical record, the face sheet (contains demographic and medical information), indicated Resident 1 was admitted on [DATE]. A review of history and physical (H&P – a formal assessment of a patient ' s health that includes 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.

Based on interviews, and record review, the facility failed to maintain an accurate controlled medication (medications that can cause physical and mental dependence) verification process for a universe of 17 residents when the controlled medication verification was not accurately completed with two (2) licensed nurses for seven (7) of 20 days from August 1, 2024, through August 20, 2024. This failure had the potential in delaying the recognition of any discrepancy to the controlled medication which can negatively affect residents ' health from misuse of medication or diversion (medication illegally going to someone without a prescription) of medication to unauthorized people. Findings: During a review of the facility ' s control drug count record for 17 residents, dated August 1, 2024, through August 20, 2024, the record indicated, missing one license nurse signature on the following days and shift (work hours): On August 1, 2024: AM shift (work shift that starts at 7:00 AM and ends at 7:00 PM) On August 4, 2024: AM shift. On August 6, 2024: PM shift (work shift that starts at 7:00…

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 interviews, and record review, the facility failed to ensure the controlled medication (medications that can cause physical and mental dependence) was kept securely within the facility for one resident (Resident 1) when License Vocational Nurse (LVN 1) took Resident 1 ' s acetaminophen and hydrocodone (Norco—one of controlled medications that combine two types of medications together for pain control) from the medication cart without permission. This failure had resulted in diversion (medication illegally going to someone without a prescription) of controlled medication, which had the potential formisuse of drugs and stealing of Resident 1 ' s medication that could put Resident 1 at risk for inadequate relief of pain. Findings: During a review of Resident 1 Face Sheet (contain resident demographic), the Face Sheet indicated, Resident 1 was admitted on [DATE], with a diagnosis of unspecified focal traumatic brain injury (brain injury that is caused by an outside force). A review of Resident 1 ' s Orders,…

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 2 of 3 sampled residents (Resident 1 and Resident 2) Schedule II medication narcotic (medication which is controlled by law due to the potential for misuse/abuse), to be unlawfully diverted (medication illegally going to someone without a prescription) from the facility The facility failed to ensure strict controls for persons authorized to access controlled substances in preventing the diversion of medication, leading to potential misuse and theft of the medications for clinically compromised Residents (Residents 1 and 2) health and safety. Findings: During a review of Resident 1 ' s admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis to include Acute Respiratory Failure, (the inability of the respiratory system to meet the oxygenation, ventilation, or metabolic requirements of the patient) Anoxic Brain Damage ( caused by a complete lack of oxygen to the brain,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to request permission, to remove a Resident ' s beard from the Responsible Person (RP, ensures the residents wishes are carried out and enforced) for one of three residents (Resident 1). This failure resulted in the nursing staff not respecting Resident 1's right to have the RP exercise his wishes. Findings: During a review of Resident 1's clinical record, the face sheet (contains demographic and medical information), indicated Resident 1 was admitted on [DATE], with diagnoses which included: Alzheimer Disease (brain disorder that causes memory loss, thinking skills and changes in behavior). The face sheet indicated Resident 1 ' s wife is the responsible party. During a review of the clinical record for Resident 1, the Brief Interview for Mental Status dated December 19, 2023, indicated a total score of 00 indicating severe cognitive impairment. During a review of the clinical record for Resident 1, the Nurses admission Note, dated December 12, 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.

Based on interview and record review, the facility failed to ensure the Dietary Supervisor (DS - plans and supervises employees in the food and nutrition services at a health care facility) was qualified and hired full-time (working 35 or more hours a week). This failure had the potential to harm 80 residents by not monitoring or managing food services to promote, maintain or restore the residents' health. Findings: During an interview on December 4, 2023, at 10:21 AM, with the Kitchen Crew Lead (KCL), the KCL stated there was a Dietary Supervisor that was recently hired and he comes a few times a week. During an interview on December 5, 2023, at 9:55 AM, with the Registered Dietitian (RD), the RD stated the DS was currently enrolled in a certified dietary manager (CDM- nationally recognized certification indicating the individual is qualified to manage menus, food purchasing, food preparation, and apply nutrition principles) certification program and the regional dietitian was overseeing the facility kitchen. The RD further stated he did not oversee the sanitation practices or food…

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 food ingredients were stored to conserve nutritive value (vitamins and minerals in food), flavor, and appearance when bulk food (food items offered in large quantities) storage was not labeled with the name of the product and initial date of storage. These failures had the potential to harm 80 highly vulnerable residents by not providing food with the full nutritive value, or food palatability (taste and/or flavor of the food). Findings: During a concurrent observation and interview, on December 4, 2023, at 10:21 AM, with the Kitchen Crew Lead (KCL), in the kitchen, two plastic bulk food containers, one contained brown flour and the second contained white flour, were inspected. It was unlabeled and undated. The KCL stated the brown flour was wheat flour and the white flour was regular flour. The KCL stated the containers were expected to be labeled with the product name and date to prevent residents from receiving old foods. During a review of the facility's policy and procedure titled, Receiving 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 maintain professional standards for food service safety when: 1. There were crumbs and dust buildup on the right side of the staff refrigerator in the kitchen. 2. Food spill stains and crumbs were found in six of six food warming drawers. 3. There were trash, crumbs, and dirt buildup under the nourishment station (an area designed for storage for food and beverages) in the resident dining room area. 4. A total of four open rodent snap traps (a trap that snaps shut when the bait or trigger is disturbed) were found in the kitchen, under the metal racks for storing clean cooking supplies and nourishment station in the resident dining room area. These failures had the potential to attract pests and expose 80 highly susceptible residents who received food from the kitchen to foodborne illness (illness caused by ingestion of contaminated food or beverages) due to cross-contamination (the transfer of harmful substances or disease-causing microorganisms to food). Findings: 1. During a concurrent observation and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed follow their own policy and procedure, and the standards of care for medication administration and reporting to physician for one of three residents reviewed for omitted (absent) medications (Resident 438) when: 1. Resident 438 had an order to receive routine Albuterol (respiratory medication) for Chronic Obstructive Pulmonary Disorder (COPD - is a chronic inflammatory lung disease that causes obstructed airflow from the lungs). The Albuterol was ordered on October 26, 2023, at 11:52 AM and did not receive the medication until October 27, 2023, at 1:00 AM. Documentation indicated the licensed nurses and RTs did not notify the physician of the omitted medication. 2. Resident 438 had an order to receive routine Umeclidinium (respiratory medication) for COPD. Resident 438 did not receive the Umeclidinium from the time it was ordered on November 21, 2023, to the time it was discontinued on November 27, 2023. Documentation indicated the licensed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a comprehensive care plan was developed and implemented for one of three residents reviewed for rehabilitative and restorative care (Resident 6) when an individualized care plan for functional maintenance program was not initiated for Resident 6. This failure had the potential for inadequate treatment and management of the resident's medical conditions and had a potential to not meet the residents' personal goals, choices and preferences that could negatively impact Residents 6. Findings: During an observation on December 6, 2023, at 9:06 AM, in Resident 6's room, Resident 6 was lying on his back, with his head tilted to the right side. The head of the bed was slightly elevated. During a review of Resident 6's clinical record, the face sheet indicated Resident 6 was admitted to the facility on [DATE], with diagnosis of osteomyelitis (bone infection). A review of Resident 6's History and Physical, dated November 20, 2023, 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 observation, interview, and record review, the facility failed to ensure the care plan (a summary of a resident's health conditions, specific care needs, and current treatments) was revised for one of five residents reviewed for nutrition (Resident 32), when Resident 32's nutrition care plan was not revised or updated from June 15, 2023, to December 6, 2023, and visual function care plan was not revised or updated since March 23, 2023. Resident 32 went from 139.5 pounds in May 2023 to 129.4 pounds in December 2023. This failure had the potential to cause Resident 32 to continue to lose weight and negatively affect her nutrition status. Findings: During an observation on December 4, 2023, at 12:40 PM through 12:48 PM, Resident 32 was sitting upright in bed, eyes closed, and appeared to be sleeping with lunch in front of her. The bowl containing chili was full, 75% of Resident 32's corn bread remained on the plate, the milk container was full, salad was untouched, and 90% of the dessert remained. 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, interview, and record review, the facility failed to establish a safe resident smoking practice for one of two residents reviewed for accidents (Resident 439) when Resident 439's smoking assessment was not completed accurately. This failure had the potential for Resident 439's safety needs to be unmet, which could place him at risk for accidents and life-threatening injuries. Findings: A review of an undated facility document titled Current Smokers List, submitted by the facility on December 4, 2023, was conducted. It indicated Resident 439 was a current smoker. During an observation on December 6, 2023, at 1:00 PM, Resident 439 was sitting in his wheelchair by the designated smoking area. He was smoking cigarettes. There was no staff observed supervising him. During a review of Resident 439's clinical record, the face sheet (contains demographic information) indicated Resident 439 was admitted to the facility on [DATE], with diagnoses of high blood sugar and generalized weakness. 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 follow the facility's policy and procedure for enteral nutrition (a form of nutrition delivered to the digestive system in the form of a liquid usually through a feeding tube) for one of five residents reviewed for tube feeding (Resident 81), when Resident 81's enteral nutrition feeding container was not dated. This failure had the potential for the enteral nutrition container and tubing set to exceed the manufacturer's prescribed hang-time (amount of time a feeding is safe to use after opening), and for Resident 81 to not receive the prescribed amount of nutritional calories resulting in weight loss. Findings: During a review of Resident 81's clinical record, the face sheet indicated Resident 81 was admitted to the facility on [DATE] with diagnoses that included anoxic brain injury (caused by a complete lack of oxygen to the brain, which results in death of brain cells), cardiac arrest (the abrupt loss of heart function), hemorrhage into…

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 2. During a review of Resident 588's clinical record, the face sheet indicated Resident 588 was admitted to the facility on [DATE], with diagnosis of diabetes mellitus (long lasting health condition that affects how the body turns food into energy). During a review of Resident 588's POLST, dated on December 1, 2023, under Section D of Information and Signatures, it indicated the Advanced Directive information was not documented. The POLST items indicating if the Advance Directive was available or not, or if the education was provided with the patient and legal representative were left blank and incomplete. During a concurrent interview and record review, on December 5, 2023, at 2:30 PM, with Licensed Vocational Nurse (LVN) 1, LVN 1 reviewed Resident 588's POLST and stated it was not filled out completely. LVN 1 acknowledged that all parts of the form should be documented in its entirety. During a concurrent interview and record review, on December 7, 2023, at 3:55 PM, with Nurse Supervisor (RN) 1, RN 1 reviewed…

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

Based on observation, interview, and record review, the facility failed to ensure a safe, comfortable, homelike environment, when the facility's main dining room was not maintained at the appropriate temperature on August 24, 2023. This failure had the potential to affect the health and wellness of 74 residents residing in the facility. Findings: During a concurrent observation and interview, on August 24, 2023, at 11:50 AM, with Resident 1, in the Main Dining room, Resident 1 was covered on her shoulders with a blanket. Resident 1 stated It's too cold in here. I put work orders for this about a month ago, but nothing ever happened, it's been cold in here for a while. During a concurrent observation and interview, on August 24, 2023, at 11:50 AM, with Resident 2, in the Main Dining room, Resident 2 was covered on her shoulders with a blanket. Resident 2 stated the room was too cold. During a concurrent observation and interview, on August 24, 2023, at 11:50 AM, with Resident 3, in the Main Dining room, Resident 3 was covered on her shoulders with a blanket. Resident 3 stated 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, observation and record review, the facility failed to protect one of three sampled residents (Resident 1) from abuse. This failure has the potential to place Resident 1 health, safety, and well-being at risk and increasing chances of psychosocial harm. Findings: During resident 1 admission Record (general Demographics) the document indicated Resident 1 was admitted to the facility June 24, 1994, with a diagnosis of C1-C4 fx (is a bone fracture of the vertebra C1 to C4), Quadriplegia (is a symptom of paralysis that affects all a person's limbs and body from the neck down) During an interview on July 26, 2023, at 11:30 AM with resident 1, he stated he has had multiple problems with CNA 1 (Certified Nursing Assistant) since 2013. States he asked CNA 1 to turn him gently and she was rough with him, states he repeatedly asked her to stop being rough and finally he I had to yell at her and curse her out because she would not stop. I then asked her to please move my arm from underneath me and she did it roughly, that I finally had to yell at her to stop and I did curse…

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.