Imperial Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to conduct an interdisciplinary team (IDT) conference (a meeting to discuss the resident's plan of care, involving the IDT [physician, registered nurse, certified nursing assistant, dietary staff, the resident, and other pertinent staff]), and develop a care plan for one of two sampled residents (Resident 26) following a resident-to-resident altercation that occurred on 11/17/2024. These deficient practices had the potential for Resident 26 to be involved in another resident-to-resident altercation. Findings: During a review of Resident 26's admission Record, the admission Record indicated Resident 26 was originally admitted on [DATE] and readmitted on [DATE]. Resident 26's admitting diagnoses included dementia (a progressive state of decline in mental abilities), restlessness, agitation, Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), and a personal history of other mental and behavioral disorders. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two out of five sampled residents (Resident 11 and Resident 72) were provided with communication tools. This deficient practice placed Residents 11 and 72 at risk of not having their needs met and potentially negatively affecting their psychosocial needs. Findings: 1. During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 11's diagnoses included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 11 's History and Physical (H&P) dated 1/19/2025, the H&P indicated Resident 11 could make needs known but could not make medical decisions. During a review of Resident 11's Minimum Data Set ([MDS] a resident assessment tool), dated 3/21/2025,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents' (Resident 21) low air loss mattress ([LALM], a mattress designed to distribute body weight over a broad surface area to help prevent skin breakdown) was accurately set to Resident 21's weight. This deficient practice had the potential to result in the avoidable development of pressure ulcers ([PU], localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) and the complications associated with impaired skin integrity. Findings: During a review of Resident 21's admission Record (Face Sheet), the Face Sheet indicated Resident 21 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included metabolic encephalopathy (a change in how the brain works due to an underlying condition and could cause confusion and memory loss), cerebral infarction (a type of stroke that occurs when part of the brain does not get enough blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a hazard-free environment for two of 22 sampled residents (Resident 4 and Resident 87) by failing to ensure: 1. Staff responded timely to Resident 4's bed alarm. 2. Resident 4, who had a Wander Guard alarm (a security system designed to prevent residents from wandering outside of designated areas) did not exit the building unsupervised. 3. Resident 87 had a functioning bed alarm. These deficient practices placed Resident 4 and Resident 87 at risk for injuries related to unsafe wandering and/or falls. Findings: 1. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE] and was most recently readmitted on [DATE]. Resident 4's admitting diagnoses included dementia (a progressive state of decline in mental abilities), generalized muscle weakness, lack of coordination, and abnormalities of gait (walking pattern) and mobility. During a review of Resident 4's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the proper use of side rails (short rails on one or both sides of the bed that can be used to assist in bed mobility) for two of two sampled residents (Residents 10 and 68) by failing to: 1. Ensure Resident 10 had grab bars (short side rails used to assist in bed mobility), instead of half side rails (longer side rails attached to the side of the bed, covering about half the length of the bed), were installed onto the bed. This deficient practice had the potential to result in Resident 10 unable to optimally utilize the half side rails in turning and repositioning in bed. 2. Ensure Resident 68 had an order for grab bars. 3. Obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) from Responsible Party (RP) 1, for Resident 68's grab bars, immediately upon Resident 68's readmission to the facility. These deficient practices…

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 their medication error rate was less than five percent (%), when Licensed Vocational Nurse (LVN) 3 failed to administer two of five randomly selected residents' (Residents 28 and 66) medications in accordance with the physicians' orders. The outcome was two medication errors out of 30 opportunities for errors, which resulted in a Medication Administration Error Rate of 6.67%, based on the following: 1. LVN 3 did not administer Resident 28's metoprolol (medication to treat high blood pressure) with food. 2. LVN 3 did not administer Resident 66's aspirin (an antiplatelet medication used to prevent blood clots from forming) with food. This deficient practice had the potential to result in Residents 28 and 66 to experience stomach pain and discomfort. Findings: a. During a review of Resident 28's admission Record (Face Sheet), the Face Sheet indicated Resident 28 was initially admitted to the facility on [DATE] and readmitted on [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 one out of eight sampled residents (Resident 72) did not store medications at the bedside when: 1. Resident 72 had a medication bottle of Adderall (a stimulant that helps improve focus, attention, and impulse control in people with attention deficit hyperactivity disorder [ADHD, chronic condition including attention difficulty, hyperactivity, and impulsiveness]) at the bedside. 2. Resident 72 had a medication bottle of Atarax (medication for anxiety [a feeling of worriedness, dread, and uneasiness]) at the bedside. 3. Resident 72 had a medication bottle of Diovan (medication for high blood pressure [the force of blood pushing against the walls of the arteries is consistently too high]) at the bedside. These deficient practices placed Resident 72 at risk for potential medication error and potential adverse effects due to overdosing of medications. Findings: During a review of Resident 72's admission Record, the admission 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 observation, interview, and record review, the facility failed to prepare and serve food to meet individual needs for one out of eight sampled residents (Resident 19) by: 1. Not ensuring Resident 19 received a regular diet during mealtime. This deficient practice did not meet Residents 19's individual needs and placed resident 19 to feel unsatisfied with the meal. Findings: During a review of Resident 19's admission Record, the admission Record indicated Resident 19 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 19's diagnoses included hypertensive heart disease (caused by persistently high blood pressure, causes chest pain, shortness of breath, fatigue, swelling in the legs or ankles, and palpitations) and malignant neoplasm (abnormal growth of cells that can spread to other parts of the body and cause harm) of the colon (longest part of the large intestine). During a review of Resident 19's History and Physical (H&P) dated 4/25/2025, the H&P indicated Resident 19…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Arbitration Agreement (an agreement between the facility and the resident where they would resolve any disputes through a neutral person rather than going to court) was provided to and signed by an individual with decision making capacity for two of three sampled residents (Resident 104 and 105). This deficient practice resulted in Resident 104 and 105 being unaware that their right to resolve a dispute in court was waived after entering into the binding arbitration agreement. Findings: a. During a review of Resident 104's admission Record (Face Sheet), the Face Sheet indicated Resident 104 was admitted to the facility on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated…

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 place one of five sampled residents (Resident 253) on enhanced barrier precaution ([EBP], infection control intervention to reduce the transmission of multi-drug-resistant organisms [MDRO] from staff to patient). This deficient practice had the potential to result in staff members, who provided direct care to Resident 253, transmitting MDRO and other bacteria to Resident 253 and other residents. Findings: During a review of Resident 253's admission Record (Face Sheet), the Face Sheet indicated Resident 253 was admitted to the facility on [DATE] with diagnoses that included infection of right lower extremity amputation stump (residual limb leftover after the removal of the body part) and dehiscence of closure of surgical wound (a surgical incision that opens after it has been closed, usually due to a problem with healing). During a review of Resident 253's Minimum Data Set ([MDS], a resident assessment tool), dated 5/3/2025, the MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility staff failed to ensure safe smoking practices were maintained for one of 10 sampled residents (Resident 79). This deficient practice placed Resident 79 at risk for burn injuries and accidents related to unsupervised cigarette smoking, and placed all facility residents at risk due to the fire hazard associated with unsafe smoking practices. Findings: During a review of Resident 79's admission Record, the admission Record indicated Resident 79 was originally admitted on [DATE] and was most recently readmitted on [DATE]. Resident 79's admitting diagnoses included generalized muscle weakness, lack of coordination, epilepsy (a brain condition characterized by recurrent, unprovoked seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]), and tobacco use. During a review of Resident 79's Minimum Data Set (MDS, a resident assessment tool), dated 3/21/2025, the MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide services for and monitor a resident with a pacemaker (a device that delivers electrical impulses to control the rhythm of the heart) for one out of three sampled residents (Resident 1), by failing to: 1. Ensure Resident 1's pacemaker information (insertion date, paced rate, type of pacemaker, the name of the cardiologist, type of leads [an insulated wire that is connected to the pulse generator in the heart], manufacturer and model, and serial number) was obtained upon admission, as indicated in the facility's policy, Resident 1's pacemaker care plan, and physician orders. 2. Ensure effective and timely management of Resident 1's pacemaker and blood pressure medications were assessed and monitored when the facility could not obtain any information regarding Resident 1's assigned cardiologist and pacemaker details before and after Resident 1's two hospitalizations due to syncope (a brief loss of consciousness that occurs due to 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: 1. Ensure Certified Nursing Assistant (CNA) 1 did not sleep at the nurses' station, use a cellular device while working, and ensure call lights were answered promptly for two out of three sampled residents (Resident 2 and Resident 3). These failures had the potential to make the residents feel less dignified and uncared for. Findings: During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE], with a diagnosis of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), diabetes (a disorder characterized by difficulty in blood sugar control), and myasthenia gravis (a condition that causes weakness of the skeletal muscles). During a review of Resident 2 ' s Minimum Data Set ([MDS], a federally mandated resident assessment tool), dated 8/27/2024, the MDS indicated that Resident 2 ' s cognitive skills (mental action or process…

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. Notify both designated emergency contacts listed on a resident ' s admission Record for one out of three sampled residents (Resident 1) when Resident 1 suffered a fall, and was sent to the General Acute Gare Hospital (GACH). These findings resulted in Responsible Party (RP) 1 becoming upset that she was not notified and was unaware that her father fell, and was transported to the hospital. Findings: During an interview, 11/21/2024, at 10:52 a.m., RP 1 stated that she was informed that her father (Resident 1) had arrived back to the facility after being transported to the GACH. RP 1 stated that she was never informed that her father had fallen around 2:00 a.m. (on 11/21/2024) and was never informed that he was sent to the GACH. During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE], with a diagnosis of traumatic subarachnoid hemorrhage, fracture of orbital…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement effective infection prevention measures during a Coronavirus Disease outbreak ([COVID-19], an infectious disease that affects a person's organs and tissues that aid in breathing) in the facility. The facility failed to: 1. Minimize Resident 1's exposure to COVID-19. 2. Stock face shields in eight of eight isolation carts (storage unit for personal protective equipment [PPE, protective clothing or equipment designed to protect the wearer's body from infection, such as a gown, gloves, mask, and face shield]) designated for the COVID-19 positive and COVID-19 exposed rooms. 3. Ensure face shields were used by staff members prior to entering Residents 2 and 3 rooms, who were COVID-19 positive. 4. Ensure Activities Assistant (AA) 1 doffed (took off) and disposed of the used PPE, inside Resident 3's room, who was COVID-19 positive. These failures resulted in Resident 1 being unnecessarily exposed and eventually contracted COVID-19 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 a complete set of vital signs (a group of the four to six most crucial medical signs that indicate the status of the body's vital functions) were taken, documented, and monitored as ordered by the physician for one out of three sampled residents (Resident 1). This deficient practice had the potential to delay the care provided to Resident 1, who exhibited an acute episode of desaturation (respiratory distress) and tachycardia (fast heart rate). Resident 1 was sent to the general acute care hospital (GACH) on 5/20/2024, and diagnosed with acute renal failure (occurs when your kidneys suddenly become unable to filter waste products from your blood), hyperkalemia (elevated potassium [an electrolyte] in the blood) , and sepsis (an infection in the blood). Findings: A review of Resident 1's admission Record indicated Resident 1 was initially admitted to the facility on [DATE], and readmitted on [DATE]. Resident 1's diagnoses included acute…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and/or implement an individualized person-centered plan of care with measurable objectives, timeframe, and interventions to meet the residents' needs for two of eight sampled residents (Residents 74 and 78) by failing to: a. Ensure Resident 74 was consistently turned and repositioned (during the month of March [2024]) as indicated on a pressure ulcer ([PU]-injury to skin and underlying tissue resulting from prolonged pressure on the skin) care plan to prevent the development of an unstageable (full thickness tissue loss) pressure ulcer. b. Develop and implement a care plan for Resident 78's multiple and consecutive RNA refusals. These deficient practices led to the development of an unstageable pressure ulcer on Resident 74's right medial lower leg and had the potential to negatively affect the delivery of necessary care and services for Residents 74 and 78. Findings: a. A review of Resident 74's admission Record indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an Interdisciplinary Team Meeting (meeting with a group of healthcare professionals with various areas of expertise who work together towards the goals of the residents) records were completed, organized, and readily accessible for three of three sampled residents (Resident 64, 78, and 194). These deficient practices resulted in staff being unaware where Resident 64, 78, and 194's medical records were located and had the potential to delay and negatively affect the delivery of necessary care and services. Findings: a. A review of Resident 194's admission Record (Face Sheet), Resident 194 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included but not limited to, traumatic subarachnoid hemorrhage (bleeding in the space between brain and the surrounding membrane), end stage renal disease ([ESRD], a stage where the kidneys can no longer support the body's needs for waste removal and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement and maintain infection control procedures for one of six sampled residents (Resident 36) when the Restorative Nursing Aide 1 (RNA 1) did not clean and disinfect shared resident equipment, a front wheeled walker ([FWW] mobility device with two wheels in the front used for support when standing or walking), after resident use and before placing the FWW into the Utility Room with other clean equipment. This deficient practice had the potential to result in the spread of infection to facility staff, residents, and visitors. Findings: A review of Resident 36's admission Record indicated Resident 36 was admitted to the facility on [DATE] and re-admitted the resident on 12/10/2023 with diagnoses including muscle weakness, acquired absence of the left leg above the knee (amputation of the leg above the level of the knee), and ischemic heart disease (damage or disease in the heart's major blood vessels). During an observation 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.

Based on observation, interview, and record review, the facility failed to ensure the therapy mat (an adjustable padded surface used for therapy treatment) in the rehabilitation room was clear of miscellaneous items including a black bag, office supplies, a large black mat, a large therapy ball (large inflatable ball used for exercise), a graded rainbow arc (device used in therapy to assist with arm exercises), two bins containing multiple balls, a foam roller, a backpack, two large cardboard boxes, and four plastic bins containing various items to ensure adequate space was available for resident use during therapy treatments. This deficient practice had the potential to minimize equipment use and usable treatment space for residents during therapy. Findings: During an observation in the rehabilitation gym on 5/14/2024 at 12:49 p.m. during the recertification survey, a black bag, office supplies, a large black mat, a large therapy ball, a graded rainbow arc, two bins containing multiple balls, a foam roller, a backpack, two large cardboard boxes, and four plastic bins containing…

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 obtain informed consent prior to administration of psychotropics (medications that affect the mind, emotions, and behavior) for three out of five residents (Resident 3, 48, and 149) by failing to: 1. Ensure an informed consent was obtained and signed by the responsible party (RP) of Resident 3 who could not make medical decisions for treatment with psychotropics. 2. Ensure Resident 48's verification signature was included on the informed consent for treatment with psychotropics. 3. Ensure Resident 149 had an informed consent for treatment with psychotropics. These failures placed Residents 3, 48, and 149 at risk for avoidable harm from unwanted adverse effects (a harmful and undesired effect resulting from a medication or intervention) related to psychotropic medication use and removed the Residents' rights to make decisions about the care and treatments they received in the facility. Findings: 1. A review of Resident 3's admission 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 observation, interview, and record review, the facility failed to ensure dignity was maintained for one of three sampled residents (Resident 86) when the privacy curtain was left open while Resident 86 was left exposed (without any clothes on) in only their diaper. This failure had the potential to result in Resident 86 having a decreased feelings of self-worth and self-confidence and the potential for feelings of humiliation. Findings: A review of Resident 86's admission Record (Face Sheet), the admission Record indicated Resident 86 was admitted to the facility on [DATE] with diagnoses that include but not limited to anoxic (a total depletion in the level of oxygen) brain damage, major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and benign prostatic hyperplasia ([BPH] age-associated prostate gland enlargement that can cause urination difficulty). A review of Resident 86'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 prevent an avoidable pressure ulcer (localized skin and soft tissue injuries that form as a result of prolonged pressure and shear, usually exerted over bony prominences) for one out of three residents (Resident 30). This deficient practice resulted in Resident 3 having a stage II pressure ulcer (an open wound with partial thickness loss where the top layer of the skin has been damaged). A review of Resident 30's admission Record indicated the facility originally admitted Resident 30 on 3/12/2021 and readmitted on [DATE] with diagnoses of pneumonia (an infection of the lungs), type 2 diabetes mellitus (a metabolic disorder where the pancreas cannot produce enough insulin to digest sugars properly, causing high blood sugar that damages organs over time if not controlled), sepsis (infection of the blood) due to streptococcus pneumoniae (a bacteria often the cause of pneumonia), and asthma (a respiratory condition marked by spasms in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure fall measures were implemented to prevent the occurrence of further falls and injuries for two out of two sampled residents (Resident 64 and Resident 194) who sustained major injuries after a fall within the facility when the facility staff failed to: 1. Ensure bilateral fall mats were in place for Resident 64. 2. Ensure a falling star sticker was placed to the name plates of Resident 64 and Resident 194. These failures had the potential for Resident 64, who had fallen on 4/10/2024, sustained a broken left hip and underwent an open reduction internal fixation ([ORIF]- surgery to repair the hip) of the left hip (because of the fall), to endure another fall. These failures also had the potential for Resident 194, who sustained a traumatic subarachnoid hemorrhage (bleeding in the space between brain and the surrounding membrane) due to a fall within the facility, to sustain further bodily injury from another fall. Findings: a. 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 respiratory care services according to professional standards for Resident 30 by failing to: 1. Change Resident 30's oxygen tubing and humidifier (a device used to keep oxygen delivery moist to prevent irritation to the airway) within one (1) week according to facility policy and procedure. 2. Providing care/treatment/services to strengthen lungs due to history of recurring pneumonia (infection of the lungs). As a result of these deficient practices, Resident 30 had the potential to have a relapse in pneumonia. A review of Resident 30's admission Record, indicated the facility originally admitted Resident 30 on 3/12/2023 and readmitted on [DATE]. Resident 30's admitting diagnoses included but were not limited to: pneumonia (an infection of the lungs), type 2 diabetes mellitus (a metabolic disorder where the pancreas cannot produce enough insulin to digest sugars properly, causing high blood sugar that damages organs over time if…

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 doors remained closed to residents' rooms that tested positive for COVID-19 (highly contagious respiratory disease) for five of five sampled residents (Resident 6, Resident 7, Resident 8, Resident 9, and Resident 10). This deficient practice had the potential to expose all residents, staff, and visitors to COVID-19. Findings: a. During a review of Resident 6's admission Record, dated 4/2/2024, the admission record indicated Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses which included COVID-19, muscle weakness, acute kidney failure (the sudden and rapid loss of kidney's ability to filter waste and balance fluid in blood), type 2 diabetes mellitus ( when your sugar is too high in the blood), hypertension (high blood pressure), and epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures [a sudden, uncontrolled burst of electrical…

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 resident-centered care plan (document helps nurses and other team care members organize aspect of resident care) for three of 10 sampled residents (Resident 4, 5, and 7) by failing to: 1. Develop a care plan for Resident 4 who had a temperature of 100 degrees Fahrenheit (F, scale for measuring temperature, typical body temperature is between 97 degrees Fahrenheit to 99 degrees Fahrenheit), congestion (a buildup of mucus in the lungs and lower breathing tubes), body weakness, and was prescribed Levaquin (an antibiotic, which is a medication to treat bacterial infection) as treatment. 2. Develop a care plan for Resident 5 who had a temperature of 101.2 degrees F, a productive cough (a cough that produces mucus) and was prescribed Tamiflu (an antiviral, which is medication used to treat and prevent influenza [infection caused by a virus that affects the nose, throat, and lungs] and other viruses) as treatment. 3. Develop a care plan for Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement effective infection prevention measures for four of 10 sampled residents (Resident 6, 7, 9, and 10) when the facility failed to: 1. Drape the privacy curtain between Resident 6 and Resident 9, and drape the privacy curtain between Resident 7 and Resident 10, who were all on droplet precautions (used to prevent the spread of pathogens that are passed through respiratory secretions). 2. Ensure the Activities Assistant (AA) 1 performed hand hygiene (a way of cleaning one ' s hands that substantially reduces the potential germs on the hands) prior to entering and upon exiting a droplet precaution room. These failures had the potential to transmit infectious microorganisms and increase the risk of infection for the residents. Findings: 1a. During a review of Resident 6 ' s admission Record (Face Sheet), the admission Record indicated Resident 6 was initially admitted to the facility on [DATE] and readmitted to the facility on [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 interview and record review, the facility failed to ensure the Interdisciplinary Team (IDT, a group of healthcare professionals with various areas of expertise who work together towards the goals of the residents) met for an IDT meeting (meeting to coordinate care and document communication between all members of the team related to residents ' plan of care and treatment goal) after a physical altercation took place between two of 10 sampled residents (Resident 1 and 2). This failure had the potential to negatively affect the provision of care and services for Resident 1 and Resident 2. Findings: a. During a review of Resident 1 ' s admission Record (Face Sheet), the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses included but not limited to Parkinson ' s disease (progressive neurological disease characterized by a fixed inexpressive face, tremor at rest, slowing of voluntary movements), 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, interviews, and record review, the facility failed to develop a comprehensive person-centered plan of care for one of three sample residents (Resident 1) by failing to 1.Develop an Activity of Daily Living (ADL) care plan for Resident 1 with extensive assistance daily care. 2. Develop an intervention in a mobility care plan. This deficient practice had a potential to result in inconsistent implementation of the care plan that may lead to a delay in or lack of delivery of care and services. Findings: During a review of Resident 1's admission record, the admission record indicated Resident 1 was admitted on [DATE] with a diagnosis that included muscle weakness (full effort doesn't produce a normal muscle contraction or movement), difficult walking (problems with the joints, bones, circulation, or even pain can make it difficult to walk properly), Osteoporosis without current pathological fractures (a condition of reduced bone mass, with decreased cortical thickness and a decrease in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility's staff failed to adhere to resident's plan of care to notify the physician when the resident's abnormal heart rate and blood pressure for one of 24 sampled residents (Resident 23). Resident 23's heart rate and blood pressure were low with 66 episodes of low blood pressure (hypotension) and 26 episodes of low heart rate (bradycardia) for 60 days and there were no documented evidence the physician was notified of the resident's change of condition (COC). This deficient practice resulted in Resident 23 experiencing a COC and required the physician to be notified and medications reevaluated and had the potential for the resident to experience dizziness, weakness, tiredness, fainting and shortness of breath which could have rsulted in an emergency situation. Findings: During a review of Resident 23's admission Record (Face Sheet), the Face Sheet indicated Resident 23 was initially admitted to the facility on [DATE] and last readmitted on [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 failed to ensure the plan of care was implemented to ensure resident's needs could be met and the call light was accesible for one of 19 sampled residents (Resident 80). Resident 80's left arm was impaired, and the call light was observed dangling from the left side of the bed and was not accessible to her. This deficient practice create a safety concern and had the potential to result in a delay in care or inability for the resident to obtain the necessary care and services timely. Findings: During an observation on 3/14/2022, at 10:26 a.m., while in the resident's room, Resident 80 was observed on her back in bed with the head of bed elevated at 45 degrees. Resident 80 had an arm sling (a device to limit movement of the shoulder, arm, or elbow while it heals) to the left upper extremity. The call light was dangling off the bed out of reach of the resident. Resident 80 was unable to grab the call light due to left arm restrictions. 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 and implement a black box medication warning (strictest warning put in the labeling of prescription drugs or drug products by the Food and Drug Administration [FDA, a government agency responsible for protecting the public health]) when there is reasonable evidence of an association of a serious hazard with the drug) care plan for Resident 23 that met professional standards of care for one of 24 sampled residents (Resident 23). Residents 23 did not have a care plan for Amiodarone (medication used for irregular heart rhythms [antiarrhythmic]), a black box warning medication for over 180 days. This deficient practice had the potential for the staff to be unaware of Resident 23's side effects of Amiodarone, such as life-threatening arrhythmias (an irregular heartbeat), painful breathing, cough, dizziness, lightheadedness, fainting and or fever which could have required an emergency evaluation and treatments. Findings: During a review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility's staff failed to ensure a resident received the necessary care and services as per the care plan for one of 24 sampled residents (Resident 23). Resident 23's plan of care stipulated the resident's blood pressure and/or heart would be monitored and any abnormal results would be reported to the physician, but nurses failed to notify the physician for 60 days. This deficient practice resulted in Resident 23 experiencing 66 episodes of hypotension (low blood pressure) and 26 episodes of bradycardia (low heart rate) for 60 days, which had the potential for Resident 23 to experience dizziness, weakness, tiredness, fainting and shortness of breath. Findings: During a review of Resident 23's admission Record (Face Sheet), the Face Sheet indicated Resident 23 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 23's diagnoses included hypertensive heart disease (heart conditions caused by high blood pressure), cardiomyopathy (heart…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of 24 sampled residents (Resident 10) room was free from cluttered to prevent accidents. Resident 10, who uses devices for mobility, room was cluttered with many items which included personal items on the bed and surrounding space. This deficient practice had the potential to result in an accident with injuries that could negatively impact the resident's safety and wellbeing. Findings: During an initial tour of the facility on 3/14/2022 at 9:30 a.m., while in , Resident 10's room, the resident was seated in her wheelchair with a movable side table in front of her. The room was clutter with things such as a front wheel walker was behind her stacked with towels and gowns, a large pile of personal belongings were scattered on the resident's bed which included incontinence pads, electronic items, books/reading materials, large amount of clothing and cloth hangers, a large pink case, plastic bags of unidentified items and 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's staff failed to ensure residents with urinary catheters (a flexible tube used to drain urine from the bladder into a drainage bag) receive the necessary care and services for two of 11 residents (Residents 81 and 239). The staff failed to adhere to the resident's plan of care and facility's policy and procedure to prevent kinking and dislodgement (to remove or force out from a position or dwelling previously occupied) by not using catheter straps. This deficient practice had the potential to cause pain, urinary blockage, bleeding and impede progress of the residents wellness. Findings: a. During a concurrent observation and interview on 3/16/2022 at 8:30 a.m. with a registered nurse (RN 1) while in Resident 81's room, Resident 81 was sitting in a wheelchair wearing short pants and the urinary catheter strap was visible on the right thigh and the catheter tubing was free hanging on the left thigh. The urinary catheter tubing was not secured in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to observe infection control measures by failing to: 1. Ensure certified nurse assistant (CNA 3) performed hand hygiene before and after resident care for one of 19 sampled residents. 2. Ensure the housekeeping staff (HK 1) donned (put on) a gown while cleaning a contact precaution (measures that are intended to prevent transmission of infectious agent which are spread by direct or indirect contact with the resident or the resident's environment) isolation room for one of one sampled room. These deficient practices were a safety concern and had the potential to result in transmission of infectious microorganisms and increase the risk of exposure to infection for the residents and staff. Findings: a. During an observation on 3/14/2022, at 10:02 a.m., certified nurse assistant (CNA 3) assist Resident 78 by removing her pants. Resident 78 's roommate, Resident 65, was calling out for help. CNA 3 removed her gloves and donned (put on) new gloves, no hand hygiene…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of 24 sampled residents (Resident 10) room was free from cluttered and was a safe environment. Resident 10, who uses devices for mobility, room was cluttered with many items which included personal items on the bed and surrounding space (crossed reference to F689). This deficient practice resulted in Resident 10's room being an unsafe, uncomfortable and dysfunctional area and had the potential to result in an accident. Findings: During an initial tour of the facility on 3/14/2022 at 9:30 a.m., while in , Resident 10's room, the resident was seated in her wheelchair with a movable side table in front of her. The room was clutter with things such as a front wheel walker was behind her stacked with towels and gowns, a large pile of personal belongings were scattered on the resident's bed which included incontinence pads, electronic items, books/reading materials, large amount of clothing and cloth hangers, a large pink case,…

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.