Sunny Hills Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to revise the comprehensive fall prevention care plan following a resident's fourth fall for one out of six sampled residents (Resident 74).This deficient practice had the potential to result in additional falls and bodily injury for Resident 74.Findings:During a review of Resident 74's admission Record, the admission Record indicated Resident 74 was initially admitted to the facility on [DATE] and readmitted [DATE]. Resident 74's diagnoses included muscle weakness, diabetes (poor blood sugar control), hypertensive (high blood pressure) heart disease, and urinary tract infection (UTI- an infection in the bladder/urinary tract).During a review of Resident 74's Minimum Data Set ([MDS], a resident assessment tool), dated 12/19/2025, the MDS indicated Resident 74's cognitive skills (ability to think and reason) for daily decision making were severely impaired. The MDS indicated Resident 74 required maximal assistance (helper does more than half…

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 staff provided necessary assistance with activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) for one of eight sampled residents (Resident 22), who required assistance with transfers (help from one or more staff members to safely move a resident between two positions, such as from a bed to a chair, a chair to a wheelchair, or standing up) and dressing.This deficient practice had the potential to result in decline in mobility (ability to move freely), muscle weakness, development of pressure injuries (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence), and decreased psychosocial well-being from remaining in bed for prolonged periods. Findings:During a review of Resident 22's admission Record, the admission Record indicated Resident 22 was admitted to the facility on [DATE] and readmitted…

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 placement of bilateral (pertaining to both) floor mats and padded siderails for two of eight sampled residents (Residents 44 and 37), who were on fall and seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) precautions. These deficient practices had the potential to result in Resident 44 sustaining an injury from a fall, and Resident 37 sustaining an injury during seizure activity. Findings: a. During a review of Resident 44's admission Record, the admission Record indicated Resident 44 was admitted to the facility on [DATE] with diagnoses which included difficulty walking, dementia (a progressive state of decline in mental abilities), stable burst fracture of the first lumbar vertebra (a broken bone in the lower spine caused by compression or pressure), unspecified fracture of the T11-T12 vertebra (broken bones in the middle portion…

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 care and services related to urinary Foley catheter (a flexible tube inserted through the urethra [a hollow tube that lets urine leave the body] into the bladder to drain urine into a collection bag) management were provided for one of six sampled residents (Resident 39), who had sediment (matter that settles to the bottom of a liquid), cloudiness and blood in the urine.This deficient practice had the potential to result in urinary catheter obstruction, urinary tract infection (UTI- an infection in the bladder/urinary tract) and a decline in Resident 39's health status.During a review of Resident 39's admission Record, the admission Record indicated Resident 39 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 39's diagnoses included dysphagia (difficulty swallowing), bradycardia (low heart rate), and hepatic encephalopathy (a serious brain dysfunction caused by liver failure) and quadriplegia (paralysis from…

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 change one of one sampled resident's (Resident 138) peripherally inserted central catheter (PICC, a thin, flexible tube inserted into the vein in the upper arm and guided into a large vein near the heart) line dressing and securement device (a sterile tool to hold the PICC in place on the skin) in accordance with the physician's orders.These deficient practices resulted in Resident 138's PICC line dressing and securement device remaining unchanged for 11 days which had the potential to result in avoidable bloodstream infection.Findings:During a review of Resident 138's admission Record, the admission Record indicated Resident 138 was admitted to the facility on [DATE] with diagnoses that included osteomyelitis of the vertebra in the lumbar region (infection in the spinal bones of the lower back), discitis in the lumbar region (infection of the disc space between the spinal bones), and spondylosis (age-related wear and tear of 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 provide oxygen (a medical gas used to help with breathing) therapy in accordance with the facility policy and physician orders for one of three sampled residents (Resident 137). This deficient practice had the potential to result in hyperoxygenation (too much oxygen) which could result in respiratory failure (sudden onset condition where the lungs cannot bring enough oxygen into the blood). Findings:During a review of Resident 137's admission Record, the admission Record indicated Resident 137 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 137's diagnoses included acute respiratory failure with hypoxia (sudden onset condition where the lungs cannot bring enough oxygen into the blood), pneumonia (an infection/inflammation in the lungs), and chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing).During a review of Resident 137's Minimum Data Set (MDS- a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to effectively manage one of two sampled residents' (Resident 30) pain, after Resident 30 complained of severe pain (pain rated seven to ten on a 10-point scale). Resident 30 was administered Norco (an opioid medication used to treat pain), which was ordered for moderate pain (pain rated four to six on a 10-point scale).This deficient practice resulted in Resident 30's pain being mismanaged which left Resident 30 feeling frustrated with his pain management regimen.Findings:During a review of Resident 30's admission Record, the admission Record indicated Resident 30 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke - caused by a blocked blood vessel in the brain) affecting the right side and osteoarthritis (a progressive disorder of the joints, caused by a gradual…

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 hemodialysis (treatment to cleanse the blood of waste and extra fluid artificially through a machine when the kidney(s) have failed) emergency kit ([E-kit]- a readily set of supplies for immediate use in the event of dialysis-related complications) was at the bedside for one of two sampled residents (Resident 45), who was receiving hemodialysis treatment. This deficient practice had the potential to result in lack of necessary treatment and services in the event of an emergency, such as bleeding for Resident 45. Findings: During a review of Resident 45's admission Record, the admission Record indicated Resident 45 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease (irreversible kidney failure) dependent on renal dialysis (a medical treatment that replaces some of the functions of the kidneys).During a review of Resident 45's Minimum Data Set (MDS - a resident assessment tool), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Registered Nurse (RN) 2 was competent regarding peripherally inserted central catheter (PICC, a thin, flexible tube inserted into the vein in the upper arm and guided into a large vein near the heart) line dressing changes for one of one sampled resident (Resident 138).This deficient practice resulted in Resident 138's PICC line dressing not being changed upon admission and placed Resident 138 at risk for avoidable bloodstream infection.Cross Reference F694 and F842Findings:During a review of Resident 138's admission Record, the admission Record indicated Resident 138 was admitted to the facility on [DATE] with diagnoses that included osteomyelitis of the vertebra in the lumbar region (infection in the spinal bones of the lower back), discitis in the lumbar region (infection of the disc space between the spinal bones), and spondylosis (age-related wear and tear of the spine).During a review of Resident 138's History and Physical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to monitor signs and symptoms of bleeding for one of five sampled residents (Resident 138), who was receiving heparin (anticoagulant medication used to treat blood clots from forming in the blood vessels and the heart).This deficient practice had the potential to result in undetected bleeding and had the potential to result in delay in care.Findings:During a review of Resident 138's admission Record, the admission Record indicated Resident 138 was admitted to the facility on [DATE] with diagnoses that included osteomyelitis of the vertebra in the lumbar region (infection in the spinal bones of the lower back), discitis in the lumbar region (infection of the disc space between the spinal bones), and spondylosis (age-related wear and tear of the spine).During a review of Resident 138's History and Physical (H&P), dated 2/20/2026, the H&P indicated Resident 138 had the capacity to understand and make decisions.During a review of Resident 138's Order Summary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of six sampled residents (Residents 3 and 4) were free from significant medication error (one which caused the resident discomfort or jeopardizes his or her health and safety) when:1. Resident 4 was administered midodrine (medication used to treat low blood pressure) outside of the ordered parameter (specific instructions that dictate whether the medication is safe to administer) 17 times in January 2026 and 19 times in February 2026.2. Resident 3 was administered metoprolol (medication used to treat high blood pressure) outside of the ordered parameters on 1/10/2026, 2/16/2026, 2/19/2026, and 2/21/2026.This deficient practice increased Resident 4's risk of headache, chest pain, and stroke (loss of blood flow to the brain), and increased Resident 3's risk of hypotension (low blood pressure) and bradycardia (slowed heart rate) that could cause dizziness, fainting, weakness, or sudden cardiac arrest.Findings:a. 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 licensed nurses accurately and completely documented the administration of intravenous (IV) antibiotics (medications administered directly into the blood stream to treat an infection), and the peripherally inserted central catheter (PICC- a thin, flexible tube that delivers medications through a vein) line dressing change for two out of three sampled residents (Resident 78 and Resident 138).These deficient practices had the potential to place Resident 78 at risk for altered peak and trough levels (blood tests used in therapeutic drug monitoring to ensure medication effectiveness and safety), which had the potential to result in subtherapeutic dosing leading to ineffective treatment of Resident 78's infection, or elevated levels that could lead to toxicity, and placed Resident 138 at an increased risk for catheter-related blood stream infection and systemic complications.Cross Reference F694 and F726. Findings: a. During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement infection (the invasion and multiplication of microorganisms[like bacteria, viruses] in body tissues, potentially causing illness or harm) control practices for one of six residents (Resident 7), when Resident 7's indwelling catheter (a flexible tube inserted into the bladder to drain urine into a bag) drainage bag was observed touching the floor.This deficient practice placed Resident 7 at risk for infection and had the potential to spread bacteria through cross contamination (the transfer of bacteria, viruses, microorganisms, or other harmful substances from one surface to another through improper or unsanitary equipment).Findings:During a review of Resident 7's admission Record, the admission Record indicated Resident 7 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 7's diagnoses included benign prostatic hyperplasia (BPH- enlargement of the prostate), dementia (a progressive state 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 notify the physician and Responsible Party (RP) of a change of condition (COC) for one of five sampled residents (Resident 1), who had a [NAME] Blood Cell ([WBC]-part of the body's immune system that protects the body from infection) count of 15,200 (normal reference range 4,000-10,000 cells per microliter [cells/ L]).This deficient practice had the potential to result in Resident 1 not receiving necessary medical care and placed the resident at risk of sepsis (a life threatening blood infection). Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and re admitted on [DATE]. The admission Record indicated Resident 1's diagnoses included mild protein -calorie malnutrition (the body receives insufficient protein and calories, leading to subtle loss of muscle and fat) and urinary tract infection (UTI- an infection in the bladder/urinary tract). During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure proper infection control practices were followed during wound care for one of five sampled residents (Resident 2), who was admitted to the facility with a stage 4 pressure injury (full-thickness loss of skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) on the sacrococcygeal region (consists of the sacrum and coccyx [tailbone]). This deficient practice placed Resident 2 at risk for poor wound healing, infection, and deterioration of the resident's existing pressure injury. Findings: During a concurrent wound care observation and interview on 2/13/2026 at 9:10 a.m., in Resident 2's room with LVN 1, Resident 2 was observed turned to side and had a soiled brief, containing a small amount of brown feces. LVN 1 was observed removing Resident 2's old wound dressing and cleansed the wound with wet gauze soaked in normal saline (NS- a saltwater solution). LVN 1 completed Resident 2's wound care, then proceeded…

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 proper nutritional assistance for one of five sampled residents (Resident 5), who is at risk for malnutrition (which occurs when a person receives too few nutrients, resulting in health problems). The facility failed to:Assist Resident 5 with eating as indicated in the resident's nutritional problem/potential nutritional problem care plan.Ensure timely meal support, as Resident 5's food tray was left open in front of the resident for 20 minutes before the resident assisted eating.These deficient practices placed Resident 5 at risk for weight loss and potential hospitalization related to malnutrition.Findings:During a concurrent observation and interview on 2/13/2026 at 12:29 p.m., in Resident 5's room, Resident 5 was observed in a high Fowler's position (head of the bed elevated between 60 and 90 degrees) with a white towel around his chest area and an open meal tray was on the bedside table in front of the Resident. Resident 5…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide a clean, comfortable and home-like environment two of six sampled residents (Resident 3 and Resident 4) by failing to ensure there were enough linen, incontinent pads (used to absorb leakage, reduce odors and control bacteria,) towels and blankets available to change for the residents.This failure had the potential to result in skin breakdown and negatively affect the psychosocial well-being of Residents 3 and 4.Findings:During an observation on 10/21/2025 at 11:45 a.m., the linen storage station 1 had no blankets and no incontinent pads. The linen cart station 1 had no blankets, no incontinent pads, no gowns, and no towels. The linen storage station 2 was observed with no blankets, no incontinent pads and no towels.During an observation on 10/21/2025 at 3:10 p.m., the linen storage station 2 was observed to have no blankets, no incontinent pads, no towels. The linen cart station 1 had no blankets, no incontinent pads, no towels.…

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 assess and treat one of two sampled residents (Resident 1) after being exposed to scabies (a highly contagious skin infection caused by the microscopic mite), by failing to ensure staff: 1. Performed a skin assessment and tested Resident 1 for scabies after Resident 1's roommate tested positive for scabies. 2. Treated Resident 1 for scabies. These deficient practices resulted in Resident 1 expressing feelings of discomfort from constant itchiness and scratching and had the increased risk of scabies transmission to residents and staff. Findings:1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) and anxiety disorder (intense, excessive and persistent worry and fear about everyday situations). 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 failed to ensure the nutritional supplement ordered by the physician for one of three sampled residents' (Resident 1), were monitored and documented.This failure had the potential to result in delayed identification of low or poor intake and interventions, causing further weight loss.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted on [DATE]. The admission Record indicated Resident 1 had a history of malignant neoplasm (cancer) of the lung, dementia (a progressive state of decline in mental abilities), stage 4 pressure ulcer (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) of the sacral region (lower back), and unstageable pressure ulcers (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence that cannot be fully evaluated due to layers of dead tissue) of the left buttock, right heel, and left heel. 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 one of three sampled residents (Resident 1) did not receive medication that is greater than the recommended dose by the manufacturer's label, and accepted standards of practice for a resident ' s condition. This deficient practice had potential to cause adverse reactions and medical complications for Resident 1. Findings During a review of Resident 1 ' s admission Record dated 5/20/2025, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 1 ' s diagnoses included diabetes mellitus (DM- a condition characterized by difficulty in blood sugar control and poor wound healing), other specified disorders of bone density and structure (a variety of conditions that affect bone strength), and muscle weakness (when muscles are not as strong as they should be). During a review of Resident 1 ' s History and Physical (H&P) dated 1/9/2025,…

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 and interview, the facility failed to provide a safe, clean, and home like environment to the 8 of 9 residents living in the affected rooms. These failures had the potential to result in unsanitary living conditions and accidental falls and injuries. Findings: a). During an observation on 1/22/2025 at 10:00 a.m., in activity room, where (unidentified) residents were observed watching televisionand drinking coffee, two ceiling vents (grilles) by the entrance of the activity room were observed full of dusts, with strands of dust hanging over the vents. The back and right-side walls were also observed with dried food spots. b). During an observation on 1/22/2025 at 10:15 a.m. in residents ' rooms 12A, 18A, 21A, 22B, 36B, 44A, 49C, the walls behind the residents ' headboard had white paints falling off from the wall. c). During an observation on 1/22/2025 at 10:35 a.m. in resident ' s room [ROOM NUMBER]C. The side wall was observed with black and white dried food spots. The ceiling vent was…

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 3), swallowed scheduled stool softener medications during medication administration. This failure resulted in Resident 3 missing a dose and placed the resident at risk for constipation. Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including primary generalized osteoarthritis (a type of joint disease that causes breakdown of cartilage, the protective tissue that cushions the ends of bones in joints that affects multiple joints, including the hands, knees, hips, and spine) and chronic obstructive pulmonary disease ([COPD], a common lung disease causing restricted airflow and breathing problems). During a review of Resident 3's Minimum Data Set (Minimum Data Set [MDS] a standardized assessment and care screening tool), dated 12/12/2024, the MDS indicated Resident 3 had moderate…

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 baseline care plan was initiated for one of three sampled residents (Resident 2) who had a history of falls. This failure had the potential for unidentified nursing interventions (actions), repeated falls and injuries for Resident 2. Findings: During a review of Resident 2's admission Record, the admission Record indicated, Resident 2 was initially admitted to the facility on [DATE] with diagnoses including contusion (medical term for bruise [an injury to the body's soft tissue caused by direct blow or impact]), laceration (a tear or opening in the skin that's caused by an injury), and hemorrhage (excessive bleeding) of brainstem with loss of consciousness of unspecified duration and repeated falls. During a review of Resident 2' History and Physical (H&P), the H&P indicated that Resident 2 had mild dementia (a group of brain disorders that cause a gradual decline in skills such as memory, thinking, reasoning and judgement). During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement gastrostomy tube (GT, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) orders, in accordance with facility policy, for four (4) of 4 sampled residents (Resident 56, Resident 41, Resident 35, and Resident 81) when: A. Resident 56 received GT feeding Glucerna (a nutrition supplement designed for people with Diabetes Mellitus [DM-a disorder characterized by difficulty in blood sugar control and poor wound healing] or abnormal sugar) 1.2 instead of Glucerna 1.5 as ordered. B. Residents 81, 41 and 35 were administered medications via GT without flushing the GT line with prescribed amount of water before and after medication administration for Resident 41; not flushing GT before and after each medication administration for Resident 81; and for Residents 81, 41, and 35, GT flushing were not performed in accordance with the physician'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 observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent (%). Eight medication errors out of 31 total opportunities contributed to an overall medication error rate of 25.81% for two of six residents (Resident 81 and Resident 41) observed during medication administration (MedPass). The facility failed to ensure: (Cross Reference F693) A. Resident 81's gastrostomy tube (GT, a tube inserted through the abdomen that delivers nutrition and/or medication directly to the stomach) was flushed after each medication administration and the resident was administered the full dosages of each medication as ordered on 10/29/2024 for the scheduled 9 AM administration. B. Resident 41's GT was flushed before administering medication and again upon completion of medication administration as ordered. The deficient practice of failing to administer medications in accordance with the physician orders increased the risk that Resident 81 and Resident 41 may…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of six sampled residents' medication regimen was free from significant medication errors (Resident 36 and Resident 55). This deficient practice jeopardized Resident 36 and Resident 55's health and safety by failing to administer necessary medications in accordance with the physician order, manufacturer's specification, and notifying physician when medication was not administered as prescribed to meet the needs of the residents. Findings: 1. During a review of Resident 36's admission Record (a document containing diagnostic and demographic information), the admission record indicated Resident 36 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 36's diagnoses included Type II diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar [BS] control) and hypertension (high blood pressure). During a review of Resident 36's Minimum Data Set (MDS), a federally mandated assessment tool, dated…

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

Based on observation, interview, and record review, the facility failed to ensure medications and biologicals were properly stored and labeled for five of five residents (Resident 15, Resident 42, Resident 2, Resident 17, and Resident 92). The facility failed to: A. Ensure one unopened, unused vial of Insulin Lispro was refrigerated until opened or labeled with the date first stored at room temperature inside of Medication Cart (MedCart) 2 labeled for Resident 2 B. Ensure one vial of expired Humulin R was removed and discarded and not stored available for use in MedCart 2 labeled for Resident 17 C. Ensure controlled [high abuse potential] medications, Lorazepam Oral Solution (a psychotropic medication which act on the brain and nerves to produce a calming effect) requiring refrigeration were stored according to the manufacturer's requirements affecting Resident 15 and Resident 42. D. Ensure one oral inhaler, TRELEGY ELLIPTA (is indicated for the maintenance treatment of patients with chronic obstructive pulmonary disease [COPD]) was dated with an open date and was labeled for…

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

Based on observation, interview, and record review, the facility failed to ensure a safe and sanitary food storage practice was upheld in the kitchen when: 1. The temperature for Refrigerator 1 was not logged for two days. 2. A container of grated cheese was not labeled with the item name, open date, and the use by date. 3. An open bag of tortillas was ripped and was not placed in a tight-lidded container after opening. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (unintentional transfer of harmful bacteria) that could lead to foodborne illness in residents that received food from the kitchen. Findings: a. During a concurrent interview and record review during the initial kitchen tour on 10/28/2024 at 8:43 a.m., with the Dietary Supervisor (DS), the Record of Refrigeration Temperature for Refrigerator 1, for October 2024 was reviewed. The Record of Refrigeration Temperature did not have a temperature and staff initials indicated for 10/26/2024 and 10/27/2024. The DS stated the refrigerator temperatures were to be checked…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement infection control practices for six of six residents (Resident 5, 54, 76, 281, 8, and 92) when the following occurred: 1. Licensed nurses did not wear appropriate personal protective equipment (PPE, equipment worn for protection against infectious materials, e.g. gown and gloves) during the handling of a gastrostomy tube (G-tube, tube inserted through the abdomen that delivers nutrition, hydration, and/or medication directly to the stomach) and during direct resident contact during medication administration to Resident 81. 2. Resident 54's nasal cannula tubing (a plastic medical device to provide supplemental oxygen therapy to people who had lower oxygen levels, device goes directly into the nostrils) was touching the floor. 3. Resident 76's indwelling urinary catheter (a thin, hollow tube that's inserted into the bladder to drain urine) tubing was touching the floor. 4. Resident 281's indwelling urinary catheter tubing was…

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 resident's responsible party (RP) was informed in advance, of the risks and benefits of the use of bedrails (adjustable metal or rigid plastic bars that attach to the bed) for one of eight sampled residents (Resident 331). This deficient practice resulted in the violation of Resident 331's RP's right to make an informed decision regarding the use of bedrails. Findings: During a review of Resident 331's admission Record (Face Sheet), the admission record indicated Resident 331 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 131's diagnoses included sepsis (a life-threatening blood infection), dementia (a progressive state of decline in mental abilities), and chronic obstructive pulmonary disease ([COPD], a chronic lung disease causing difficulty in breathing). During a review of Resident 331's Minimum Data Set ([MDS], a federally mandated resident assessment tool), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of eight sampled resident's (Resident 5) call light was within reach. This deficient practice prevented Resident 5 from communicating with staff and had the potential to delay appropriate care, treatment, and services. Findings: During a review of Resident 5's admission Record, dated 10/31/2024, the admission record indicated Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 5's diagnoses included muscle weakness, anxiety disorder (a mental health disorder that produces fear, worry, and a constant feeling of being overwhelmed), dementia (a progressive state of decline in mental abilities), functional quadriplegia (paralysis from the neck down, including legs, and arms without injury to the brain or spinal cord), contracture of right hand (a stiffening/shortening at any joint, that reduces the joint's range of motion), lack of coordination, and anemia (a condition where the body does…

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 remove the identifiable health information (any information that could be used to identify the individual, such as the full name, date of birth , etc.) on the intravenous (IV, within the vein) medication bag prior to disposition in the trash can for one of nine sampled residents (Resident 30). This deficient practice had the potential to result in unauthorized disclosure of Resident 30's personal information to unauthorized users. Findings: During an observation on 10/28/2024 at 9:33 a.m., in Resident 30's room, Resident 30's empty IV medication bag with identifiable health information was found in the trash can with no lid. During a review of Resident 30's admission Record, the admission record indicated Resident 30 was admitted to the facility on [DATE]. Resident 30's diagnoses included diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), dysphagia (difficulty swallowing), sepsis…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a homelike environment for three of eight sampled residents (Residents 46, 94, and 100) who shared a room and had old, yellow stains on the celling and an unfinished painted wall of their room. This deficient practice resulted in Residents 46, 94, and 100 being unhappy with the quality of their living space. Findings: During an observation on 10/28/2024 at 1:30 p.m., inside Residents 46, 94, and 100's room, a yellow stain was observed sprawled along the ceiling near the door. The wall near the door was observed with an uneven surface and an uneven pain color. a. During a review of Resident 46's admission Record (Face Sheet), indicated Resident 46 was admitted to the facility on [DATE]. Resident 46's diagnoses included chronic kidney disease (a long-term condition where the kidneys are damaged and can't filter blood properly), depression (mood disorder that causes a persistent feeling of sadness and loss of interest in life), 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 interview and record review, the facility failed to conduct background criminal checks for four of four randomly selected employees prior to hire and upon completion of orientation (a process that introduced new hires to their job, company, and coworkers) in accordance with the facility's policy. This deficient practice had the potential to place residents at risk for abuse which could lead to serious harm and/or injuries. Findings: During a concurrent interview and record review on 10/31/2024 at 3:46 p.m. with the Director of Staff Development (DSD), Registered Nurse (RN) 1's employee file was reviewed. The DSD stated RN 1 was hired on 9/9/2003 and there was no background criminal check upon hire. The DSD stated the earliest background criminal check on file for RN 1 was done in 6/2007. During a concurrent interview and record review on 10/31/2024 at 3:50 p.m. with the DSD, Licensed Vocational Nurse (LVN) 4's employee file was reviewed. The DSD stated LVN 4 was hired on 10/25/2023 and the background criminal check was done on 11/3/2023. The DSD stated LVN 4's orientation…

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 a person-centered care plan (document that helps nurses and other team care members organize aspects of resident care) with interventions (actions a nurse takes to implement a care plan, intend to improve the resident's comfort and health) for two of 16 sampled residents' (Residents 66 and 331) by failing to: 1. Develop a care plan for Resident 331's use of bedrails. 2. Develop a care plan for Resident 66 whose predominant language was Korean. These failures had the potential to negatively affect Residents 331 and 66's physical and mental, and psychosocial and potentially delay delivery of necessary care and services. Findings: a. During a review of Resident 331's admission Record (Face Sheet), indicated Resident 331 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that include but not limited to sepsis (a life-threatening blood infection), dementia (a progressive state 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 meet professional standards of quality of care for three out of 16 sampled residents (Resident 14, 30, and 49) when the following occurred: 1. Licensed nurses failed to follow the physician's order for bilevel positive airway pressure ([BIPAP], noninvasive ventilation mask that helps a person breathe, a treatment to provide oxygen and get rid of carbon dioxide) therapy for Resident 14. 2. Licensed nurses falsified on the Medication Administration Record (MAR) that BIPAP application was carried out as ordered for Resident 14. 3. Licensed nurses failed to provide medications, treatments, and monitoring as ordered on multiple shifts for Residents 30 and 49. These deficient practices could have potentially led to a negative respiratory outcome and oxygen deprivation for Resident 14 during her sleep and delayed necessary care and treatment for Residents 30 and 49. Findings: 1. During a review of Resident 14's admission Record, the 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 observation, interview, and record review, the facility failed to ensure nursing staff used a communication board, device, and/or interpreter services for two of 16 sampled residents (Resident 66 and 92) who did not speak the dominant language of the facility (English). This deficient practice had the potential to negatively affect Resident 66 and 92's physical, mental, and psychosocial needs by preventing the residents from communicating with staff and potentially causing missed or delayed care and/or treatments. Findings: a. During a review of Resident 66's admission Record, dated 10/31/2024, the admission record indicated Resident 66 was admitted to the facility on [DATE]. Resident 66's diagnoses included fracture of the right femur (a break of the thigh bone), dysphagia (difficulty swallowing), difficulty walking, hypertension (HTN - high blood pressure), end stage renal disease (ESRD - irreversible kidney failure), sepsis (a life-threatening blood infection), dependence on renal dialysis (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 up on a mammogram (imaging of the breast that is used to detect and diagnose breast disease in women) appointment for one of eight sampled residents (Resident 32). This deficient practice resulted in Resident 32 feeling frustrated with her healthcare team and this failure had the potential to result in a delay in treatment based on the result from Resident 32's mammogram results. Findings: During a review of Resident 32's admission Record (Face Sheet), indicated Resident 32 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 32's diagnoses included chronic kidney disease stage four (4) (a long-term condition where the kidneys are damaged and can't filter blood properly), type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss 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 2. During a review of Resident 331's admission Record (Face Sheet), the admission record indicated Resident 331 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 331's diagnoses included sepsis (a life-threatening blood infection), dementia (a progressive state of decline in mental abilities), and chronic obstructive pulmonary disease ([COPD], a chronic lung disease causing difficulty in breathing). During a review of Resident 331's MDS, dated [DATE], the MDS indicated Resident 331's cognition was severely impaired. The MDS indicated Resident 331 was dependent on staff for assistance with oral hygiene, toileting, bathing, dressing, and personal hygiene. The MDS indicated Resident 331 utilized a pressure reducing device for a bed. During a review of Resident 331's H&P, dated 10/26/2024, the H&P indicated Resident 331 did not have the capacity to understand and make decisions. During a review of Resident 331's Braden Scale Assessment, dated 10/24/2024, the Braden…

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 safe oxygen administration practices, for three of 16 sampled residents (Residents 14, 54, and 99), by failing to ensure: 1. Resident 14's nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) was dated with an open date. 2. Precautionary (warning) sign was posted outside of Resident 14, Resident 54, and Resident 99's room, who were using oxygen. 3. Resident 14 and Resident 54's nasal cannula was not touching the floor. These deficient practices had the potential to Residents 14 and 54 to acquire respiratory infection and placed Residents 14, 54 and 99, at risk for injuries due to fire hazard. Findings: 1. During an observation on 10/28/2024 at 11:28 a.m. in Resident 54's room, Resident 54's nasal cannula was touching the floor. Outside of Resident 54's room had no sign indicating oxygen was in use. During an observation on 10/29/2024 at 12:58 p.m. in Resident 54's room,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure proper use of bedrails (adjustable metal or rigid plastic bars that attach to the bed) for one of eight sampled residents (Resident 331) as indicated in the facility's policy and procedure (P&P) by failing to: 1. Assess Resident 331's risk for entrapment (the state of being caught in or as in a trap). 2. Assess Resident 331's need for bedrails. 3. Conduct monitoring specific to Resident 331's use of bedrails. These deficient practices had the potential to result in an accident such as a body part being caught between the bedrails, entrapment, and/or a fall if Resident 331 were to attempt to climb over, around, between, or through the bedrails. Findings: During a review of Resident 331's admission Record (Face Sheet), indicated Resident 331 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 331's diagnoses included sepsis (a life-threatening blood infection), dementia (a progressive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure licensed nurses were trained on the use of a bilevel positive airway pressure ([BIPAP], noninvasive ventilation mask that helps a person breathe, a treatment to provide oxygen and get rid of carbon dioxide) machine for one out of eight sampled residents (Resident 14). This deficient practice prevented Resident 14 from receiving the benefits of BIPAP therapy and placed Resident 14 at risk for respiratory complications during her sleep. Findings: During a review of Resident 14's admission Record, the admission record indicated Resident 14 was admitted to the facility on [DATE]. Resident 14's diagnoses included obstructive sleep apnea (Intermittent airflow blockage during sleep) and chronic obstructive pulmonary disease ([COPD] group of chronic lung diseases that block airflow and make it harder to breathe air out of the lungs). During a review of Resident 14's History and Physical (H&P) dated 9/15/2024, the H&P indicated Resident 14…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) prior to administering Seroquel (a medication used to treat several kinds of mental health conditions) to Resident 118 at bedtime on 10/29/2024. This deficient practice had the potential to result in Resident 118 and his responsible party's (RP) unawareness of adverse effects (unwanted, uncomfortable, or dangerous effects that a drug might have) related to the medication therapy and may cause impairment or decline in mental, physical condition, functional, and/or psychosocial status of the resident. Findings: During a review of Resident 118's admission Record, the admission record indicated Resident 118 was admitted to the facility on [DATE]. Resident 118's diagnoses included sepsis (a life-threatening blood infection), dysphagia (difficulty swallowing), depression (a constant feeling 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 observation, interview, and record review, the facility failed to offer alternative food choices and provide an alternative menu for two of eight sampled residents (Residents 24 and 77). This deficient practice had the potential to impact Resident's 24 and 77 nutritional status, quality of life and result in food dissatisfaction leading to insufficient food intake. Findings: a. During a review of Resident 77's admission Record, dated 10/31/2024, the admission record indicated Resident 77 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 77's diagnoses included diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), dysphagia (difficulty swallowing), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) and hyperlipidemia (an abnormally high amount of fat in the blood). During a review of Resident 77's Minimum Data Set (MDS - a federally…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure Nursing staff completed the following for one of six sampled resident's (Resident 1): 1 Reconciled (process of reviewing resident medications to identify the most accurate list of all medications and resolve any discrepancies) the medication list correctly upon admission to the facility. 2. Administered Sucralfate (a drug used to decrease bleeding associated with radiation-induced proctitis) twice a day as ordered by the physician. 3. Accurately documented the administration of Sucralfate in the medical record. These deficient practices had the potential to result in medication errors, worsening of symptoms and condition, which could lead to hospitalization and complications for Resident 1. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm (disease when abnormal cells grow out of control) of 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 staff failed to protect one resident (Resident 1) from abuse by failing to: 1. Ensure Resident 1 was free from verbal abuse. 2. Ensure a contracted Xray provider (Xray Provider 1, a healthcare professional who uses X-rays [a type of radiation that produces an image of the inside of the body to help diagnose and treat diseases] and other imaging techniques to create images of a patient's body) did not verbally abuse Resident 1 by using profanity towards Resident 1. 3. Ensure Xray Provider 1 treated Resident 1 with dignity and respect. These deficient practices had the potential to affect Resident 1's emotional state and negatively affect Resident 1 ' s experience during the Xray process. Findings: A review of Resident 1 ' s admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a brain disease that alters brain function or structure, causing a declining ability 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 implement infection control practices according to professional standards by failing to: 1. Place Resident 1 on Novel Respiratory Precautions (a transmission-based precaution to prevent the spread of respiratory illnesses) on 7/9/2024 when Resident 1was reported being exposed to COVID-19 (an infectious disease caused by the SARS-CoV-2 virus) by the Infection Preventionist Nurse (IPN). 2. Fit test (a test required for healthcare providers to ensure they have tight-fitting respirator mask to prevent infection or the spread of respiratory diseases) Certified Nursing Assistant (CNA1) and CNA 2 who was working with and came into direct contact with Resident 1, who was a positive COVID-19 resident. 3. Train CNA 1 and CNA 2 how to properly don (put on) and doff (take off) personal protective equipment ([PPE] equipment used to prevent or minimize exposure if infectious diseases). These failures had the potential to result in a widespread outbreak of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an accurate post fall reassessment was conducted for one of three sampled residents (Resident 1). This failure had the potential that the causes of repeated fall will not be identified timely, individualized care plan interventions not modified and placing Resident 1 for recurring falls and injuries. Findings: During a telephone interview on 3/6/2024 at 10 a.m., Resident 1's family member stated Resident 1 had several falls in the facility. During a review of Resident 1's admission record, the admission record indicated Resident 1 was admitted to the facility on [DATE], with diagnosis of dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), and depression (a depressed mood or loss of pleasure or interest in activities for long periods of time). 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 implement the care plan for two out of three sampled residents (Resident 2 and Resident 3) after an altercation in Activity Room A. This failure had the potential to result in another altercation between Resident 2 and Resident 3. Findings: During a review of Resident 3 ' s admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included but not limited to encephalopathy (condition that causes brain dysfunction) and diabetes (poor blood sugar control). During a review of Resident 3 ' s Minimum Data Set ([MDS]- a standardized assessment and care planning tool), dated 12/6/2023, the MDS indicated that Resident 3 ' s cognition (mental action or process of acquiring knowledge and understanding) as severely impaired. The MDS indicated Resident 3 requireded maximal assistance for showering, toileting, and getting dressed. During a review of Resident 3 ' s Change of Condition Note,…

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 closely monitor one out of four sampled residents (Resident 1) with a history of attempted elopement (to leave unnoticed). Resident 1 eloped from the facility and was later found at a nearby restaurant and reported to have eaten an entire meal two hours after being last seen by facility staff. This failure resulted in the potential for Resident 1 to endure bodily injury and a fall while outside of the facility's premises without supervision from staff. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE], with diagnoses that included but not limited to dementia(impaired ability to remember, think, or make decisions) and history of falls. During a review of Resident 1 ' s Minimum Data Set ([MDS]- a standardized resident assessment and care planning tool), dated 1/16/2024, the MDS indicated Resident 1 ' s cognitive skills (mental action or process 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 observations, interviews, and record review, the facility failed to follow their infection prevention and control policy and procedure (P&P) by failing to report the facility's Coronavirus Disease ([Covid-19], a highly contagious respiratory infection caused by a virus that could easily spread from person to person) outbreak (at least one confirmed Covid-19 resident case who had resided in the facility for at least 7 days) to the California Department of Public Health (CDPH) District Office. This deficient practice had the potential to result in a delay of the District Office' response to the facility's Covid-19 outbreak and cause the spread of the COVID-19 infection to other residents, staff and visitors. Findings During a review of Resident 1's Face Sheet (admission record), dated 11/28/2023, the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including fracture of the pubis (a break in the bones of the pelvis), muscle weakness (decreased strength in the muscles),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Ensure residents' call lights (a device used by patients to call and alert nurses or other nursing personnel to assist a patient when in need) were placed within reach for four of ten sampled residents (Resident 79, Resident 22, Resident 41, and Resident 13). 2. Ensure one of ten sampled residents (Resident 16) did not wait for the call light to be answered for almost an hour when Resident 16 needed pain medication. These failures had the potential to affect the prompt and quality care provided to the residents and the inability to maintain the highest practicable physical, mental, and psychosocial well-being of the residents under the facility's care. Findings: 1a. During a review of Residents 79's admission Records, the admission records indicated Resident 79 was admitted to the facility on [DATE]. Resident 79's diagnoses included muscle weakness, difficulty walking and reduced mobility. During a review of Resident 79's Minimum Data…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe environment for three of six sampled residents, (Residents 5, 73, and 100), by failing to: 1. Ensure Resident 5 had both siderails padded to prevent injury during seizure activity (involuntary jerking, shaking, uncontrolled movement), and ensure the abdominal binder was applied to prevent the gastrostomy tube (g-tube, a tube surgically inserted into the stomach to administer nutrition and medications) from being accidentally pulled out by the resident. 2. Ensure Resident 73 had a padded siderails to prevent injury due to his seizure disorder. 3. Ensure Resident 100, who had history of seizure disorder, had padded siderails, fall mats at the bedside, and the bed kept at the lowest position for safety and to prevent injury. These failures had the potential to jeopardize the affected residents' safety and at a higher risk of causing physical harm. Findings: 1. During a review of Resident 5's admission Record (Face Sheet), 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, facility staff failed to ensure enteral feeding (a special liquid food mixture containing protein, carbohydrates, fats, vitamins, and minerals) was administered as ordered for three of seven sampled residents (Resident 73, 169, and 115). This failure created the potential for Resident 73, 169, and 115 to not meet their nutritional requirements, placing them at risk for avoidable weight loss, malnutrition, and skin breakdown or worsening of existing wounds. Findings: 1. During a review of Resident 73's admission Record, the admission record indicated the facility initially admitted Resident 73 on 7/11/2022 and re-admitted Resident 73 on 2/10/2023. Resident 73's admitting diagnoses included, but were not limited to dysphagia (difficulty swallowing) following a cerebral infarction (disruption of blood flow to the brain due to problems with the blood vessels that supply it), gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the…

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

Based on interview and record review, the facility failed to provide sufficient staffing for 123 of 123 residents when the Infection Preventionist Nurse (IPN) and the Case Manger (CM) were taken out of their primary roles to pass medications to the residents. This failure had the potential to result in the delay in care for the residents. Findings: During an interview on 10/25/2023 at 12:36 p.m., with the CM, the CM stated being the case manager was his primary role in the facility. The CM stated his responsibilities included reviewing new admissions, making residents' appointments, setting up transportation, and facilitate discharges. The CM stated he was the only case manager in the facility. The CM stated, staffing has been a challenge and he had to pass medications to the residents that day (10/25/2023). The CM stated if he was not on the medication cart, there would not be anyone else who could pass medications. The CM stated being assigned to the medication cart took him away from his primary duties and could be difficult to finish all his tasks. The CM stated after he…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Record the medication refrigerator temperature for one of one inspected medication rooms (Medication Room Station 1). 2. Account for one dose of controlled medication ([CM]- medications which have a potential for abuse and may also lead to physical or psychological dependence) for Resident 6 in one of two inspected medication carts (Medication Cart 1C). 3. Document one dose of CM in the [DATE] Medication Administration Record ([MAR] - a record of mediations administered to residents) for Resident 6 in one of two inspected medication carts (Medication Cart 1C). 4. Document the monitoring of signs and symptoms of bleeding for 21 shifts to one of five residents observed for medication administration (Resident 76). These failures increased the opportunity for CM diversion (the transfer of a controlled substance or other medication from a lawful to an unlawful channel of distribution or use) and increased the risk that Residents 6 could…

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

Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%) due to four (4) errors observed out of 25 total opportunities (error rate of 16 %). The medication errors were as follows: 1. Resident 76 and 418 received a form of multivitamin (a medication used as a dietary supplement to provide essential vitamins, minerals, and other nutritional elements) that was different than the one ordered by Resident 76's and 418's physician. 2. Resident 418 received a dose ascorbic acid (a medication used to improve the immune system) that was not ordered by Resident 418's physician. 3. Resident 418 did not receive duloxetine (medication used to treat depression) as ordered by Resident 418's physician. These failures had the potential to result in Residents 76 and 418 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) and the potential to result in Residents 76's and 418's health and well-being to be negatively impacted. Findings: 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 observation, interview, and record review, the facility failed to ensure: 1. To administer duloxetine (a medication used to treat depression [ persistent sadness]) as ordered to one of five residents (Residents 418) observed for medication administration. 2. Not administered expired insulin (a medication used to regulate blood sugar levels) to one of five residents (Resident 218) observed for medication availability. As a result, Residents 218 received a total of four (4) doses of expired insulin, and Resident 418 did not receive three (3) consecutive doses of duloxetine. These failure had the potential to cause Residents 218 and 418 to experience serious health complications due to increased depressive behaviors and uncontrolled blood sugar levels, possibly resulting in hospitalization or death. 3. To stop the enteral feeding (a special liquid food mixture containing protein, carbohydrates, fats, vitamins, and minerals) one hour prior to and one hour after administration of Dilantin (a medication to…

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

Based on observation, interview, and record review, the facility failed to: a. Remove and discard from use one expired eye drop bottle for Resident 39 in accordance with manufacturer's requirements in one of two inspected medication carts (Medication Cart 1C). b. Label two inhalation aerosol (form of medication that is inhaled through the mouth) devices for Resident 72 and 113, with an open date in accordance with the manufacturer's requirements in one of two inspected medication carts (Medication Cart 1C). c. Remove and discard from use one expired insulin (medication used to regulate blood sugar levels) kwikpen (an injection device containing insulin) for Resident 218, in accordance with manufacturer's requirements in one of two inspected medication carts (Medication Cart 2A). These practices increased the risk that Residents 39, 72, 113 and 218 could have received medication that had become ineffective or toxic due to improper storage or labeling, possibly leading to health complications resulting in hospitalization or death. Findings: During an observation on 10/26/2023 at 11:08…

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 facility was equipped with a nourishment refrigerator to ensure proper sanitation and food handling practices to prevent the potential outbreak of foodborne illness for 1 (Resident 61) out of 122 residents within the facility. This failure had the potential to spread food borne illness to Resident 61. Findings: During an interview, on 10/25/2023, at 1:07 p.m. with Certified Nursing Assistant (CNA) 6, CNA 6 stated, We do not have a fridge for the residents. Sometimes, we put the residents' food in the staff lounge refrigerator. During an interview, on 10/25/2023, at 1:08 p.m., with CNA 5, CNA 5 stated the residents' food was housed in the staff lounge refrigerator. During an interview, on 10/25/2023, 2:18 p.m., with the Infection Prevention Nurse (IPN), the IPN stated, We do not have a refrigerator for residents. If it is fast food, the staff would have to dispose of the food after two hours. It is not acceptable to house…

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 infection control measures were implemented or maintained when the following occurred: 1. While providing care to Resident 168, facility staff failed to: a. Ensure signage for the required transmission-based precautions (TBP, precautions implemented to prevent or control the spread of infection) was posted outside of Resident 168's room. b. Wash their hands with soap and water after providing direct care to Resident 168. c. Disinfect shared medical equipment with the appropriate disinfectant following use on Resident 168, who had a transmissible (contagious) infection. 2. Facility staff failed to date and store oxygen delivery equipment per facility policy and procedure for Resident 78. 3. Facility staff failed to store and handle clean linens in a sanitary environment. 4. Facility staff failed to change the enteral feeding (a special liquid food mixture containing protein, carbohydrates, fats, vitamins, and minerals) bottle 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 provide a safe, clean, comfortable, sanitary, and home like environment when Room A, Room C, Room D, Room E, Room F, Room I and Room G were observed with dry stool on the toilet seats, Room A and Room C's toilet was leaking and observed with a white towel at the base of the toilet, Room I had clutter on the floor, the privacy curtains were dirty, and two resident pillows were observed on the floor, an extension cord was observed with multiple plugs were coiled around Resident 79's metal side rail, and Station 2's shower room was dirty, had a strong smell of feces (technical word for poop, stool), water observed coming from the door toward the hallway, a wet floor with dirty masks and feces observed. These deficient practices had the potential for residents to feel uncomfortable and increased the residents' risk due to improper sanitary conditions and infection control practices. Findings: During a concurrent observation and interview on 10/24/2023 at 10:30 a.m., with Licensed Vocational Nurse (LVN) 4, Room…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide a privacy cover for one of three sampled resident's (Resident 168) indwelling urinary catheter (flexible tube inserted and left in the bladder to empty urine) drainage bag. This failure had the potential to negatively affect Resident 168's sense of dignity and psychosocial well-being. Findings: During a review of Resident 168's admission Record (Face Sheet), the admission Record indicated Resident 168 was admitted on [DATE] with diagnoses including chronic kidney disease (a disease characterized by progressive damage and loss of function in the kidneys) and urinary retention (a condition in which you cannot empty all the urine from your bladder). During a review of Resident 168's History and Physical (H&P), dated 10/21/2023, the H&P indicated Resident 168 had the capacity to understand and make decisions. During a review of Resident 168's physician orders, dated 10/22/2023, the orders indicated for Resident 168 to have 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 observation, interview, and record review, the facility failed to ensure one of 7 sampled residents (Resident 169) who was receiving enteral feeding (a way of delivering nutrition directly to the resident's stomach), was provided care and services to prevent aspiration (food or liquid entering the airway or lungs) by failing to ensure the resident's head of the bed was elevated. This failure had the potential to cause aspiration and complications including choking, difficulty breathing, lung infection and hospitalization for Resident 169. Findings: During a review of Resident 169's admission Record (Face Sheet), the Face Sheet indicated Resident 169 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including dysphagia (difficulty swallowing), metabolic encephalopathy (brain disease that alters brain function or structure), protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), 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 treat one of four sampled residents (Resident 3) with dignity and respected her preference when Resident 4 ' s family members pulled the curtain of Resident 3 open multiple times (on 9/1/2023 by Family Member 1 and on 9/6/2023 by Family Member 2) against Resident 3 ' s preference and comfort. On 9/6/2023, when Resident 3 re-opened the privacy curtain separating Resident 3 ' s and Resident 4 ' s beds after being closed by Family Member 2, Family Member 2 pointed a back scratcher stick and saying, No, No, No! towards Residents 3 while standing in front of Resident 3 ' s foot of the bed on 9/6/2023. This failure resulted in Resident 3 feeling disrespected, threatened, and stressed outduring and after the incident on 9/6/2023. Findings: During an observation on 9/11/2023, at 10:25 a.m., in Resident 3 ' s room, the 2 beds in the room could be separated by a privacy curtain. During an interview on 9/11/2023, at 10:29 a.m., with Certified Nurse…

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 promptly report one of four sampled residents' (Resident 3) verbal grievance to the facility's Executive Director (ED, Administrator) for resolution. Resident 3 notified Licensed Vocational Nurse (LVN 3) on 9/3/2023 regarding the incident that happened on 9/1/2023 with her roommate's (Resident 4) family member (Family Member 1) pulling Resident 3's privacy curtain closed aggressively, against her preference and without her permission while she was asleep and woken up. This failure resulted in Resident 3 feeling disrespected. Resident 3's grievance was unresolved from 9/3/2023 until a second incident happened with another family member of Resident 4 (Family Member 2) on 9/6/2023. (Cross Reference F557) Findings: During an observation on 9/11/2023, at 10:25 a.m., in Resident 3's room, the 2 beds in the room could be separated by a privacy curtain. During an interview on 9/11/2023, at 10:29 a.m., with Certified Nurse Assistant (CNA) 3, CNA 3…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident who received hemodialysis (process of removing waste products and excess fluid from the body, when the kidneys are not able to adequately filter the blood) treatment received services consistent with professional standards of practice for one of one sampled residents (Resident 1), by: 1. Failing to assess and document Resident 1 ' s dialysis access site upon return to the facility after dialysis treatment on the Dialysis Communication Record. 2. Not providing a sacked meal for Resident 1 prior to a dialysis appointment. 3. Failing to provide transportation for Resident 1 after dialysis treatment. These deficient practices had the potential to result in undetected complications of a dialysis access site. This deficient practice caused Resident 1 to feel unimportant due to the facility not providing transportation from the dialysis treatment center and the facility not providing her with something to eat. Findings: During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the necessary care and services for five out of five sampled residents (Resident 1, 2, 3, 7, and 8) by failing to answer the call lights in a timely matter, as long as 30 minutes to one hour. This deficient practice resulted in the residents to feel upset, anxious and worried, and had the potential to result in a negative impact on residents' health. Findings: a). During a record review of Resident 1's admission record, the record indicated Resident 1 was admitted to thefacility on 7/20/2023, with a diagnosis of chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body. The main symptoms of chronic respiratory failure are trouble breathing and fatigue) and heart failure (progressive heart disease that affects pumping action of the heart muscles. This causes fatigue, shortness of breath). During a review of Resident 1's history and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to: 1. Ensure oxygen was not administered to Resident 4 without a physician's order. 2. Ensure Resident 2 was administered two liters of oxygen as ordered and not one liter. 3. Ensure the humidifier bottle for Residents 2, 4, and 7 were labeled with an open date. This deficient practice had the potential to cause a negative respiratory outcome and increase the risk for residents to acquire a respiratory infection. Findings: a). During a review of the admission record (face sheet) for Resident 2, the record indicated Resident 2 was originally admitted to the facility on 1/17/, with a diagnosis of chronic obstructive pulmonary disease (COPD, group of chronic lung diseases that block airflow and make it harder to breathe air out of the lungs) and absence of partial of lung (surgical removal of part of the lung). During a review of Resident 2's doctor orders, dated 7/9/2022, the doctor's order indicated to administer oxygen to Resident 2 at two…

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 their medication and administration policy and procedure for two out of three sampled residents (Resident 2 and 3) by failing to ensure the licensed nurses did not: 1. Document on the medication administration record (MAR) Metformin (medication used to control diabetes [high blood sugar]) was administered to Resident 2, when it was not 2. Administer medications at the scheduled time as indicated on the MAR for Resident 2 and Resident 3. 3. Administer medication from another scheduled time bubble packet to Resident 2. These deficient practices had the potential to negatively impact Resident 2 and Resident 3's health, and also make the residents feel unimportant because the staff knew the resident's medication were not available. Findings: a. During a review of Resident 2's admission record, the admission record indicated Resident 2 was originally admitted to the facility on [DATE] with diagnosis including diabetes mellitus (high…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide documentation for four of four randomly selected residents (Residents 3, 4, 5, and 6) to show that they were accurately informed of their Medicare (a government national health insurance program) Non-Coverage services. 1. Residents 5 and 6 had a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN, provides information to the beneficiary so that s/he can decide whether or not to get the care that may or may not be paid for by Medicare and assume financial responsibility) and a Notice of Medicare Non-Coverage (NOMNC, written notice of when your covered services will end) on file without a beneficiary or a representative signature demonstrating that they received notice and understood that the termination decision could be disputed. 2. Resident 3, 5, and 6 ' s NOMNC on file had no date of when the facility spoke to the resident ' s representatives regarding the end date of coverage. 3. Resident 3, 5, and 6 ' s NOMNC on file did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of 10 sampled residents (Resident 1 and Resident 2) were free from the use of physical restraints for discipline or staff convenience. Residents 1 and 2 were tied to their wheelchair with a bedsheet to prevent the residents from falling. This deficient practice resulted in Resident 1 and Resident 2 being physically restrained to their wheelchairs, and inhibited Resident 1 ' s and Resident 2 ' s freedom of movement. Findings: a. During a review of Resident 1 ' s admission Record, the record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses that included dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities) and anxiety (intense, excessive, and persistent worry and fear about everyday situations). During a review of Resident 1 ' s History and Physical (H&P), dated 7/1/2023, the H&P indicated Resident 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an allegation of abuse to the Department of Public Health (DPH) for two of ten sampled residents (Resident 1 and Resident 2), who were physically restrained to their wheelchairs by Licensed Vocational Nurse 1 (LVN 1) and failed to ensure staff were able to identify the act of physically restraining residents as abuse. This deficient practice resulted in unidentified abuse in the facility and the failure to protect residents from abuse. Findings: a. During a review of Resident 1 ' s admission Record, the record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses that included dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities) and anxiety (intense, excessive, and persistent worry and fear about everyday situations). During a review of Resident 1 ' s History and Physical (H&P), dated 7/1/2023, the H&P…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to conduct a proper and thorough investigation of an abuse incident for two of ten sampled residents (Resident 1, Resident 2) by failing to: 1. Investigate the alleged abuse incident for Resident 1 and Resident 2. 2. Protect Resident 1 and Resident 2 by not allowing the alleged perpetrator (Licensed Vocational Nurse 1 [LVN 1]) to continue to work at the facility after the incident. These deficient practices placed Residents 1 and 2, and other residents at further risk for abuse. Findings: a. During a review of Resident 1 ' s admission Record, the record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses that included dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities) and anxiety (intense, excessive, and persistent worry and fear about everyday situations). During a review of Resident 1 ' s History and Physical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care and services that meet professional standards for two of three sampled residents (Resident 1 and 2) by failing to: 1. Obtain a blood pressure reading after Resident 1 reported dizziness. 2. Provide oxygen as ordered by a physician for Resident 2. As a result of these deficient practices, Resident 1 had the potential to go into cardiac arrest (sudden, unexpected loss of heart function, breathing, and consciousness), and Resident 2 had the potential to develop oxygen toxicity (when the body has too much oxygen). Findings: a. During a review of Resident 1's Face Sheet , dated 7/14/2023, the face sheet indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included pneumonia (infection that inflames the air sacs in one or both lungs), hypertension (high blood pressure), type 2 diabetes mellitus (a chronic condition where the body does not produce enough insulin hindering the processing of sugar), 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 notify the physician for one of three sampled residents (Resident 1) when Resident 1 left the facility against medical advice (AMA). As a result, this deficient practice had the potential to cause a delay in care and medical harm since the resident did not receive the information regarding the risks of leaving AMA. Findings: During a review of Resident 1's Face Sheet, dated 7/14/2023, the face sheet indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included pneumonia (infection that inflames the air sacs in one or both lungs), hypertension (high blood pressure), type 2 diabetes mellitus (a chronic condition where the body does not produce enough insulin hindering the processing of sugar), and severe sepsis with shock (a life threatening blood infection that causes low blood pressure, resulting in damage to multiple organs). During a review of Resident 1's History and Physical (H&P), dated 6/5/2023, the H&P 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.