Rocky Point Care Center

Based on interviews and record reviews, the facility failed to protect Resident 1's right to be free from verbal abuse when Resident 2 verbally abused Resident 1 by yelling profanities and calling her an expletive.These failures decreased the facility's potential to prevent mental anguish and emotional distress among residents.Findings:A review of Resident 1's admission record indicated admission to the facility in January 2026 with diagnoses which included anxiety disorder (excessive, persistent fear or worry that interferes with daily life) and depression (a mood disorder characterized by persistent sadness). Resident 1 was her own responsible party (RP, a person who can manage their own health and financial decisions).A review of Resident 2's admission record indicated admission to the facility in August 2025 with diagnoses which included depression. Resident 2 was his own RP.A review of Resident 1's Brief Interview for Mental Status (BIMS) score conducted on 11/5/25, indicated she had a BIMS score of 12 which meant she had moderate ability to think, reason, and learn.A review…

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

Based on interviews and record reviews, the facility failed to report an allegation of verbal abuse within two hours to the California Department of Public Health (CDPH) for one resident (Resident 1) of two sampled residents when Resident 2 yelled and threated Resident 1 on 12/25/25, 12/31/25, and 1/7/26.This failure decreased the facility's potential to ensure residents were protected against abuse.Findings:A review of Resident 1's admission record indicated she has anxiety disorder (excessive, persistent fear or worry that interferes with daily life) and depression (a mood disorder characterized by persistent sadness). Resident 1 was her own responsible party (a person who can manage their own health and financial decisions).A review of Resident 1's Brief Interview for Mental Status (BIMS) score conducted on 11/5/25, indicated she had a BIMS score of 12 which meant she had moderate ability to think, reason, and learn.A review Resident 2's BIMS score conducted on 12/3/25, indicated Resident 2 had a BIMS score of 15 (no cognitive impairment).A review of Resident 2's progress notes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 store, prepare, and serve food in a safe and sanitary manner when:1. Muffins with mold (mold is a type of fungus that can grow on food) were served on breakfast trays, and six residents consumed them.2. Dry goods were improperly stored when expired cocoa powder was in the storage area, a gravy packet had leaked, chocolate chips were in an open plastic bag without a date when it was opened.3. Deli meat in a refrigerator was ten days past its use by date.4. Frozen pancakes and frozen egg rolls did not have a date when they were received.5. Trash cans were uncovered during tray line (name of process where food was served on resident's plates). This failure had the potential to cause food-borne illness in 64 of 64 vulnerable residents.Findings:1. During an interview on 8/26/25 at 2:15 p.m., [NAME] A stated she received a report from Dietary Aide B (DA B) that moldy muffins were served to residents on [NAME] A's day off.During an interview on 8/26/25 at 4 p.m., Licensed Nurse C (LN C) stated the moldy muffins were…

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

Based on observation, interview and record review, the facility failed to ensure food was stored, prepared and served safely in accordance with professional standards of food service when:1. Soiled equipment was observed in a food prep area;2. The floor was noted to have solid food debris, built up dust, and dirt underneath the sink and behind the oven;3. Kitchen staff did not monitor the tray line food temperatures; and,4. Kitchen staff did not use facial hair nets.These failures posed the risk for food borne illnesses for 57 of 57 residents who resided in the facility and consumed food prepared in the kitchen.Findings:1. During an observation on 7/16/25 at 12:15 p.m., the following observations were made:The stovetop had black residue and debris in burner wells; The dishrack had visible grime and black residue; The ceiling vents over the steamtable had a large amount of dust build up; and the air conditioning unit had dust build up on the vents over the food prep table. During an interview on 7/17/25 at 12:20 p.m., the Corporate Registered Dietician (CRD) acknowledged the kitchen…

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

Based on observation and interview, the facility failed to create a homelike environment for a census of 57 residents when walls in multiple residents' rooms were damaged and carpeting throughout the facility was worn and stained.These failures decreased the facility's potential to ensure residents were provided a safe, clean, comfortable, homelike environment to support their overall well-being.Findings:During interval observations on 7/17/25 between 9:48 a.m. and 2:50 p.m., carpeting throughout hallways of the facility was noted to be worn with multiple stains of varying sizes and colors. The carpeting was matted down with dirt and heavy traffic at each doorway entry.During an observation on 7/17/25 at 10:16 a.m., torn wallpaper and wall damage with exposed drywall (building material) was observed in Resident 2's room. During a concurrent observation and interview on 7/17/25at 10:26 a.m., torn wallpaper in several areas in Resident 3's room was observed. Resident 3 stated, It's been that way for a long, long time. I don't know how it happened. But you can't miss it…

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

Based on interviews and record reviews, the facility failed to: 1. Ensure staff were aware of whom to report abuse allegations and the timeframe for reporting abuse allegations. 2. Report an abuse allegation timely, when two out of two abuse allegations (Residents 36 and 15's altercation and Resident 221's alleged abuse) were reported more than two hours later after the abuse allegation was made. These failures could lead to ongoing abuse and could result in residents feeling scared, upset, and frustrated. Findings: A review of Resident 36's face sheet (demographics) indicated an admission date of 1/14/21. His diagnoses include bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy and causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression)), Muscle Weakness and Cerebellar Ataxia (the inability to control voluntary muscle movements, which can cause problems with balance, walking (gait), speech, swallowing). Resident 36's Brief Interview for Mental Status (BIMS, a mandatory tool used to screen and identify…

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

Based on interviews and record reviews, the facility failed to ensure the nurses were following the Physician's Order for pain medication for one out of two sampled residents (Resident 37), when the nurses administered a pain medication that was not appropriate for the pain level Resident 37 was reporting. This failure could result in unrelieved pain, worsened pain, impaired mobility, and residents feeling upset, angry and frustrated. Findings: A review of Resident 37's face sheet (demographics) indicated an admission date of 3/21/24. Her diagnoses include Chronic Pain Syndrome (CPS, a long-standing pain that persists beyond the usual recovery period or occurs along with a chronic health condition), Essential Hypertension (HTN, high blood pressure) and right Tibial fracture (a break in the shinbone). Resident 37's Brief Interview for Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive condition of residents), dated 4/30/24, score was 15 out of 15 indicating intact cognition (the conscious and unconscious processes involved in thinking, perceiving, 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.

During an observation, interviews, and record reviews, the facility failed to ensure residents were served food items that were palatable and at the right temperature, for four out of four sampled residents (Residents 30, 6, 38, and 43). These failures could put the residents at risk for loss of appetite, frustration, malnutrition (condition that develops when the body is deprived of vitamins, minerals, and other nutrients it needs to maintain healthy tissues and organ), and weight loss. Findings: A review of Resident 30's Brief Interview for Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive condition of residents), dated 3/18/24, score was 1, indicating severely impaired cognition (the mental process involved in knowing, learning, and understanding things). A review of Resident 6's BIMS, dated 3/22/24, score was 15, indicating intact cognition. A review of Resident 38's BIMS, dated 5/11/24, score was 15, indicating intact cognition. A review of Resident 43's BIMS, dated 5/11/24, score was 13, indicating intact cognition. During an interview on 06/17/24…

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

Based on observations, interviews and record reviews, the facility failed to ensure refrigerated items in the kitchen were clearly labeled, easily identified, and dated. These failures could compromise food safety and could lead to residents getting sick with gastrointestinal (GI, made up of organs that food and liquids travel through when they are swallowed, digested, absorbed) illness such as Salmonella (an infection with Salmonella bacteria that causes diarrhea- passage of three or more liquid stools, fever and stomach pains), Gastroenteritis (stomach flu) and food poisoning (an illness caused by eating contaminated food). Findings: During a concurrent observation and interview on 6/17/24 at 9:25 a.m., the Dietary Supervisor (DS) verified the following items in the three-door refrigerator had no use-by or discard date: vanilla extract, chocolate syrup and a yellow mustard. There was also a bin that contained sandwiches for lunch alternates for the day, which had no labels, no date on when it was made and had no use-by date. [NAME] 3 verified the sandwiches were not labeled or…

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

Based on observation, interviews and record review, the facility failed to ensure: 1. Perishable food items from home, stored in the refrigerator for the residents, was dated and labeled with the resident's name. 2. Staff were aware on the facility's policy on when to discard refrigerated food items from home. These failures could lead to cross-contamination, and unsafe and unsanitary storage of food, which were a safety risk that could lead to accidental ingestion of expired food items and food being served to the unintended residents. Findings: During a concurrent observation and interview on 6/18/24 at 2:45 p.m., the Director of Nursing (DON) stated it was important to label the food with residents' names, date when it was opened and date when to discard. The DON stated it was important to label the food with residents' names so that the food would go to the right resident. The DON stated food in the refrigerator was discarded after three days from opening to prevent residents from getting sick. The DON verified the following items were not labeled with the residents' names:…

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

Based on observations and interviews, the facility failed to ensure: 1. Hand hygiene (HH, hand-washing with water and plain or antiseptic soap or rubbing hands with an alcohol-based product in the form of a gel to clean hands and remove dirt, bacteria, and viruses) was offered and provided, for seven out of seven sampled residents (Residents 18, 29, 28, 10, 54, 1 and 14). 2. Utensils were cleaned thoroughly and stored under sanitary conditions, when there was a plate on the plate warmer noted with dried food, and kitchen utensils were not properly dried prior to storing in the drawer. These failures could lead to residents getting sick with infection if they were not offered or provided HH before and after meals. Dishes and utensils that have not been thoroughly cleaned, rinsed, and dried could result in cross-contamination and bacteria growing on dishes and utensils, which could result in residents' getting sick. Findings: 1. During an observation on 6/17/24 at 12:13 p.m., Resident 18 was not offered or provided HH prior to eating her lunch. During an observation on 6/17/24 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an explanation for not providing a SNF ABN (Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage) and a NOMNC (Notice of Medicare Non-Coverage), to one of three residents (Resident 220), prior to discharge from the facility. This failure had the potential to prevent the resident from making an informed decision about their discharge from the facility. Findings: During an interview on 6/18/24 at 10 AM, the Administrator was given three SNF (Skilled Nursing Facility) Beneficiary Notification Review Forms (Form CMS-20052). Each form contained the name of a resident who had been discharged from the facility. Per Form CMS-20052, The intent of the checklist is to provide the surveyor with all copies of the forms issued to the resident, and if the notification was not required, an explanation of why the form was not issued. During a record review on 6/19/24 at 3:24 PM, the SNF Beneficiary Protection Notification Review for two of three Residents was completed correctly. The SNF Beneficiary Protection…

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

Based on interviews and record reviews, the facility failed to ensure : 1. Staff were aware of the Baseline Care Plan (BCP, an initial person-centered care plan, completed within 48 hours of admission, that provides instructions for the care of the residents) completion timeframe. 2 .The BCP was completed timely for three out of three sampled residents (Residents 54, 60 and 28). These failures had the potential to lead to delayed or omitted care, missed medications or treatments, medical complications, and deconditioning. Findings: A review of Resident 54's face sheet (demographics) indicated an admission date of 3/21/24. Her diagnoses include Muscle Weakness, Lymphedema (a chronic disease marked by the increased collection of lymphatic fluid in the body, causing swelling) and Dysphagia (difficulty swallowing). A review of Resident 54's Brief Interview for Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive condition of residents), dated 3/25/24, score was 14 out of 15 indicating intact cognition (the conscious and unconscious processes involved in…

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

Based on observation, interviews and record reviews, the facility failed to ensure that three of eight sampled residents, Resident 2, 38, and 51, received care and services that met their physical, mental, and emotional needs, and according to the facility's policy and procedure on answering call lights and repositioning, when these residents had to wait for a long time before they were assisted after pushing their call light buttons to request for assistance from their aides. These failures had the potential to result in skin breakdown, when the residents were left soiled in urine or feces (the material in a bowel movement), or when residents were left in a certain position for a significant amount of time and could also affect their emotional well-being. Findings: A review of Resident 2's MDS (Minimum Data Set- is part of the federally-mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) Section C- Cognitive (Cognitive means relating to the mental process involved in knowing, learning, and understanding things) Patterns, 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, interviews and record reviews, the facility failed to ensure residents were not receiving food items that they did not like, for one out of three sampled residents (Residents 117). This failure could result in Resident 117 not eating the food and could put Resident 117 at risk for weight loss and inadequate nutrition. Findings: A review of Resident 117's face sheet indicated his admission date as 6/6/24, with diagnoses of Dysphagia (difficulty swallowing), Muscle Weakness and Essential Hypertension (HTN, high blood pressure). A review of Resident 117's lunch diet ticket on 6/19/24 at 12:03 p.m., indicated he disliked breaded food. A review of the menu for 6/19/24, indicated lunch included breaded fried chicken. During a concurrent observation and interview on 6/19/24 at 12:04 p.m., [NAME] 1 stated she had already finished plating for Resident 117, and verified she added a breaded fried chicken on his lunch tray. [NAME] 1 stated his meal tray was already placed in the meal cart. [NAME] 1 verified Resident 117 disliked breaded food items and should not be served…

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

Based on observation and interviews, the facility failed to ensure the kitchen floor was in good repair, when the linoleum (a hard, washable floor covering formed by coating burlap or canvass with linseed oil, powdered cork, and resin, and adding pigments to create the desired colors and patterns) floor on multiple parts of the kitchen area (by the gas stove, door leading to the hallway, the sink) was coming apart and its edges were raised off the floor. This failure could be an infection control issue due to difficulty in ensuring the floor was adequately cleaned and sanitized. This failure could also be a safety issue due to being a trip hazard. Findings: During a concurrent observation and interview on 6/17/24 at 9:19 a.m., [NAME] 3 verified the linoleum floor was falling apart on different parts of the kitchen area. [NAME] 3 stated the kitchen floor should always be clean, and the floor should always be in good repair. [NAME] 3 stated she tripped on the linoleum floor by the gas range every time she went to work. [NAME] 3 stated, the linoleum flooring not being in good repair…

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

Based on observations and interviews, the facility failed to ensure the kitchen was free of flies. This failure posed a health risk, as flies carry diseases such as Salmonella (a group of bacteria that can cause diarrhea-passage of three or more liquid stools, in humans) and Cholera (an infectious disease that causes severe watery diarrhea), which could contaminate the food stored, prepared and served to the residents in the facility. Findings: During an observation on 6/19/24 at 12:05 p.m., the Dietary Supervisor (DS) and the Registered Dietitian (RD) both verified there was a fly in the kitchen. During a concurrent observation and interview on 6/19/24 at 12:11 p.m., [NAME] 2 verified there was a fly hovering in the kitchen. [NAME] 2 stated this was not an isolated incident, and flies could be seen in the kitchen from time to time. [NAME] 2 stated there should be no flies in the kitchen area. [NAME] 2 stated the facility could only do so much, and although they have a fan blower, it was not enough to keep the flies away. [NAME] 2 stated it was not acceptable to have flies in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to follow physician orders to get blood work done for Resident 1 which would have included Resident 1's blood sugar level. This failure to have blood work drawn caused the facility to not identify and treat Resident 1's diabetes, resulting in elevated blood sugar levels that interfere with healing processes. Findings: During a review of Resident 1's acute care medical record, Resident 1's History and Physical dated 10/1/23, documented Resident 1 had an elevated Hbg A 1c (a measure of one's average blood sugar levels over the past 3 months) at 13.3% indicating her blood sugar was poorly controlled. During a review of the medical records, Resident 1's admission Record documented she was admitted to the facility on [DATE] from the acute care hospital. Resident 1's diagnosis included: Acute Respiratory failure, Pneumonia, Heart Failure, and Type 2 Diabetes without complications. During a review of the medical records, Resident 1's Order Summary Report (printed…

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

Based on observation and interview, the facility failed to provide a safe, clean, comfortable, and homelike environment to two of two residents (Residents 1 and 2) by not ensuring their room was free of flies. This failure resulted in Residents 1 and 2's well-being and sleep being disturbed by the flies. Findings: During an observation of Residents 1 and 2's room on 8/30/23, at 3:35 p.m., two flies were in the room. During a concurrent interview, Residents 1 and 2 reported the presence of flies in their room bothered them and disturbed their sleep. During an interview on 8/30/23, at 4:15 p.m., the Administrator stated there should not be flies in residents' rooms.

Based on observation, interview, and record review, the facility failed to follow the menu as posted when residents on a pureed diet were not served the rice dish, and wheat rolls were not served when on the menu. This resulted in residents not getting a full meal and missing an opportunity to have whole grain bread. Findings: During an interview on 7/11/22 at 12:30 p.m., Unsampled Resident 8 stated the food served was not what it said on the menu. Review of the posted menu for 7/11/22 through 7/17/22 revealed that on 7/13/22 the residents would be served Balsamic Glazed Pork, Herb Rice, Spinach with Onions, Wheat Roll, and Raspberry Bavarian for lunch. Review of the Resident Council meeting minutes dated 1/20/2022, on page titled Resident Council Discussion of New Business, the Dietary Department section indicated, Menus - concerns that menus are not being followed. Meeting minutes dated 2/17/2022, on page titled Old Business was written Dietary - concerns that menus are not being followed (unresolved). Meeting minutes dated 3/17/22, on New Business page, indicated in dietary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 honor residents' request for more variety of fruits and seasonal fruits when the dietary department only ordered and kept in stock oranges and bananas. This failure caused residents to eat the same fruit repeatedly with no variation. Findings: During an interview on 7/11/22 at 12:20 p.m., Unsampled Resident 8 stated it was rare to have fresh fruit, we get bananas, but who wants bananas all the time? . There are no peaches, it's peach season. Review of the Resident Council meeting minutes January 2022 through June 2022 revealed the Resident Council had requested to have fresh fruit in season. Meeting minutes dated 4/21/22, on page titled Resident Council Discussion of New Business, Dietary Department section indicated, Would like fresh fruit. Meeting minutes dated 5/19/22, on page titled Old Business, Fresh fruit was marked as unresolved. Meeting minutes dated 6/16/22, on New Business page in dietary department section was written Seasonal fruits instead of with no further information. During an observation and…

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

Based on observation, interview, and record review, the facility failed to keep the floors clean under the refrigerators and freezers in the kitchen. This failure could potentially attract vermin in the kitchen. Findings: During an observation and concurrent interview on 7/11/22 at 12:02 p.m., an Initial tour of the kitchen was conducted. Several refrigerators and freezers on casters lined the walls adjacent to the dietary managers office. Underneath the refrigerators and freezers was accumulation of dust, debris, corn kernals, butter packets, and plastic lids. Management Staff E verified there was corn, a butter packet, and plastic lids under the refrigerators and freezers. She stated the dietary staff were expected to mop under the refrigerators and freezers nightly. Management Staff E verified the build up of debris looked like more than would happen after preparing two meals. Management Staff E verified it was not up to her standards of cleanliness. Review of the Food and Drug Administration (FDA) Food Code, last revised 2017, Chapter 4, subsection 4-6 Cleaning of Equipment 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 implement its Policy and Procedure on filing grievances/complaints by residents when: 1) Residents did not know where to get the grievance forms. 2) Residents did not know how to file grievance when their right were violated. 3) Residents were in fear of discrimination and fear of retaliation from staff when they voiced their concern or grievance. These failures had the potential to result in violation of resident's rights, maltreatment, neglect, and unresolved grievances. Findings: 1) During the Resident Council interview on 7/12/2022 at 10:30 a.m. in the Dining room, 15 Residents attended, the ombudsman and this Surveyor. When asked if they know how to file grievance. 10 Residents raised hands to indicate that they don't know where to get the grievance form. During an observation on 7/13/2022 at 10 a.m., blank grievance form found inside a folder in a slot at the front door entrance of the Dining room behind the front desk screener. The slot was position above eye level when seating on a wheelchair. 2) During 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 interviews and record reviews, the facility failed to follow it policy and procedure to provide a copy of transfer/discharge notice to the representative of the Office of the Long-Term Care (LTC) Ombudsman for two out of three sampled residents (Resident 10 and Resident 5). These failures could have prevented the Ombudsman to advocate for Resident 10 and Resident 5 and potentially resulted in inappropriate transfers/discharges from the facility. Findings: Resident 10 During a review of resident 10's Progress Notes, dated 3/29/22, at 9:10 p.m., authored by Licensed Staff A, the progress note indicated that Resident 10 was found on the bathroom floor after a fall and 911 call was placed. During a review of Resident 10's Progress Notes, dated 3/29/22, at 10:50 a.m., authored by Licensed Staff H, the progress note indicated, MD (MD O, a physician) ordered resident transfer to (name of hospital) for eval (evaluation) and treatment with a 4-7 day bed hold. Order entered by this nurse. 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 observations, interviews, and record reviews, the facility failed to develop comprehensive person-centered care plans to 5 of 18 sampled residents (Residents 103, 5, 23, 16, and 25), that meets the resident's medical, nursing, and mental and physical needs, that were identified in their comprehensive assessments. These failures had the potential to negatively impact Resident 103, 5, 23, 16 and 25's quality of life, as well as the quality of care and services they received. Findings: Resident 103 During a review of Resident 103's admission Record, the admission record indicated Resident 103 was admitted to the facility on [DATE]. The admission record indicated one of Resident 103's medical diagnosis was tobacco use. During a review of Resident 103's Smoking Safety Evaluation, dated 6/29/22, it indicated that supervision was required for all residents during designated smoking times. During a review of Resident 103's Care Plan on 7/12/22, at 3:01 p.m., the care plan indicated that there was no plan…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medications were given timely for eight residents (Resident 46, Resident 30, Resident 9, Resident 33, Resident 7, Resident 18, Resident 35, and Resident 17). This failure could result in residents having increased pain or anxiety due to delay in receiving their medications on time. Findings: During a medication pass observation on 7/13/22 at 09:20 am, with Licensed Staff F, Licensed Staff F gave Resident 46, 5 of his 08:00 medications at 09:20 am. They were as follows: Carvediol (medication for heart failure), Amlodipine (medication for high blood pressure), Lisinopril (medication for high blood pressure), Paroxetine (medication for depression), and Flomax (medication for treating the symptoms of an enlarged prostate). During a medication pass observation on 7/13/22/at 09:30 am, with Licensed Staff F, Licensed Staff F gave Resident 30, 7 of his 08:00 medications at 09:30 am. They were as follows: Clonazepam (medication used to prevent and control seizures), Cymbalta (medication for depression 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 serve a flavorful pureed food to residents on a pureed diet. This failure resulted in residents on a pureed diet being served a bland food. Findings: During a tray line observation and interview on 7/13/22 at 12:35 p.m., Dietary Staff L plated two pureed diets with pork and spinach. Dietary Staff L placed a plate cover over each plate, and handed them to Dietary Staff M, who placed them on trays with drinks and untensils. Dietary Staff M placed the trays of pureed food on the tray cart. When queried, Management Staff E verified there was no pureed starch for the pureed diet. Management Staff E stated, He (Dietary Staff L) forgot to make the rice, and stated, It's too late now. He could make cream of rice? Management Staff E spoke with another dietary staff who got a pot of water and made cream of rice. During a test tray observation with Management Staff J on 7/13/22 at 12:49 p.m., the pureed rice tasted bland. During an interview on 7/14/22 at 9:16 a.m., Management Staff E stated when Dietary Staff L…

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

Based on observation, interview, and record review, the facility failed to ensure that the physician was made aware of a significant weight loss for one of one sampled residents (Resident 27). This failure could result in continuous weight loss and harm to Resident 27. Findings: Resident 27's admission record indicated Resident 27 had diagnoses including Dementia (impairment in memory and judgement), Alzheimer's disease (progressive disease of memory loss and confusion), and Adult Failure to Thrive (weight loss, decreased appetite and poor nutrition and inactivity). During a concurrent observation and interview on 7/11/22 at 1:30 pm , Resident 27 was in her room and appeared sleeping in bed. Resident 27 appeared thin. Unlicensed staff I was at her bedside speaking with her and encouraging her to get up. Unlicensed Staff I stated Resident 27 looked so different from when she (Unlicensed Staff I) was here a few months ago. Unlicensed Staff I stated Resident 27 was up and walking around, but now she is mostly in bed. During a record review on 7/11/22 at 3:00 pm, the Patient Weight…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a prescribed psychotropic (a drug that affects brain activities associated with mental processes and behavior) medication had a documented, specific diagnosis with adequate monitoring for effectiveness for one of five residents sampled for unnecessary medication review (Resident 23). This failure potentially resulted in Resident 23 taking an unnecessary medication. Findings: During an observation on 7/11/22 at 1:43 p.m., Resident 23 was in her wheelchair and self-propelled out of her room into hallway. At the nurses' station, Resident 23 asked her CNA (certified nursing assistant) for something. The CNA responded, A soda pop? They're in the med[ication] room, I don't have the keys. The CNA walked away. Resident 23 approached this surveyor and briefly discussed the warm weather in a calm and pleasant affect. Resident 23 stated she would like a soda. When asked what kind of the soda she would like, Resident 23 stated she 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.