Lawndale Healthcare & Wellness Centre LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to: 1.Ensure low air loss mattresses settings were correct for one of six sampled residents (Resident 1). This deficient practice had the potential to result in further skin breakdown.Findings: During a review of Resident 1's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 1's diagnoses included acute respiratory failure (a sudden, life-threatening syndrome where the respiratory system fails to properly oxygenate the blood or remove carbon dioxide), sepsis (a life-threatening blood infection), schizophrenia (a mental illness that is characterized by disturbances in thought) and type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 1's history and physical (H&P) form, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to:Ensure smoking assessment was completed accurately for one of one sampled resident (Resident 38).This deficient practice had the potential to place Resident 38 at risk for injury and inadequate care planning.Findings:During a review of Resident 38's admission Record, the admission Record indicated Resident 38 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 38's diagnoses included low back pain, chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty in breathing), and bipolar disorder (sometimes called manic-depressive disorder, mood swings that range from the lows of depression to elevated periods of emotional highs), and nicotine (cigarette) dependence.During a review of Resident 38's History and Physical (H&P), dated 1/12/2026, the H&P indicated, Resident 38 can make needs known but could not make medical decisions.During a review of Resident 38'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 observation, interview and record review the facility failed to ensure two liters of oxygen was administered as ordered by physician for two of ten sampled residents (Resident 1 and Resident 23). This deficient practice had the potential to place residents at risk for not receiving oxygen therapy as prescribed by the physician and complications such as decreased breathing drive (result of too much oxygen in the body reducing the urge to breathe) and carbon dioxide retention (less breathing resulting in less carbon dioxide exhalation and increase of carbon dioxide in blood). a. During a review of Resident 1's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 1's diagnoses included acute respiratory failure (a sudden, life-threatening syndrome where the respiratory system fails to properly oxygenate the blood or remove…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to:Ensure one of one sampled resident (Resident 6) was evaluated by a physician initially in the first 90 days of admission and document his visit in resident's clinical records.This deficient practice had the potential for Resident 6's current medical condition not timely assessed by a physician that can lead to delay in necessary care and treatment.Findings:During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 6's diagnoses included rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility), muscle weakness, and neuralgia (intense, sharp, or stabbing pain caused by damage, irritation, or compression of nerve).During a review of Resident 6's History and Physical (H&P), dated 7/20/2025, the H&P indicated, Resident 6 had the capacity to understand and make…

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 upon observation, interview and record review, the facility failed to: 1.Ensure appropriate medication treatment was administered for one of six sampled residents (Resident 25) who was observed yelling loudly throughout various shifts for 4 days. This deficient practice had the potential to result in escalation of behavioral issues.Findings: During a review of Resident 25's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 25's diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) and major depressive…

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 medications were administered at the time of preparation for one of three sampled residents (Resident 27). This failure had the potential to place resident at risk for medication errors. Findings: During a review of Resident 27's admission Record (Face sheet), the admission Record indicated the facility admitted the resident on 12/11/2023 and was readmitted [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and dementia (a progressive state of decline in mental abilities). During a review of Resident 27's History and Physical (H&P) dated 11/8/2025, the H&P indicated the resident did not have the capacity to understand or make decisions. During a review of Resident 27's Minimum Data Set (MDS- a resident assessment tool), the MDS 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 medications were secured and visible to registered nurse administering medications for one of three sampled residents (Resident 27). This deficient practice had the potential to result in safety issues such as unauthorized resident access to medications and medication errors. Findings: During a review of Resident 27's admission Record (Face sheet), the admission Record indicated the facility admitted the resident on 12/11/2023 and was readmitted [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and dementia (a progressive state of decline in mental abilities). During a review of Resident 27's History and Physical (H&P) dated 11/8/2025, the H&P indicated the resident did not have the capacity to understand or make decisions. During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Implement the physician's orders to draw laboratory tests (a medical analysis of a body sample (blood, urine, tissue) to check health, diagnose diseases and monitor chronic conditions) for two of two sampled residents (Residents 5 and 9).This deficient practice had the potential to result in the delay of identification of medical concerns, delaying the care and services necessary for the affected residents.Findings:1.During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 5's diagnoses included cerebral infarction (a condition that occurs when the blood flow to the brain is disrupted due to issues with the arteries that supply it) with hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), heart failure (a heart disorder that causes the heart to not pump the blood efficiently, sometimes resulting 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Ensure one of one sampled resident (Resident 38) was referred to Dental service for readjustment of his dentures.This deficient practice had the potential to result in inability to chew food and weight loss for Resident 38.Findings:During a review of Resident 38's admission Record, the admission Record indicated Resident 38 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 38's diagnoses included low back pain, chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty in breathing), and bipolar disorder (sometimes called manic-depressive disorder, mood swings that range from the lows of depression to elevated periods of emotional highs).During a review of Resident 38's History and Physical (H&P), dated 1/12/2026, the H&P indicated, Resident 38 can make needs known but could not make medical decisions.During a review of Resident 38's Minimum Data Set ([MDS] - a 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 upon observation, interview and record review, the facility failed to: 1.Ensure resident identifiable documentation was accurate for one of six sampled residents (Resident 25).This deficient practice had the potential to negatively impact Resident 25's psychological needs.Findings: During a review of Resident 25's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 25's diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) and major depressive disorder (a mood disorder that causes a persistent 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 interview and record review, the facility failed to ensure two of three sampled residents (Resident 1 and Resident 6), were protected from incidents of abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, deprivation by an individual, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being, including various forms such as physical [any intentional act of force that causes harm, injury, or trauma to another person's body] and sexual [any sexual activity or contact imposed on a person without their consent, often involving force, coercion, or exploitation of vulnerability] abuse), by failing to: 1). Ensure a care plan was developed for Resident 2 who had a history of inappropriate (improper) exposure of his private parts (sexual organ) and harassing female staff and residents when admitted to the facility on [DATE].2). Implement its policy and procedure (P&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 report allegations of sexual and/or physical abuse to the California Department of Public Health (CDPH), for two of three sampled residents (Residents 1 and 6) when: Resident 1 informed the facility that Resident 2 entered her room, lowered his pants, kissed her and touched her vagina on 12/19/2026. Resident 6 informed the facility that Resident 2 hit him on his leg and told him (Resident 6) he wanted to suck his penis on 12/19/2026. This deficient practice resulted in a delay in investigation by the CDPH and placed Resident 1 and Resident 6 at risk for continued abuse. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 1's diagnoses included 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 affecting the arm, leg…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Resident 2's incidents of abuse abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, deprivation by an individual, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being, including various forms such as physical [any intentional act of force that causes harm, injury, or trauma to another person's body] and sexual abuse [any sexual activity or contact imposed on a person without their consent, often involving force, coercion, or exploitation of vulnerability]) on two of three sampled residents (Resident 1 and Resident 6) were investigated, as indicated in the facility's policy and procedure (P&P) titled, Abuse Prevention and Management. This deficient practice placed Residents 1 and 6 at risk for further sexual abuse. This deficient practice placed Resident 6 at risk for further physical abuse. This…

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 3), was provided quality care and services, and assistance with activities of daily living, necessary to ensure the resident was kept clean, dry and comfortable. This failure placed Resident 3 to experience feelings of neglect, anger and sadness. This failure placed Resident 3 at risk of skin breakdown.Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 3's diagnoses included muscle weakness and hypertension (high blood pressure). During a review of Resident 3's History and Physical (H&P) dated 10/21/2025, the H&P indicated Resident 3 had fluctuating capacity to understand and make decisions. During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool) dated 12/23/2025, the MDS indicated Resident 3 usually was able to understand and be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement its infection prevention and control measures for one of three sampled residents (Resident 3) by failing to ensure: Certified Nurse Assistant (CNA) 2 replaced/doffed (remove) gloves, and performed hand performed hand hygiene (washing hands or using an alcohol-based hand sanitizer) during incontinence (lack of voluntary control over urination and/or defecation) care for Resident 3. This deficient practice had the potential to result in cross contamination (transfer of harmful bacteria or viruses from one place, object or person to another) and increased the risk of transmitting disease-causing organisms leading to illness for residents. Findings:During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 3's diagnoses included muscle weakness and hypertension (high blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to: 1.Ensure a written room change with a reason was provided for one of 4 sampled residents (Resident 1). This deficient practice resulted in Resident 1 losing his bed while in the hospital.Findings:During a review of Resident 1's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included metabolic encephalopathy (a condition where the brain's metabolism is disrupted, leading to altered brain function), pneumonia (an infection/inflammation in the lungs), type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 1's history and physical (H&P), dated 8/28/2025, the H&P indicated Resident 1 did…

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 upon interview and record review, the facility failed to: 1.Ensure one of 4 sample residents (Resident 1) was readmitted to the facility after being admitted to the General Acute Care Hospital. This deficient practice resulted in Resident 1 not being re-admitted to the facility and prolonging his GACH stay (four days).Findings:During a review of Resident 1's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included metabolic encephalopathy (a condition where the brain's metabolism is disrupted, leading to altered brain function), pneumonia (an infection/inflammation in the lungs), type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) and schizophrenia (a mental illness that is characterized by disturbances in thought). 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 upon interview and record review, the facility failed to: 1. Ensure one out of 4 sampled residents was readmitted to the facility after being hospitalized (Resident 1). This deficient practice resulted in Resident 1 staying in the hospital for 30 days. Findings: During a review of Resident 1 ' s face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy (a brain dysfunction resulting from problems with the body's metabolism or chemical imbalances), spinal stenosis (a condition where the spinal canal narrows, potentially compressing the spinal cord and nerves), type 2 diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing) and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a review of Resident 1 ' 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 interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Grievances and Complaints which indicated the facility would promptly review, investigate and resolve grievances and complaints for one out of three sampled residents (Resident 1). This failure had the potential for unaddressed and unresolved grievances for Resident 1 and had the potential to negatively affect the resident's quality of life and safety. 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 lack of coordination and hypertensive heart disease (a condition where the heart is damaged or malfunctions due to persistently high blood pressure [hypertension]). A review of Resident 1's History and Physical (H&P) dated 12/24/2024, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1'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 interview and record review, the facility failed to ensure pain management was effective for one of three sampled residents (Resident 1) by failing to: 1.Thoroughly assess and reassess Resident 1 when the resident complained of 4 out of 10 pain (pain rating reference: 1-4=mild pain, 5-7=moderate pain, 8-9= severe pain, 10=excruciating pain) 2.Administer pain medication and/or provide non-nonpharmacological interventions (techniques other than medications to alleviate pain) as ordered by the physician. This failure had the potential to leave Resident 1 with unresolved pain and had the potential to negatively affect Resident 1's physical, mental, and psychosocial wellbeing. 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 lack of coordination and hypertensive heart disease (a condition where the heart is damaged or malfunctions due to persistently high blood pressure [hypertension]).…

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 functional call device (a device used by residents to communicate their needs to staff) for two out of three sampled residents (Residents 1 and 2). This failure had the potential to result in a delay in care for Resident 1 and Resident 2 and the resident ' s needs not being met. 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 lack of coordination and hypertensive heart disease (a condition where the heart is damaged or malfunctions due to persistently high blood pressure [hypertension]). A review of Resident 1 ' s History and Physical (H&P) dated 12/24/2024, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1 ' s Minimum Data Set ([MDS] a resident assessment tool) dated 2/24/2025, indicated Resident 1 had no cognitive (the ability to think and reason) impairment. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide sufficient staff for resident care and safety for one of 30 sampled residents (Resident 7). This deficient practice caused a delayed response to care for Resident 7 after Resident 7's fall and the potential to affect the entire facility. Findings During a review of Resident 7's admission Record, dated 3/23/2025, the admission Record indicated Resident 7 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including muscle weakness (decreased strength in the muscles), glaucoma (an eye disease that gradually damages the optic nerve and can lead to blindness), and legal blindness (a significant level of vision loss). During a review of Resident 7's History and Physical (H&P), dated 3/6/2025, the H&P indicated Resident 7 did not have the capacity to understand and make decisions. During a review of Resident 7's Minimum Data Set (MDS, a mandated resident assessment tool), the MDS indicated Resident 7 sometimes…

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

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation practices in the kitchen when: 1. The cook (Cook 1) and dietary aid (DA) were not wearing a mask while plating breakfast trays. 2. The DA did not change gloves when returning to the tray line (a system of food preparation, used in hospitals, in which trays move along an assembly line) after touching non-food items. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness for residents who received food from the kitchen. 3. Expired foods were stored in the kitchen and accessible for use while preparing foods. This deficient practice had the potential to result in the residents ingesting expired food and the potential for foodborne illnesses leading to symptoms such as nausea, vomiting, stomach cramps, and diarrhea, and a decrease in food flavoring and taste. Findings: a. During an observation of the tray line service for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to implement infection control interventions to prevent the spread of germs in accordance with the facility's Respiratory Protection Program policy and procedure (P/P) impacting 57 of 57 residents and staff, with the improper wear of a N95 (a type of filtering facepiece respirator designed to provide protection from inhaling certain airborne particles) Respirator Mask while in a resident care area. This deficient practice had the potential to lead to the spread of COVID 19 (infectious disease caused by the SARS-CoV-2 virus) to residents and staff. Findings: During an observation on 3/22/2025 at 2:50 p.m., observed Certified Nurse Assistant (CNA 1) entering room [ROOM NUMBER] with a N95 respirator. The string was hanging to the front of the mask. During an interview on 3/22/2025 at 2:55 p.m., with CNA 1, CNA 1 stated she had entered room [ROOM NUMBER] wearing her mask improperly and that wearing the mask with the string to the front did not provide a proper…

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 perform an accurate fall assessment for one of 17 residents (Resident 49) after a fall. This deficient practice had the potential to result in Resident 49 to have recurrent falls and could have lead to improper care planning. Findings: During a review of Resident 49's admission Record, the admission Record indicated Resident 49 was admitted to the facility on [DATE], with diagnosis of lack of coordination and muscle weakness. During a review of Resident 49's History and Physical (H&P), dated 12/24/2024, H&P indicated Resident 49 had the capacity to understand and make decisions. During a review of Resident 49's Care Plan titled Resident is high fall risk and risk for injury dated 12/31/2024, the care plan interventions indicated to follow facility fall protocol. During a review of Resident 49's Minimum Data Set ([MDS] a resident assessment tool), dated 2/25/2025, the MDS indicated Resident 49 was able to understand and be understood by others. The MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a care plan for three of four sampled residents (Resident 43 and Resident 44 and Resident 12) by failing to: 1. Develop a care plan for Resident 43's Restorative Nursing Assistance (RNA) services. 2. Develop a care plan for the use Resident 44's antipsychotic (class of medications used to treat mental illness) medication Risperdal (type of antipsychotic medication that treats mental health conditions such as schizophrenia [a mental illness that is characterized by disturbances in thought] and bipolar disorder [sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs]). 3. Implement a care plan addressing Resident 12's fingernails. These deficient practices had a potential to result in inconsistent implementation of the care plan that may place Resident 43, Resident 44, and Resident 12 at risk of inadequate health care. 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 interview and record review, the facility failed to create a care plan timely for the use of side rails for one of 30 sampled residents (Resident 7). This deficient practice had the potential to cause Resident 7 to not have the appropriate interventions in place. Findings During a review of Resident 7's admission Record, dated 3/23/2025, the admission Record indicated Resident 7 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including muscle weakness (decreased strength in the muscles), glaucoma (an eye disease that gradually damages the optic nerve and can lead to blindness), and legal blindness (a significant level of vision loss). During a review of Resident 7's History and Physical (H&P), dated 3/6/2025, the H&P indicated Resident 7 did not have the capacity to understand and make decisions. During a review of Resident 7's Minimum Data Set (MDS, a mandated resident assessment tool), the MDS indicated Resident 7 sometimes understand and was sometimes…

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 30 sampled residents (Resident 12) was provided care and services to maintain good grooming and personal hygiene. This deficient practice resulted in Resident 12 not receiving nail care and had the potential to cause an infection or injury from the long fingernails. Findings During a review of Resident 12's admission Record, dated 3/23/2025, the admission Record indicated Resident 12 was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy (a change in how the brain works due to a chemical imbalance in the blood), spinal stenosis (a condition when the space inside the backbone is too small), and type 2 diabetes mellitus (a chronic condition when the body cannot use insulin correctly and sugar builds up in the blood). During a review of Resident 12's History and Physical (H&P), dated 2/21/2025, the H&P indicated Resident 12 had fluctuating capacity to understand and make decisions. 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 two of seven residents (Resident 43 and Resident 44), with limited range of motion (ROM, the extent of movement of a joint), received restorative nursing program (designed to improve or maintain the functional ability of residents) care five times a week daily as indicated in the physician order. This deficient practice had the potential to place Residents 43 and 44 at increased risk for ROM decline. Findings: a. During a review of Resident 43's admission Record, the admission Record indicated Resident 43 was admitted to the facility on [DATE], and re-admitted on [DATE] with diagnoses including cerebral infarction (blood flow to the brain is interrupted, leading to damage or death of brain tissue), hemiplegia and hemiparesis (hemiplegia refers to complete paralysis on one side of the body, while hemiparesis describes a more mild weakness or partial paralysis on one side), and quadriplegia unspecified (partial or complete 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 Based on interview and record review, the facility failed to provide side rails as ordered for one of 30 sampled residents (Resident 7). This deficient practice caused Resident 7 to fall and had the potential to cause Resident 7 to have injuries from the fall. Findings During a review of Resident 7's admission Record, dated 3/23/2025, the admission Record indicated Resident 7 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including muscle weakness (decreased strength in the muscles), glaucoma (an eye disease that gradually damages the optic nerve and can lead to blindness), and legal blindness (a significant level of vision loss). During a review of Resident 7's History and Physical (H&P), dated 3/6/2025, the H&P indicated Resident 7 did not have the capacity to understand and make decisions. During a review of Resident 7's Minimum Data Set (MDS, a mandated resident assessment tool), the MDS indicated Resident 7 sometimes understand and was sometimes understood by…

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

Based on observation, interview, and record review, the facility failed to follow the pureed diet (diet that involves consuming foods that are blended, mashed, or strained to a smooth, pudding-like consistency, making them easier to swallow for individuals with chewing or swallowing difficulties) recipe during breakfast by serving liquid consistency French toast. This deficient practice had the potential to result in inadequate nutrition status and placed the residents at a high risk of choking (person can not breath due to blocked airway). Findings: During a concurrent observation and interview on 3/22/2025 at 7:32 a.m. with [NAME] 1, [NAME] 1 was observed plating a pureed diet, which consisted of pureed French toast and pureed eggs. The French toast plated in a cup was liquidly. [NAME] 1 stated the plate was a pureed diet and the bread should have more consistency and not be as watery. [NAME] 1 stated he would add more bread and blend it to make it the French toast pureed. [NAME] 1 was observed blending more French toast with milk to get more a pureed consistency. [NAME] 1 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 observation, interview, and record review, the facility failed to ensure the call light was within reach and accessible for one out of one sampled resident (Resident 8) who needed assistance. This deficient practice resulted in Resident 8 feeling unheard and forgotten while screaming for assistance. Findings: During a review of Residents 8's admission Record, the admission Record, indicated Resident 8 was originally admitted to the facility on [DATE], with diagnoses including a history of muscle weakness and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 8's History and Physical (H/P), dated 3/12/2025, the H/P indicated Resident 8 could make needs known but could not make medical decisions. During a review of Resident 8's Care plan titled High Risk for Falls dated 3/12/2025, the care plan's interventions included to place the resident's call light within reach and encourage the use of the call light. During a review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to: a. Monitor one of three sampled resident ' s (Resident 2) behaviors while the resident was on Risperidone (a psychotropic medication, used to treat certain mental/mood disorders). b. Document one of three sampled resident ' s (Resident 2) indication for an increased dose of Depakote [medication used to treat (bipolar disorder, a chronic mental health condition characterized by significant and persistent shifts in mood, energy, and activity levels)] These failure had the potential to result in inconsistent behavior monitoring and placed Resident 2 at risk for not receiving the necessary interventions for increased psychiatric behaviors. Findings: During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), schizoaffective disorder (a mental illness that can affect thoughts,…

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 protect one of three sampled residents' (Resident 2) right to be free from physical abuse. This failure resulted in Resident 2 slapping Resident 1 on the left side of the face. Findings: During a review of Resident 1's admission Record, the admission Record indicted Resident 1 was admitted by the facility on 8/22/2017 and readmitted to the facility on [DATE] with diagnoses including Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow imprecise movements), polyosteoarthritis (a progressive disorder of the joints caused by a gradual loss of cartilage) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 1/24/2025, the MDS indicated Resident 1's cognitive (ability to think and reason) skills for daily decision-making was moderately impaired…

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 intervention in a resident's care plan titled Comprehensive Person-Centered Care Planning, which indicated hourly visual monitoring should be conducted to one of seven sampled residents (Resident 2), who was at risk for wandering(walking aimlessly)/ eloping (when a resident who is cognitively, physically, mentally, emotionally, and/or chemically impaired leaves a care-giving facility or environment unsupervised, unnoticed, and/or prior to their scheduled discharge). This deficient practice resulted in Resident 2 wandering into other resident ' s rooms and placed Resident 2 at risk for an altercation with another resident. Findings: During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including polyneuropathy (a condition where the nerves that are located outside of the brain and spinal cord are…

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 ensure the call light for one of seven sampled residents (Resident 1) was placed within reach while Resident 1 was in bed. This deficient practice had the potential to cause Resident 1 to not be able to get the help she needed in a timely manner. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including polyneuropathy (a condition where the nerves that are located outside of the brain and spinal cord are damaged), dementia (the loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life), and paranoid personality disorder (a mental disorder characterized by exaggerated distrust and suspicion of other people). During a review of Resident 1 ' s history and physical (H&P), dated 2/29/2024, the H&P indicated Resident 1 did not have…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a comprehensive person-centered care plan (a written plan of care developed by the resident's medical provider, the interdisciplinary team ([IDT] group of healthcare professionals working together to provide residents with needed care), and the resident to help resident achieve his or her treatment goals) was developed and implemented for the safe storage of smoking materials (cigarettes and lighters) for three of three sampled residents (Residents 3, 2 and 1), who were smokers by failing to ensure: 1). Resident 3 was not holding a lighter while coming out of his room on 7/2/2024 at 2 p.m. 2). Resident 2 did not have a lighter on her wheelchair seat while in the room, on 7/2/2024 at 1:50 p.m. 3). Resident 1 did not have a cigarette lighter in her purse on 7/2/2024 at 1:45 p.m. 4). Its Nursing Manual-Resident Rights, titled, Smoking Residents, which indicated the IDT will develop an individualized plan of care for safe storage, use…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Implement its abuse policy and procedure titled Reporting Abuse, indicated the facility should report any resident-to-resident altercations to the State Survey Agency and Ombudsman within 2 hours for one of three sampled residents (Resident 1). This deficient practice placed Resident 1 and other residents in the facility at risk for further abuse. Findings: a. A review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included cerebral infarction (a disrupted blood flow to the brain due to problems with the blood vessels that supply it), atrial fibrillation (abnormal heartbeat), and celiac disease (a chronic digestive and immune disorder that damages the small intestine). A review of Resident 1's History and Physical (H&P), dated 6/6/2024, the H&P indicated Resident 1 had fluctuated capacity to understand and make decisions. A review of Resident 1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility staff failed to notify the physician for one of six sampled residents (Resident 2), when Resident 2 continued to refuse to take her medications: 1. Remeron (antidepressant, medication used to treat depression) 2. Buspirone (antianxiety, medication used to treat anxiety) 3. Seroquel (antipsychotic, medication used to treat schizophrenia) This deficient practice resulted in Resident 2's physician being unaware of Resident 2's change of condition, delayed medical intervention and Resident 2 experienced unnecessary hostile behavior. Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including schizophrenia (mental illness that effects how person thinks, feels, and behaves) bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels), metabolic encephalopathy (problem in the brain), depression (loss of pleasure 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident was free from verbal abuse for one of six sampled residents, (Resident 1). This deficient practice had the potential for Resident 1 to have psychological distress and caused Resident 1 to experience feelings of humiliation and disrespect. Finding: A. A review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including diabetes (high blood sugar), hypertension (high blood pressure), dysphagia (difficulty swallowing), depression (loss of pleasure or interest), and anxiety (feeling fear, afraid, and worry). A review of Resident 1's History and Physical (H&P) dated 4/18/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set ([MDS] a comprehensive standardized assessment and care-screening tool) dated 4/11/2024, the MDS indicated Resident 1 was totally dependent (helper does all the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the State Survey Agency (Bureau of Health Facility Licensing, Certification and Resident Assessment, within the Department of Public Health), a written report of findings for the investigation of an allegation of abuse within five (5) working days for an incident of verbal abuse for one of six samples residents, (Resident 1). This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect residents from further abuse. Findings: A.A review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including diabetes (high blood sugar), hypertension (high blood pressure), dysphagia (difficulty swallowing), depression (loss of pleasure or interest), and anxiety (feeling fear, afraid, and worry). A review of Resident 1's History and Physical (H&P) dated 4/18/2024, the H&P indicated Resident 1 had the capacity to understand 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 implement the baseline care plan for one of six sampled residents, (Resident 2) by failing to: 1. Monitor Resident 2's psychotropic (drug that affects behavior, mood, and thoughts) medications side effects every shift. 2. Monitor Resident 2's mental status closely and report changes to the physician. 3. Assess Resident 2's for signs of distress or anxiety (feeling fear, afraid, and worry). These deficient practices had the potential to result in inconsistent implementation of the care plan that could lead to a delay or lack of delivery of care and services. Findings: A review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including schizophrenia (mental illness that effects how person thinks, feels, and behaves) bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels), metabolic encephalopathy (problem in the brain),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the residents have the right to be free from verbal abuse for one of three sampled residents (Resident 1). This deficient practice had the potential for Resident 1 to have psychological distress. Findings: A review of Resident 1's admission Record (Face Sheet), indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including hypertension (high blood pressure), muscle weakness (a lack of strength in the muscles), diabetes (high blood sugar), and heart failure (a condition in which the heart doesn't pump enough blood to meet the body needs). A review of Resident 1's History and Physical (H&P) dated 11/15/2023, indicated Resident 1 could make needs known but could not make medical decisions. A review of Resident 1's Minimum Data Set ([MDS] a comprehensive standardized assessment and care-screening tool) dated 3/20/2024, indicated Resident 1 could make himself understood, and understand others. The MDS indicated Resident 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility staff failed to timely report the allegation of verbal abuse regarding one of three sampled Residents (Resident 1) to the facility Administrator (ADM), and to other officials including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities. These deficient practices had the potential to place Resident 1 at risk of further abuse, and neglect. Findings: A review of Resident 1's admission Record (Face Sheet), indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including hypertension (high blood pressure), muscle weakness (a lack of strength in the muscles), diabetes (high blood sugar), and heart failure (a condition in which the heart doesn't pump enough blood to meet the body needs). A review of Resident 1's History and Physical (H&P) dated 11/15/2023, indicated Resident 1 could make needs known but couldnot make medical decisions. A review of Resident 1's Minimum Data…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled Abuse-Prevention, Screening, and Training Program, which indicated facility did not condone any form of resident abuse or neglect, for one of three sampled residents (Resident 1), after Resident 2 hit Resident 1. This deficient practice placed Resident 1 at risk for further abuse. Findings: a. A review of Resident 1's admission Record, indicated, Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnosis included schizoaffective disorder (a mental illness that affects person's thoughts, mood, and behavior), Type 2 diabetes mellitus ([DM] abnormal blood sugar), and dementia. A review of Resident 1's History and Physical (H&P), dated 2/18/2024, indicated, Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set ([MDS] an assessment and care screening tool), dated 2/18/2024, indicated, Resident 1 had…

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 within two (2) hours, resident to resident allegation of physical abuse (Resident 2 hitting Resident 1 on the face and right eye with a wooden back scratcher) to the Department of Public Health, Licensing and Certification unit (CDPH), for one of three sampled residents (Resident 1). This failure resulted in the delay of investigation by the Department of Public Health and placing Resident 1 at risk for further abuse and psychosocial harm. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated, Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including schizoaffective disorder (a mental illness that can affect your thoughts, mood, and behavior), Type 2 diabetes mellitus ([DM] - a disease characterized by an impairment of the body ' s ability to control blood sugar levels), and dementia (a decline in memory, language, problem-solving and other thinking…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure a care plan (the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) was formulated for three of 15 sampled residents (Residents 17, 24, 27 and 54). This deficient practice had the potential for the affected residents not to receive the care and services needed and the provision of a poor-quality care. Findings: a. During a review of Resident 17's admission record, the admission record indicated Resident 17 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE], with diagnoses that included major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), metabolic encephalopathy (a problem in the brain, when the imbalance affects the brain, it can lead to personality change), schizoaffective disorder (a mental…

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

Based on observation, interview and record review, the facility failed to: 1. Ensure expired diced tomatoes and candy sprinkles discarded after expiration date. 2. Ensure produce, seasonings, milk, mocha mix, tomato sauce, lemon juice, mayonnaise, mustard, dressings, ice cream, shakes, frozen vegetables, and pasta were labeled with received date and use by date. 3. Ensure personal staff food items were not stored in the refrigerator and dry storage room. 4. Ensure the ice machine was clean. These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization. Findings: During a concurrent observation and interview on 3/5/2024 at 8:15 a.m. with Dietary Supervisor (DS) 1 in the kitchen's: 1. Refrigerator 1, was produce that was not dated. DS 1 stated I didn't think it needed to be labeled. 2. Staff Seasoning 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: 1. Ensure a peripheral catheter ([IV], a thin tube inserted into a vein for therapeutic purposes such as administration of medications, fluids and/or blood products) dressing was dated and kept clean for one of one sample resident (Resident 24). This deficient practice had the potential for the IV insertion site to develop an infection and/or hospitalization for Resident 24. Findings: During a review of Resident 24's admission Record, the admission Record indicated Resident 24 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 24's diagnoses included sepsis (a serious condition that happens when the body's immune system has an extreme response to an infection. The body's reaction causes damage to its own tissues and organs), hypoxemia (a low level of oxygen in the blood), and dementia (loss of the ability to think, remember, and reason to levels that affect daily life and activities). During a review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Ensure respiratory care consistent with professional standards of practice when two of three sampled residents Resident 21 and Resident's 24 oxygen (air) nasal cannula (a device used to deliver supplemental oxygen) tubing, and humidifier (liquid that moistens the air) bottle was not labeled with the date of change. These failures had the potential to result in unsafe use or storage of oxygen equipment, respiratory infection, and/or hospitalization for Resident 21 and Resident 24. 2. Ensure oxygen precaution sign was posted on the door for one of three sampled residents (Resident 21) who was receiving oxygen. This failure had the potential to place residents at risk of injury due to a fire hazard. Findings: During a review of Resident 21's admission Record, the admission Record indicated Resident 21 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 21's diagnoses included acute respiratory failure…

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 there was a physician's order for oxygen (air) therapy for one of three sampled residents (Resident 24). 2. Ensure there was a physician order for the placement, and assessment of a peripheral catheter ([IV], a thin tube inserted into a vein for therapeutic purposes such as administration of medications, fluids and/or blood products) for one of one sampled resident (Resident 24). These failures had the potential to result in unnecessary procedures and/or hospitalization for Resident 24. Findings: During a review of Resident 24's admission Record, the admission Record indicated Resident 24 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 24's diagnoses included sepsis (a serious condition that happens when the body's immune system has an extreme response to an infection. The body's reaction causes damage to its own tissues and organs), hypoxemia (a low level of oxygen in the blood), 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 implement its abuse policy and procedure (P&P) titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating to ensure an allegation of abuse was reported to the California Department of Public Health (CDPH) within two hours, for one of three sampled residents (Resident 1). This deficient practice resulted to the delay in the abuse (monies) investigation by the CDPH and placed Resident 1 at risk for continuous abuse at the facility. Findings: During a review of Resident 1's admission record, the admission record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe), Metabolic encephalopathy (an alteration in brain function caused by an underlying illness causing a chemical imbalance in the bloodstream), major depressive disorder (a mental health disorder…

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 Minimum Data Set ([MDS] a standardized care assessment and care screening tool) significant change in status was completed within the required time frame for one of three sampled residents (Resident 3) This deficient practice had the potential to negatively affect the provision of necessary care and services. Findings: During a review of Residents 3 ' s Face Sheet (admission record), indicated Resident 3 was originally admitted to the facility on [DATE], with diagnoses that included muscle weakness, and dysphagia oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat). During a review of Resident 3 ' s Change of Condition Report dated 11/9/2023, it indicated Resident 3 was having aggressive behavior with complain of increasing pain. During a review of Residents 3 ' s Psychiatric Evaluation Team Assessment Form dated 11/9/2023 it indicated Resident 3 had violent behavior and was threatening to hurt the staff. During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to develop a comprehensive person-centered plan of care for three of twelve sampled residents (Resident 10, Resident 11, Resident 12) to monitor oxygen used via nasal cannula {(medical device that provides oxygen (colorless, odorless, tasteless gas essential to living organisms)}, whom had an order for continuous and as needed oxygen used. This deficient practice had the potential to decrease blood oxygen leading to possible re-hospitalization. Findings: a.During a review of Resident 10 ' s admission Record, the admission record indicated Resident 10 was admitted on [DATE] and readmitted on [DATE] with a diagnosis that included Chronic obstructive Pulmonary Disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs.), Acute Bronchitis (airways of the lungs swell and produce mucus in the lungs.), Congestive Heart Failure (heart muscle has become less able to contract over time or has a mechanical problem that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility staff failed to provide knowledgeable treatment following professional standards of practice by failing to: 1.Verbalized the amount of chest compression per minute for a Cardiopulmonary resuscitation (CPR) (emergency procedure consisting of chest compressions to manually preserve intact brain flow) and ambu bag (provide positive pressure ventilation to patients who are not breathing or not breathing adequately) used according to American Heart Association (AHA) recommendations of 100-120 chest compressions per minute 2. Following the facility policy and procedure to document assessments and interventions during a CPR provide to one of fourteen sampled residents (Resident 4) on [DATE] These deficient practices had the potential to negatively affect the delivery of care and services necessary for patient ' s occupant at the facility. Findings: a.During an interview on [DATE] at 1:40 p.m., with Certified Nurse Assistance (CNA) 4. CNA 4 stated, the…

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

Based on interview and record review, the facility failed to: 1. Ensure a Licensed Vocational Nurse (LVN) 1 had an active professional nursing license before the start of his employment orientation. 2. Ensure a Licensed Vocational Nurse (LVN) 1 had a competency skill (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics in performing that an individual need to perform work roles or occupational functions successfully) check prior to orientation or upon hire. 3. Ensure a Licensed Vocational Nurse (LVN) 1 did not sign the Individual Narcotic (a drug that in moderate doses dulls the senses, relieves pain, and induces profound sleep but in excessive doses causes stupor, coma, or convulsions) Record form without a valid professional nursing license. 4. Follow facility ' s Policies and Procedures of Pre-Employment Activities and Resources, Job Description Manual of LVN, Staff Competency Assessment and Facility Assessment Tool. For one of three randomly selected staff. This deficient practice had the potential for the facility not be able to assess 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: 1. Ensure a Licensed Vocational Nurse (LVN) 1 had an active professional nursing license before the start of his employment orientation. 2. Ensure a Licensed Vocational Nurse (LVN) 1 had a competency skill (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics in performing that an individual need to perform work roles or occupational functions successfully) check prior to orientation or upon hire. 3. Ensure a Licensed Vocational Nurse (LVN) 1 did not sign the Individual Narcotic (a drug that in moderate doses dulls the senses, relieves pain, and induces profound sleep but in excessive doses causes stupor, coma, or convulsions) Record form without a valid professional nursing license. 4. Follow facility ' s Policies and Procedures of Pre-Employment Activities and Resources, Job Description Manual of LVN, Staff Competency Assessment and Facility Assessment Tool. For one of three randomly selected staff. This deficient practice had the potential for the facility not be able to assess the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of four sampled residents (Residents 3) had develop a baseline care plan addressing vaginal bleeding. This deficient practice had the potential to negatively affect the delivery of nursing care and medical interventions to Residents 3. Findings: During a review of Resident 3 ' s admission Record (facesheet), dated 10/6/2023, the face sheet indicated Resident 3 was admitted to the facility on [DATE] with the diagnoses that include type 2 diabetes mellitus (abnormal blood sugar), abnormal uterine and vaginal bleeding, legal blindness, and schizoaffective disorder. During a review of Resident 3 ' s History and Physical (H&P), dated 8/20/2023, the H&P indicated Resident 3 had the capacity to understand and make decisions. During a review of Resident 3 ' s Minimum Data Set ([MDS], a standardized assessment and care planning tool), dated 8/25/2023, the MDS indicated Resident 3 required setup or clean-up assistance for personal hygiene, eating.…

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.