Lodi Creek Post Acute

Based on observation, interview, and record review, the facility failed to follow professional standards of practice for the use of an indwelling urinary catheter (a thin, flexible tube left inside the bladder for continuous urine drainage into a bag, held in place by a small, water-filled balloon at the tip, allowing for long-term or short-term use) for 1 of 7 residents with an urinary catheter (Resident 1) when Resident 1's urinary bag was positioned improperly.This failure had the potential to cause Resident 1 to have complications related to the use of an indwelling urinary catheter.Findings:A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility in 2025 with diagnoses including retention of urine and obstructive and reflux uropathy (a blockage in the body that makes it difficult or impossible to urinate).During a concurrent observation and interview on 11/18/25, at 10:25 a.m., with Licensed Nurse (LN) 2 and Licensed Nurse Consultant (LNC), LN 2 confirmed Resident 1's urinary catheter was placed on the upper bedside rail above the resident'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.

Based on observation, interview, and record review, the facility failed to provide appropriate care for one of one resident (Resident # 6) requiring tube feeding (method of providing nutrients via a tube directly into the stomach or intestine when a person is unable to eat by mouth) when Resident 6's head of bed was not at the prescribed elevated angle.This failure had the potential for Resident 6 to have complications related to tube feedings such as aspiration (when food goes into the lungs instead of the stomach), pneumonia (infection of the lungs), and possible hospitalization. Findings:During a review of Resident 6's clinical record titled, admission Record, the record indicated Resident 6 was admitted to the facility in 5/25 with diagnoses which included dysphagia (difficulty swallowing foods or liquids) and the presence of a gastrostomy (a tube that is surgically inserted into the resident's stomach to allow access for food, fluids, and medications).During an observation in Resident 6's room on 11/18/25 at 10:20 a.m., Resident 6's head of the bed was noted to be almost flat…

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 1 of 18 sampled residents (Resident 106) who required hemodialysis (HD/dialysis, a medical procedure that helps remove waste and excess fluid from the blood when the kidneys are unable to perform this function), received services consistent with professional standards of practice when Resident 106 was not provided meals during and after dialysis sessions.This failure has the potential to cause complications including weight loss for residents on dialysis.Findings:A review of Resident 106's admission RECORD, indicated Resident 106 was admitted to the facility with a diagnosis of, but not limited to, end stage renal disease (when the kidneys are permanently damaged and can no longer filter waste, fluids, and electrolytes from the blood effectively), acute kidney failure (the sudden and rapid loss of the kidneys' ability to filter waste from the blood, balance fluids, and regulate electrolytes), and dependence on renal dialysis (medical treatment that acts like artificial kidneys).During a concurrent…

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 medication management for 1 out of 22 sampled residents (Resident 21) when Resident 21's saline nasal spray was allowed to remain at Resident 21's overbed table without a physician's order for self-administration and without completion of a self-administration assessment.This deficient practice had the potential to result in Resident 21's unsupervised medication use, improper administration, and safety risks.Findings:During a review of Resident 21's admission RECORD, indicated Resident 21 was admitted to the facility with a diagnosis of, but not limited to chronic respiratory failure (long-term condition where the lungs cannot get enough oxygen into the blood), obstructive sleep apnea (a sleep condition where the airway becomes repeatedly blocked during sleep, causing breathing to repeatedly stop and start), abnormalities of gait and mobility, and need for assistance with personal care.During a concurrent observation and interview on 11/18/25, at 2:30 PM, with Resident 21, in Resident 21's room,…

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

Based on observation, interview, and record review, the facility failed to ensure two of eight sampled residents (Resident 69, Resident 34) medication administration record (MAR) maintained accurate documentation when:1. Licensed Nurse (LN) 4 administered Resident 69's Tylenol and did not document administration in Resident 69's Medication Administration Record (MAR); and2. LN 5 administered Resident 34's Docusate (medication used to relieve occasional constipation, usually helps produce a bowel movement in 12 to 72 hours), but was documented as not given on the MAR.This failure had the potential for residents at risk for medication errors, by getting a double dose of the same medication, risk for injury, and possible hospitalization. Findings:1. During a review of Resident 69's admission RECORD, indicated Resident 69 had a diagnosis of diastolic congestive heart failure (a serious condition in which the heart does not pump blood as effectively as it should), chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate…

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 administer the pneumococcal (a serious bacterial infection that can cause respiratory illness) vaccine to two out of five sampled residents (Resident 7 and Resident 105) and the influenza (or the flu, is a contagious viral infection of the respiratory system that can range from mild to severe, causing symptoms like fever, cough, sore throat, muscle aches, and fatigue) vaccine and covid-19 (an infectious respiratory disease caused by the SARS-CoV-2 virus) vaccine to one out of five sampled residents (Resident 105) when:1. Resident 7 was not given the pneumococcal vaccine after consenting to receive it.2. Resident 105 was not given the influenza, pneumococcal and covid-19 vaccines after consenting to receive them.These failures had the potential for Resident 7 and Resident 105 to go unvaccinated with the risk for serious health related illness and/or death.Findings:1. A review of Resident 7's admission Record indicated, she was admitted to the facility…

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 their infection control policy and procedure by failing to ensure that two of six sampled residents (Resident 1 and Resident 4) were tested for COVID-19 after being exposed to a COVID-19 (a contagious disease) positive resident.This deficient practice had the potential to place residents, staff members, and visitors at risk for spreading infection. There was also the potential to cause further delay in the treatment for Resident 1 and Resident 4.Findings:a. Resident 4's admission RECORD indicated Resident 4 was admitted to the facility in 2022 with diagnoses including chronic obstructive pulmonary disease (group of lung diseases that cause long-term breathing problems). A review of Resident 4's medical record titled, SBAR & INITIAL COC/ALERT CHARTING & SKILLED DOCUMENTATION, dated 7/14/25, indicated, .Pt [Patient] tested for COVID19 via rapid nasal swab with positive result.A review of Resident 3's medical record titled, SBAR [Situation Background Assessment Recommendation- communication form] & [and] INITIAL…

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 the proper notice for discharge for Resident 1 when: 1. Resident 1 was not given a 30-day advance written notice of the impending transfer or discharge from the facility, 2. The facility did not notify or send Resident 1's Notice of Transfer or Discharge form to the Ombudsman's office (a government appointed person who actively supports the rights of the residents) on the same day that Resident 1 was served the notice; and, 3. The location listed on Resident 1's Notice of Transfer or Discharge (a document given by the facility to the resident indicating an upcoming transfer or discharge from the current facility to another location) did not match the location listed on Resident 1's discharge order location. These failures could have resulted in Resident 1 not having the opportunity to have had an advocate to inform him of his right to appeal, and Resident 1 could have had an inappropriate transfer or discharge. Findings: 1. A review of Resident 1's medical record titled, admission RECORD, indicated Resident 1 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.

Based on observation, interview, and record review, the facility failed to ensure professional standards of care were met for one of three sampled residents, (Resident 1) when Resident 1 was not repositioned or assisted with care needs in a timely manner. This failure put Resident 1 at risk of discomfort and skin breakdown. Findings: A review of Resident 1 ' s admission RECORD, indicated, she was admitted to the facility in late 2024 with diagnoses which included dementia (condition characterized by memory disorders, personality changes, and impaired reasoning) and muscle weakness. A review of Resident 1 ' s clinical care plan indicated, Resident is at risk for pressure injury development and skin breakdown r/t [related to] immobility, incontinence. Turn and reposition q2h [every 2 hours] and PRN [as needed] During an observation and interview on 10/29/24, at 12:45 PM, with family member (FM) 1, Resident 1 was observed sitting in her wheelchair, FM 1 was sitting in a chair beside Resident 1. FM 1 stated he visited from 9:30 AM until 2:30 PM everyday and Resident 1 was never…

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

Based on observation, interview, and record review, the facility failed to protect one of 6 sampled residents (Resident 1) from physical abuse when Resident 1's arm was grabbed by Resident 2. This failure resulted in Resident 1 sustaining a scratch to her arm and felt unsafe in her room. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in August 2024 with multiple diagnoses including anoxic brain injury (damage to the brain caused by lack of oxygen to the brain) and bipolar disorder (a mental health disorder that causes mood swings). A review of Resident 1's Minimum Data Set (MDS-a Federally mandated assessment tool), Cognitive Patterns, dated 9/5/24, indicated Resident 1 had Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 13 out of 15 that indicated Resident 1 was cognitively intact. A review of Resident 1's SBAR [Situation, Background, Assessment, Recommendation] & Initial COC [Change of Condition]/Alert Charting & Skilled Documentation, dated 9/18/24, indicated .Unwitnessed resident to 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.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of a census of 81 residents, when the emergency Kit (E-Kit, limited number of medications for use in an emergency) log was not filled out for two opened E-Kits. This failure increased the potential for the facility to not have the needed medications available during emergencies that could jeopardize residents' health and safety. Findings: During a concurrent observation and interview on 9/4/24 at 10:01 a.m. with Licensed Nurse 3 (LN 3), stations one and two medication storage rooms had three E-Kits with injectable medications (medications to be administered by injection into the vein or muscle) with blue plastic locks. LN 3 stated the three E-kits with blue locks were recently opened. LN 3 confirmed two out of three E-kits were not logged in the E-kit log. LN 3 stated she does not know when the two E-kits were opened and the yellow form inside it were to be filled out and faxed to the pharmacy letting them know the E-kits were opened, then the yellow form will…

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

Based on observation, interview and record review, the facility failed to ensure medications were labeled, stored, and disposed of consistently according to standards of practice for a census of 81, when: 1. Expired medications were not removed from the medication cart and the medication storage room; 2. Pharmaceutical products were found in the medication storage room and the medication cart without an opened date; 3. Pharmaceutical products with an unclear and torn label was found in a medication cart; 4. Loose medications were found in a medication cup in the first drawer of the medication cart; and, 5. A white powdered medication in medication cups were left unattended at the resident's bedside. These failures had the potential to result in the lack of effectiveness of the medications, increase the potential for medication administration errors and jeopardize residents' health and safety. Findings: 1.During a concurrent observation and interview on 9/4/24 at 10:01 a.m. with Licensed Nurse 3 (LN 3), in station one and two medication storage room there was an opened bottle 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.

Based on observation, interview and record review the facility failed to accurately check and test sanitizing solutions in the kitchen for a census of 81, when: 1. The dishwasher sanitizing solution was not accurately checked for effectiveness; and, 2. The Quatenary Ammonium Compound (QAC; a type of chemical that is used to kill bacteria, viruses, and mold) was not tested at the right temperature and concentration. These failures had the potential to expose residents to foodborne illnesses from improperly sanitized eating utensils served with the residents' meals. Findings: 1. During a concurrent observation and interview with the Registered Dietitian (RD) and the Dietary Aide 1 (DA 1) on 9/4/24 at 1:34 p.m. in the kitchen, the dishwashing activity was observed. DA 1 stated she was doing the dishwashing and the dishwashing machine was a low temperature dishwasher. DA 1 also stated she did not know what should the low temperature dishwashing machine's minimum operational temperature be. The temperature gauge of the machine while operating was observed and registered a temperature 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.

2. A review of Resident 331's admission record, indicated Resident 331 was admitted to the facility in August of 2024 with diagnoses that included, urinary tract infection (UTI; when bacteria multiply in the urinary organs), sepsis (a severe response to infection which can lead to organ damage), and chronic kidney disease (when kidneys are damaged and can't filter blood properly). A review of Resident 331's Order Summary Report, dated 9/4/24, indicated Resident 331 had an active order that started on 8/19/24 for an indwelling urinary catheter (IUC: a medical device that drains and collects urine from the bladder) and a peripherally inserted central catheter intravenous line (PICC IV: a long thin tube put into a vein used to deliver medications over a long period of time). During an interview on 9/4/24 at 1:52 p.m. with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated a timely set up of personal protective equipment (PPE: supplies, such as gloves, gowns, face masks, goggles, to minimize exposure to hazards) and signage indicating a resident was on a transmission based precaution…

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 six residents (Resident 14, 26, 30, 38, 42, and 51) out of 20 sampled residents had call lights (equipment used by a patient to alert or communicate with a caregiver) within easy reach or call lights that were operable. This failure had the potential for residents to be unable to contact nursing staff when needed. Findings: A review of Resident 51's admission Record, indicated Resident 51 was admitted to the facility in October 2021 with diagnoses which included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and dementia (a group of thinking and social symptoms that interferes with daily functioning). During a concurrent observation and interview on 9/3/24 at 10:37 a.m. with Resident 51, in Resident 51's room, Resident 51's call light was observed coiled on the wall where the call light attaches, broken, without a button to push. Resident 51 statedvI don't know where my call light is. During a concurrent observation and interview on 9/3/24 at 12:58…

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

Based on interview and record review, the facility failed to ensure two of 20 sampled residents (Resident 11 and Resident 20) had an informed consent for the use of antipsychotic medications (drugs that mainly treat psychosis-related conditions and symptoms), when: 1. Resident 11's antipsychotic informed consent was not updated every six months; and, 2. Resident 20 had no informed consent for an antipsychotic. This failure decreased the facility's potential to ensure residents or their responsible person(s) were fully informed of the risks, benefits, and alternative treatment options prior to the use of an antipsychotic medication. Findings: A review of Resident 11's admission Record, inidcated Resident 11 was admitted to the facility in 2021 with diagnoses including depression (a serious medical illness that negatively affects how you feel, the way you think and how you act) and bipolar disorder (a mental health condition that causes extreme mood swings). The record further indicated Resident 11's sister was the Responsible Party (RP, a person designed to make healthcare decisions…

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

Based on observation, interview and record review, the facility failed to ensure a baseline care plan (instructions needed to provide effective and person-centered care for the resident developed within 48 hours of admission) for one of 20 sampled residents (Resident 331), when Resident 331's baseline care plan did not include an indwelling urinary catheter (IUC; a medical device that drains and collects urine from the bladder). This failure had the potential to place Resident 331 at risk for unmet care needs. Findings: A review of Resident 331's admission record indicated Resident 331 was admitted to the facility in August of 2024 with diagnoses that included urinary tract infection (when bacteria multiply in the urinary tract [kidneys, ureters, bladder and/or urethra]), sepsis (a severe response to infection which can lead to organ damage) and chronic kidney disease (when kidneys are damaged and can't filter blood properly). During an observation on 9/3/24 at 10:29 a.m., in Resident 331's room, Resident 331 was walking with use of a walker in his room while an IUC drainage bag 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.

Based on observation, interview and record review the facility failed to revise and implement a communication care plan for one of 20 sampled Residents (Resident 20) who did not speak English. This failure increased Resident 20's potential to receive inadequate and inaccurate care. Findings: A review of Resident 20's admission Record, indicated she was admitted with diagnoses of dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), apraxia (a neurological disorder that makes it difficult to perform purposeful movements or tasks, even though the person understands the request and is willing to do it). During an observation on 9/3/24 at 11:24 a.m., Resident 20 was sitting in her wheelchair. The Department was unable to communicate with Resident 20 in English. Resident 20 was observed communicating in a different language and had no communication board in her room. During an interview on 9/3/24 at 11:26 a.m. with Certified Nursing Assistant 4 (CNA 4), CNA 4…

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

Based on observation, interview, and record review the facility failed to provide care and services in accordance with acceptable professional standards of quality for two of 20 sampled residents (Resident 331 and Resident 135) when: 1. Resident 331's peripherally inserted central catheter intravenous line (PICC IV: used to deliver medications into a vein over a long period of time) flushes (a procedure that uses a mixture of salt and water to clear an IV line and reduce the risk of infection) were not documented in accordance with professional standards; and, 2. Resident 135's urinary drainage bag was not enclosed in a privacy bag, the urinary drainage bag collection tube was not kept properly positioned and kept free from kinks for optimal drainage. These failures decreased the facility's potential to prevent worsening of the residents' clinical condition. Findings: 1. A review of Resident 331's admission record, indicated Resident 331 was admitted to the facility in August of 2024 with diagnoses that included urinary tract infection (UTI: when bacteria multiplies in the urinary…

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

Based on observation, interview, and record review, the facility failed to provide a communication board or use translator during assisting care for one resident (Resident 1) of 20 sampled residents. This failure decreased the facility's potential to meet Resident 1's ability to communicate her basic needs. Findings: A review of Resident 1's admission Record, indicated, Resident 1 was admitted to the facility in 2022 with diagnoses including depression (a serious medical illness that negatively affects how you feel, think, and act). A review of Resident 1's undated care plan titled, [Resident 1] has a communication problem [related to] language barrier. Primary language is Portuguese, indicated the interventions were: Listen attentively and allow ample time to communicate. Provide communication board. Utilize help of a translator or interpreter if applicable. During a concurrent observation and interview on 9/3/24 at 9:03 a.m. with Certified Nursing Assistant 2 (CNA 2) in Resident 1's room, CNA 2 confirmed she did not use translator nor communication pictures to communicate with…

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

Based on observation, interview, and record review, the facility failed to ensure two of 20 sampled residents (Resident 282 and Resident 331) who had Vascular Access Devices (VAD, thin flexible tube that provides access to veins for the delivery of IV [Intravenous, administered into a vein] medications) received the necessary care and services when: 1. Resident 282's Midline catheter (a type of VAD used for intravenous treatments of more than six days) was not monitored for signs and symptoms of infection every shift as ordered; and, 2. Resident 331's peripherally inserted central catheter intravenous line (PICC IV: a type of VAD used to deliver medications into a vein over a long period of time) was not monitored for signs and symptoms of infection every shift as ordered. These failures placed the residents at risk for VAD related infections. Findings: 1. A review of Resident 282's clinical record indicated he was admitted to the facility summer of 2024 with multiple diagnoses that included cellulitis (potentially serious bacterial skin infection) of the left lower limb. During an…

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

Based on observation, interview, and record review, the facility failed to provide the necessary care and services for one of 20 sampled residents (Resident 281) who received hemodialysis (HD, a medical procedure that helps remove waste and excess fluid from the blood when the kidneys are unable to perform this function), when her output was not accurately measured as ordered. This failure increased Resident 281's risk in developing fluid overload. Findings: A review of the clinical record indicated Resident 281 was admitted to the facility in summer of 2024 with multiple diagnoses that included end stage renal disease (ESRD, permanent kidney failure that requires a regular course of dialysis or a kidney transplant) and fluid overload. During a conccurent observation and interview on 9/3/24 at 1:10 p.m. in Resident 281's room, Resident 281 was eating lunch. She stated she was feeling tired the day after HD, was urinating in the bathroom and was continent. A review of Resident 281's Order Summary dated 8/30/24, indicated to record intake and output (I&O) in milliliters (ml; a unit 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.

Based on interview and record review, the facility failed to ensure one resident (Resident 11) out of 20 sampled residents received proper monitoring for psychotropic medication (any drug that affects brain activities associated with mental processes and behavior) when there was no manifestation, no diagnosis identified, and no side effect monitoring for Resident 11's buspirone (an antianxiety medication). These failures placed Resident 11 at risk for unnecessary psychotropic medication use side effects. Findings: A review of Resident 11's admission Record, indicated Resident 11 was admitted to the facility in 2021 with diagnoses including depression (a serious medical illness that negatively affects how you feel, the way you think and how you act) and bipolar disorder (a mental health condition that causes extreme mood swings). A review of Resident 11's Minimum Data Set (MDS, an assessment tool), dated 6/20/24, indicated Resident 11 scored 12 out of 15 on the Brief Interview for Mental Status (BIMS) indicating her cognition (the mental action or process of acquiring knowledge and…

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

Based on observation, interview and record review the facility failed to maintain an essential kitchen equipment in good working order and repair for a census of 81, when freezer number (#) six was observed to have an internal temperature of 10 degrees Fahrenheit (a unit of measure for temperature) and was not in good repair. This failure had the potential for residents to become sick from food borne illnesess. Findings: During a concurrent observation and interview on 9/3/24 at 8:25 a.m. with the Certified Dietary Manager (CDM) in the kitchen dry storage area, freezer # six was inspected and the thermometer inside the freezer indicated the temperature was 10 degrees Fahrenheit. A box of turkey ham was stored in the freezer and was rock hard to touch. CDM confirmed the thermometer indicated 10 degrees Fahrenheit and stated the freezer temperature must be kept at zero degrees Fahrenheit or lower. CDM further stated Freezer # six's door seals were not forming a tight seal. Freezer # six had an accumulation of frost inside the top part of the freezer. CDM stated a latch at the bottom…

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

Based on observation, interview, and record review, the facility failed to protect the right to be free from abuse for 1 of two sampled residents (Resident 1) when Resident 1 was hit in the face by Resident 2 causing a scratch to the bridge of the nose and bruise to the left eye. This failure to protect Resident 1 resulted in a scratch to his nose and a bad bruise to the left eye. Findings: During a record review of Resident 1's Face Sheet (FS), the FS indicated, Resident 1 was admitted with diagnoses which included hemiplegia and hemiparesis (one-sided weakness) and aphasia (impairment of language). During a record review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 5/29/24, indicated, Resident 1 had severe memory problems. During a record review of Resident 1's Care Plan (CP) dated 8/14/24, the CP indicated, resident to resident physical altercation in [Resident 1's room] the victim and [Resident 2's room] the perpetrator. During a record review of Resident 1's interdisciplinary team (IDT, a group of healthcare professionals from complementary fields who work…

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 protect the rights to be free from abuse for 1 of 3 sampled residents (Resident 2) when staff witnessed Resident 1 punched Resident 2 in the face during an altercation causing Resident 2's eyes to bleed. This failure resulted in Resident 2 abused by Resident 1 and sustaining a bruise and a skin tear on the right eye. Findings: A review of Resident 1's admission record indicated he was admitted to the facility fall of 2022 with multiple diagnoses that included Dementia (impaired ability to remember, think, or make decisions) and history of traumatic brain injury. A review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 6/13/24, indicated, he had severe memory problems. A review of Resident 1's undated care plan indicated as one of the interventions, Check resident at least every 2 hours and as needed for comfort and safety . A review of Resident 1's Physician History and Physical, dated 6/17/24, 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.

Based on observation, interview, and policy record review, the facility failed to ensure medications were stored locked for the census of 82, when a medication cart (Med Cart 2) was left open and unattended in the hallway. This failure had the potential for medication misuse and drug diversion. Findings: During a concurrent observation and interview on 8/1/24 at 11:17 a.m. with Licensed Nurse 1 (LN 1), the Medication Cart 2 was observed left opened and unattended in the hallway. There were other residents in their wheelchairs and staff near the medication cart. LN 1 was not near the Medication Cart 2, but was sitting down and, on the phone, talking at the nursing station. LN 1 confirmed she was not aware the medication cart was unlocked and confirmed it should always be locked. During an interview on 8/1/24 at 12:07 p.m. with the Director of Nursing (DON), the DON confirmed the expectation is staff members lock the medication cart when they are not attending to (close by) the cart. The DON further stated staff may not see residents sitting in wheelchairs because they are too low…

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

Based on interview and record review, the facility failed to ensure complaints and grievances were documented as directed by their grievance policy and procedure for one of 3 sampled residents (Resident 1). This failure had the potential for Resident 1's concerns not to be thoroughly investigated and resolved. Findings: A review of Resident 1's clinical records indicated she was admitted to the facility late 2021 with multiple diagnoses that included Alzheimer's Disease (brain disorder that affects memory, thinking and behavior). A review of Resident 1's IDT [Interdisciplinary, a group of professional staff ]- CARE CONFERENCE & CARE PLAN dated 2/23/24 indicated, Spoke with RP [Responsible Party] .Here are the primary concerns we have re [regarding] her care and lack thereof at [name of facility]: : We call to speak with [Resident's name] and are told to hold for the transfer to her ward but no one ever responds and puts her on the phone .this has been for the past 2-3 months. We have not been able to speak to her .Last time we visited, [Resident 1's] personal hygiene was not good.…

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 adequate supervision of two residents (Resident 1 and Resident 2) of three sample residents when Resident 2 allegedly pushed Resident 1, resulting in Resident 1's fall and experiencing pain, swelling and hematoma (bad bruise, an injury that causes blood to collect and pool under the skin). This failure decreased the facility's potential to ensure sufficient staff monitoring of residents to ensure resident safety. Findings: A review of an admission Record indicated Resident 1 was re-admitted to the facility late 2022 with multiple diagnoses which included dementia (loss of cognitive functioning - thinking, remembering, and reasoning) difficulty walking and history of falling. Resident 1's Minimum Data Set (MDS, an assessment tool), dated 5/17/23, indicated moderate memory problems. A review of an admission Record indicated Resident 2 was admitted to the facility late 2022 with multiple diagnoses which included dementia, 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 ensure the medication error rate did not exceed 5% when: 1. Resident 60 was administered crushed metoprolol (a medication to treat high blood pressure) XR [extended release] and omitted a dose of aspirin; and, 2. Resident 45 was administered isophane insulin (an intermediate-acting medication to lower blood sugar levels) without being rolled prior to administration. These failures resulted in two medication errors and one omitted dose being identified out of 29 opportunities during an observation of medication administration which resulted a medication error rate of 10.34%. Findings: 1. A review of Resident 60's admission Record indicated Resident 60 was admitted in early 2023 with diagnoses including palliative care (specialized medical care for people with a serious illness) and dysphagia (difficulty swallowing). During a concurrent observation and interview on 8/1/23 at 8:11 a.m., during the medication pass with Licensed Nurse 1 (LN 1), LN 1 took 1 tablet of metoprolol 50 mg (milligrams, a unit 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 safe medication storage practices for a census of 81 when: 1. One of three medication carts was left unlocked; 2. Loose pills were found in two of two medication carts; and, 3. Outdated medication was found in two of two medication carts. These failures had the potential to contribute to medication error, unsafe medication use and storage, and diversion. Findings: 1. During an observation on [DATE] at 3:20 p.m., Licensed Nurse 4 (LN 4) was administering medication for a resident in room [ROOM NUMBER]. The medication cart was in the hallway and unlocked. The LN 4 was inside the resident's room with her back facing the medication cart. During an interview on [DATE] at 3:23 p.m., LN 4 confirmed the medication cart should be locked when not in view. During an interview with the Director of Nursing (DON) on [DATE] at 11 a.m., the DON confirmed the medication cart should be locked at all times when not in view. During a review of the…

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

Based on interview and record review, the facility failed to maintain confidential information when resident meal tickets were thrown in the regular trash. These failures decreased the facility's potential to prevent resident-identifiable information being accessible to the public. Findings: During a follow up tour and observation of the kitchen on 8/1/23 at 8:34 a.m. the Dish Washer Personnel (DWP) was observed cleaning the dirty dishes from the served breakfast meal. The DWP was observed scraping away food scraps and placing resident meal tickets into the regular trash. In a concurrent interview, the DWP confirmed she scraped away all the food items from the trays including the residents meal tickets and threw them together in the regular garbage. The DWP confirmed the meal tickets had the resident's name, room number, type of diet, food allergies and food dislikes. The DWP stated she was trained to throw all of these together in the regular trash. In an interview with the Food Service Manager (FSM) on 8/1/23 at 8:35 a.m., the FSM confirmed the DWP scraped the food away and threw…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to establish and maintain infection control practices designed to provide a safe and sanitary environment and help prevent the transmission of diseases and infections for a census of 81 when: 1. The Dietary Assistant (DA) used a gloved hand to rub her nose and continued to prepare lunch plates without washing her hands or putting on new gloves; 2. The Dietary Services Supervisor (DSS) refilled fresh butter sauce into a bottle with older butter sauce which had initially been filled 11 days prior; 3. Staff members did not use hand hygiene before and after providing resident care or during medications administration; 4. A juice dispensing machine spike was left uncovered; 5. The dry storage room was not maintained in a clean and sanitary manner; 6. The base of the bench can opener was not clean; and, 7. The ice machine was unsanitary in the kitchen. These failures had the potential to result in transmission of infection in the facility 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 and record review the facility failed to maintain essential kitchen equipment in good working order and repair when: 1. The beverage dispensing machine was not kept in a sanitary condition; 2. The ice machine was not cleaned and sanitized; and, 3. The kitchen equipment cleaning schedule was not followed. These failures had the potential for residents to become sick. Findings: 1. In a tour of the kitchen on 8/1/23 at 8:25 a.m. there was a juice dispensing machine on the kitchen counter. The Dietary Service Supervisor (DSS) stated they use the machine to pour and serve juice for the residents. Upon further observation of the juice dispensing machine there were two spike connectors for the beverage machine which were not in use and were left at the bottom of the shelf. In a concurrent interview with the DSS she confirmed the connectors were not in use and were stored uncovered below the shelf. The DSS stated spiked connector ends should be covered. The DSS was asked for a policy and maintenance manual of the beverage machine, but was unable to provide one. 2.…

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

Based on interview and record review, the facility failed to ensure services provided met professional standards when: Staff did not follow physician orders when they cleaned Resident 16's indwelling catheter (a tubing that collects urine attached to a drainage bag). This failure decreased the potential to provide effective care and services that meet the nursing standards of quality. Findings: 2. A review of a physician's order dated 6/22/23 indicated for staff to cleanse Resident 16's indwelling catheter site with water and soap, rinse then pat dry every shift (morning (AM), evening (PM), and nocturnal (NOC)). During a concurrent interview with the Medical Records Director (MRD) and record review of Resident 16's Treatment Administration Record (TAR) on 8/3/23 at 3:10 p.m., the TAR indicated no charting and no LNs initials on 3/24/23 PM shift, 3/26/23 NOC shift, 3/31/23 PM shift, 3/31/23 NOC shift, 5/3/23 AM shift, 5/12/23 PM shift, 5/20/23 NOC shift, 5/21/23 NOC shift, 6/23/23 PM shift, and 7/15/23 AM shift. The MRD confirmed she was not able to verify if the order was carried…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow a physician's order to clean an indwelling catheter (a tubing that collects urine attached to a drainage bag) for one resident (Resident 16) of 23 sampled residents for a census of 81. This failure reduced the facility's potential to prevent urinary tract infections. Findings: During a review of an admission Record indicated Resident 16 was admitted to the facility on [DATE] with multiple diagnoses, which included major depressive disorder, and encounter of palliative care (care for life-limiting illness). During a review of Resident 16's physician's order, dated 6/22/23, indicated nursing staff were to cleanse the indwelling catheter site with water and soap, rinse then pat dry every shift (morning (AM), evening (PM), and nocturnal (NOC)). During a concurrent interview and record review on 8/3/23, at 3:10 p.m., with the Medical Records Director (MRD), Resident 16's Treatment Administration Record (TAR) indicated no charting and no…

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

Based on interview and record review, the facility failed to ensure three residents (Resident 59, Resident 11, and Resident 21) out of 23 sampled residents received proper monitoring for psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) when: 1. Resident 59 did not have orders to monitor behavior and side effects; and 2. Resident 21 was prescribed quetiapine (a psychotropic medication that affects the brain associated with mental processes and behavior) without appropriate indications for use, behavior, and medication side effects monitoring. These failures placed the residents at risk for unnecessary psychotropic medication use. Findings: 1. A review of Resident 59's admission record indicated Resident 59 was admitted in early 2023 with diagnoses including dementia with behavioral disturbances (exhibiting agitation, including verbal and physical aggression, wandering, and hoarding) and major depressive disorder. A review of Resident 59's Minimum Data Set (MDS, standardized assessment tool) indicated Resident 59 had mild…

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.