Lodi Nursing & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure interventions were implemented to maintain and prevent decline in functional ability (the resident's ability to move and perform daily activities) for one of 23 sampled residents (Resident 31) when Resident 31's physical therapy (PT: a healthcare specialty service focused on improving movement, reducing pain, and restoring physical function through tailored exercises, manual techniques, and education) was discontinued despite a physician's order to extend physical therapy and without a plan to maintain or prevent decline in functional abilities through restorative nursing assistant (RNA - a program where trained staff help residents practice exercises and daily activities to maintain strength and mobility) services.This failure placed Resident 31 at risk for functional decline and complications related to decreased mobility such as muscle atrophy (muscle becomes smaller and weaker from lack of use), pressure injuries, contractures…

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's Quality Assurance Committee (a mandatory, internal group within a nursing home or skilled nursing facility. Its purpose is to identify, monitor, and improve the quality of care and life for residents, as required by federal law for facilities receiving Medicare or Medicaid funding) failed to meet quarterly with all required members, when the Administrator (ADM) and the Medical Director (MD) did not attend the scheduled quarterly meetings as required.This failure decreased the facility's potential to identify, monitor, implement and enhance the quality of care for residents for a census of 69.Findings:During a concurrent interview and record review on 3/6/26, at 11:17 AM, with the Director of Nursing (DON) and the ADM, the Quality Assurance and Performance Improvement (QAPI- a data-driven, proactive approach mandated by the Centers for Medicare & Medicaid Services [CMS] for healthcare facilities to continuously monitor, analyze, and improve the quality of care and services) binder was reviewed. The ADM confirmed that the previous…

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 functioning call light system (system/device used by residents to call staff for assistance) was in place for 2 of 23 sampled residents (Resident 61 and Resident 62) when Resident 61 and Resident 62's call light was not working.This failure had the potential to result in Resident 61 and Resident 62 being unable to call staff for help when needed and their needs not being met.Findings:1a. A review of Resident 61's admission RECORD, indicated Resident 61 was admitted to the facility in the spring of 2025 with diagnoses including difficulty in walking, muscle weakness, and acute respiratory failure with hypoxia (a condition where there is not enough oxygen or too much carbon dioxide in the body).A review of Resident 61's clinical record titled, Care Plan Report, dated [DATE], indicated .Focus: Altered bladder elimination due to incontinence related to: Mobility deficit .The interventions include: Answer light promptly.Focus: High…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN: a notice that informs residents of changes to their Medicare Part A coverage for the purpose of determining financial liability for expenses incurred for extended care items or services furnished to a beneficiary and for which Medicare does not pay) to one of one sampled resident (Resident 2) reviewed for Medicare benefit notification after skilled services ended.This failure had the potential for Resident 2 not to be able to make informed decisions about his care and finances, being unaware of his right to appeal and placed him at risk for unexpected medical bills.During a concurrent interview and record review on 8/6/25, at 2:48 PM, the Admissions Coordinator (AC) stated Resident 2's Medicare Part A skilled services coverage ended on 7/23/25. The AC stated Resident 2 continued to stay in the facility after his skilled care ended. The AC confirmed that Resident 2'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 interview, and record review, the facility failed to ensure an accident-free environment when necessary rehabilitation care instructions for nursing staff were not updated in the care plan for one of three sampled residents (Resident 1) when Resident 1 was placed in a regular wheelchair instead of a recliner wheelchair with a non-slip mat.This failure resulted in Resident 1 falling out of the wheelchair and hitting his head on the floor on 7/27/25. Findings:A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility in 2025 with diagnoses including hemiplegia (paralysis or weakness to one side of the body) and hemiparesis (one- sided muscle weakness) following cerebral infarction (also known as stroke, when blood flow to the brain is interrupted, leading to brain tissue damage) affecting right dominant side, difficulty in walking, and paraplegia (inability to voluntarily move the lower parts of the body).A review of Resident 1's Brief Interview for Mental Status (BIMS - a standardized assessment to quickly evaluate a resident's cognitive…

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.

The facility failed to store, prepare, distribute and serve food in accordance with professional standards and facility policy for food service when: 1. An Ice machine was not cleaned per manufacturer's guidelines and facility policy. 2. Lunch meal foods were not handled and served safely under sanitary conditions during a trayline observation. 3. Coffee machine water filter was expired for more than 1.5 years. 4. Serving ladles and scoop handles were damaged and not maintained in food safe manner. 5. A Griddle top collection tray cup had black sticky grime, brown stains and food residue inside of it. 6. Curry powder seasoning was out of date and code. 7. Parsley was found to be discolored with a tannish brown color on the leaves and stems. These failures had the potential to cause widespread foodborne illness in the 61 residents eating facility prepared meals. Cross reference F802 Findings: 1. During an interview 10/29/24 at 10:50 AM with the Maintenance Director (MTD), the MTD stated the ice machine was cleaned every three months. During an interview on 10/31/24 at 2:08 PM 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 needs were accommodated for 8 of 21 sampled residents (Resident 36, Residents 40, Resident 21, Resident 38, Resident 1, Resident 23, Resident 50, and Resident 39), when: 1. Residents 40, Resident 21, Resident 38, Resident 1, and Resident 39 call light did not work and were not provided alternative means to contact staff, and for Resident 23 and Resident 50 staff did not respond timely to calls made by Resident 23 and Resident 50 who were given and alternative means to contact staff; and 2. Resident 36's call light (device used to contact staff for assistance) was not within reach. This failure had the potential to result in Resident 36, Residents 40, Resident 21, Resident 38, Resident 1, Resident 23, Resident 50, and Resident 39 experiencing frustration and anxiety about calling for assistance, and not having needs met. Findings: 1. Review of Resident 40's admission record indicated Resident 40 was admitted with diagnoses including Ataxic Gait (uncoordinated movements when walking), Acute Respiratory…

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 kitchen staff competently carried out the functions of the food and nutrition services department according to facility policy and standards of practice when: 1. Two Cooks and two Dietary Aides did not use proper food safety and sanitation practices to prevent cross-contamination; and 2. Weekly thermometer temperature calibrations were not completed by kitchen staff per facility policy. These failures had the potential to expose residents to bacterial contamination, that could result in food borne illnesses for all residents who consume food from the kitchen. The census was 61. Findings: 1. During a tray line observation on 10/29/24 at 12:49 PM, two cooks and two dietary aides were observed not wearing gloves and using their bare hands while plating the lunch meal food to be served. [NAME] (CK) 1 was observed placing her bare thumb on the inside of a foam container while placing a portion of meatloaf into the space of the container touched by her thumb. CK 2 was observed preparing small dessert…

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

Based on observation, interview and record review, the facility failed to ensure that food was served at an acceptable texture and palatability (taste) for six of six residents (Resident 12, Resident 55, Resident 22, Resident 26, Reisdent 16, and Resident 25) on a pureed (to blend, chop, mash, or strain a food until it reaches this soft consistency) diet when; 1. The cook did not follow a pureed recipe as written for the preparation of dilled zucchini and carrots; and 2. Pureed food items were not of correct texture and consistency. These failures had the potential to affect meal and food intake which could impair the nutrition status for the six residents on a pureed diet. Findings: 1. During a concurrent kitchen observation and interview on 10/29/24 at 12:49 PM with [NAME] (CK) 2, a small metal pan with puree dilled carrots and zucchini vegetables were placed on a steam table. The puree carrot and zucchini mixture was noted to have a dark brownish color. [NAME] (CK) 2 stated that she put the puree vegetable mixture in the oven to keep it warm before 10:00 AM. CK 2 then used 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.

Based on observation, interview, and record review, the facility failed to ensure residents received snack foods that met their preferences, including two unsampled residents (Resident 19 and Resident 63), based on facility policy. This failure had the potential to lead to decreased food intake which could impair the resident's nutrition and health status. The facility census was 61. Cross reference F805 Findings: During a review of the facility's resident council meeting minutes from April 2024-October 2024, the meeting minutes indicated several concerns about not receiving regular snacks and nourishments. 1. During the resident council meeting on 10/30/24 at 10:27 AM with ten anonymous facility residents, the residents were asked Do you receive snacks at bedtime or when you request them? and the residents stated no, they run out of snacks, peanut butter and jelly, crackers, chocolate cookies, white bread, and dietary preferences for medical preferences are not met. The resident council attendees also stated the food here could be a lot better .we complained about meals and food…

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 practice appropriate infection prevention and control measures for a census of 61, when: 1. A used urinal (a container used to collect urine) in Resident 51's shared bathroom was not labeled with a resident identifier; and, 2. The shared glucometer (a device used to measure blood sugar) and blood pressure device (BP device, measures the pressure of blood pushing against the walls of arteries) were not cleaned and sanitized in-between resident care based on manufacturer's recommendation and standards of practice. These failures had the potential to spread infections to residents residing in the facility, negatively impacting their health and well-being. Findings: 1. During an observation on 10/29/24 at 10:49 a.m. in Resident 51's shared bathroom (shared with Resident 27 and Resident 43), one urinal with no resident name and/or room number was observed on a metal grab bar. During a concurrent observation and interview on 10/29/24 at 10:51 a.m., with Certified Nursing Assistant (CNA) 2, CNA 2 confirmed 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 observation, interview, and record review, the facility failed to ensure kitchen equipment was maintained in a safe, operating, and fully functioning manner, when a low-temperature dishwashing machine was not maintaining the correct wash temperature, per manufacturer specifications and facility policy. This failure had the potential to impact the ability of dietary staff to prepare and serve food in a safe and sanitary manner. The facility census was 61. Findings: During the initial kitchen tour observation on 10/29/24 at 9:05 AM, the low temperature dish machine was observed during a wash cycle of dishes and the wash temperature ranged between 90-100 degrees Fahrenheit (F) on the thermometer. During an interview on 10/29/24 at 9:10 AM with Dietary Aide (DA) 1, DA 1 stated the minimum temperature for the dish machine wash cycle should be 120 degrees F. DA 1 also stated that the booster equipment attached to the dish machine that heats the water temperature up to the proper level, was not working, causing the dish machine not to reach 120 degrees F. DA 1 further stated 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 failed to ensure residents were treated with dignity and respect for one of twenty-one sampled residents (Resident 10) when: 1. Certified Nursing Assistant (CNA) 1 stood over Resident 10 while assisting him with his meals; and, 2. CNA 1 called residents feeders who needed assistance with meals. This failure resulted in Resident 10 not being provided with a respectful and dignified dining experience, which could further impact Resident 10's quality of life. Findings: 1. During a review of Resident 10's admission Record (a summary of information regarding a patient which includes patient identification, past medical history, and other pertinent information), indicated Resident 10 was admitted to the facility in August 2024 with diagnoses which included dysphagia (difficulty in swallowing) and muscle weakness. During a review of Resident 1's Minimum Data Set (MDS- an assessment and care screening tool), the functional status section of the MDS dated…

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

Based on observation, interview, and record review, the facility failed to protect the right for privacy of one of twenty-one sampled residents (Resident 45) when Resident 45 had no privacy curtains (cloth that separates residents and provides them with privacy). This failure had the potential to negatively impact Resident 45's psychosocial well-being. Findings: During a review of Resident 45's admission Record, the record indicated Resident 45 was admitted to the facility on Fall of 2023. Resident 45's diagnoses included muscle weakness. During a concurrent observation and interview on 10/29/24 at 11:13 AM Resident 45 pointed to his curtains and stated, Curtain isn't able to close all the way. Since I've been here, I have no privacy. During an interview on 10/29/24 at 11:15 AM with Certified Nursing Assistant (CNA) 2, CNA 2 stated she had not been aware Resident 45's curtain was missing, and stated that without the curtain she would not be able to give Resident 45 privacy if she was providing care for Resident 45. During an interview on 10/29/24 at 11:17 AM with the Director 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 ensure one of twenty-one sampled residents (Resident 43) was assisted with nail care as a part of Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) when staff did not trim Resident 43's long, thick, and discolored toenails. This failure had the potential for Resident 43 to sustain injury and/or to acquire an infection. Findings: Review of Resident 43's admission Record (AR - a summary of information regarding a patient which includes patient identification and past medical history), indicated Resident 43 was admitted to the facility in June 2024 with diagnoses which included neoplasm (abnormal mass of tissues) of bladder, encounter for palliative care ( specialized medical care that focuses on providing relief from pain and other symptoms of illness), anxiety, and heart failure. Review of Resident 43's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 9/12/24, indicated Resident 43 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 observation, interview, and record review, the facility failed to provide restorative services to one of twenty-one sampled residents (Resident 35) when physical therapy was discontinued and further services by Restorative Nursing Assistant were not provided. This failure had the potential to cause a decline in Resident 35's optimal level of function. Findings: During a review of Resident 35's admission Record (AR - a summary of information regarding a patient which includes patient identification and past medical history), indicated Resident 35 was admitted to the facility in August 2023 with diagnoses which included fracture of lower end of right femur (the bone of the thigh), abnormalities of gait and mobility, and muscle weakness. During a review of Resident 35's care plan initiated on 8/30/23, indicated, .Focus .Self Care Deficit as evidenced by - Requiring assistance or is dependent in: Bed mobility (extensive) .toileting (extensive) .personal hygiene (extensive) .interventions .Physical therapy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of four residents (Resident 27) with an indwelling catheter (foley catheter-a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage) received proper care and services consistent with professional standard of care, when Resident 27's urinary collection bag was not positioned lower than his bladder (body organ where urine is collected). This deficient practice had the potential to result in urinary tract infection (UTI- an infection in any part of the urinary system, the kidneys, bladder, and urethra) for Resident 27. Findings: Review of Resident 27's admission Record (AR - a summary of information regarding a patient which includes patient identification and past medical history), indicated, Resident 27 was admitted to the facility in November 2024 with diagnoses which included encounter for palliative care ( specialized medical care that focuses on providing relief from pain…

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 storage practices for a census of 61 residents when: 1. Staff's personal belongings were stored in one of two medication storage rooms; and, 2. Loose pills were found on the floor and at the bottom of the base cabinet in the medication storage room. These failures had the potential to contribute to unsafe medication storage and diversion. Findings: 1. During a concurrent observation and interview on 10/30/24, at 2:44 p.m. with the Director of Nursing (DON) and Licensed Nurse (LN) 1, the Station 2 medication storage room was inspected with the DON. One personal bag and an insulated water bottle were observed to be stored on the top of the base cabinet. LN 1 confirmed the personal bag and insulated bottle belonged to her. LN 1 stated the personal items should not be stored in the medication room. During an interview on 10/30/24, at 2:46 p.m. with the Director of Nursing (DON), the DON acknowledged staff's personal belongings were stored in Station 2 medication room. The DON stated it 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 provide a diet in the correct texture to meet the needs of an unsampled resident, (Resident 19), according to facility policy. This failure had the potential to negatively impact Resident 19's food intake which could further impair nutrition status and lead to weight loss. The facility census was 61. Cross reference F806, CA Title 22-72337 Findings: Review of Resident 19's admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses which included, essential hypertension (high blood pressure), gastro-intestinal esophageal reflux disease (GERD) (a condition in which stomach acid repeatedly flows back up into the tube connecting the mouth and stomach, called the esophagus), and constipation (difficulty having bowel movements). Review of the Minimum Data Set document indicated Resident 19 had a BIMS (Brief Interview of Mental Status) of 13, where 13-15 points indicated a person's cognition (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.

Based on observation, interview, and record review, the facility failed to ensure the needs of two of twenty-one sampled residents (Resident 3 and Resident 36) accommodated when water pitchers were not available or empty at the bedside. These failures had the potential to result in potential health problems related to dehydration (A condition that occurs when the body loses too much water and other fluids that it needs to work normally.) for Resident 3 and Resident 36. Findings: During an observation on 10/30/24 at 11:34 AM in Resident 36's room, the water pitcher on the bedside table was empty. During a concurrent observation and interview on 10/30/24 at 4:06 PM, in Resident 3's room, Resident 3 was observed sitting in her wheelchair with no water pitcher on her bedside table in front of her. Resident 3 stated that she was thirsty and wanted something to drink. During a concurrent observation and interview on 10/31/24 at 2:09 PM just outside of Resident 3 and Resident 36's room, with Certified Nursing Assistant (CNA) 3, CNA 3 confirmed Resident 3 did not have a water pitcher 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 the usual body weight of one resident (Resident 28) who experienced an unplanned 19 pound (lb)/14.8% weight loss over 9 months. This had the potential of decreased immune function, decreased muscle mass, and loss of independence. Findings: Resident 28 was readmitted to the facility winter of 2022 with diagnoses including COVID-19 (a disease caused by a virus that is contagious), anemia (blood condition lacking healthy red blood cells), and muscle weakness. Weight history included the following: 12/27/22=128 lbs. 1/23/23=121 lbs. 3/2/23=119 lbs. 4/5/23=116 lbs. 5/2/23=115 lbs. 6/4/23=113 lbs. 7/3/23=109 lbs. 8/1/23=110 lbs. 9/4/23=108 lbs. 10/1/23=109 lbs. This represented a decrease of 19 lbs./14.8% of her body weight. During an interview with Resident 28 conducted on 10/10/23 at 3:55 p.m., she reported that she did not like the facility food, stating that the food tasted off and the spices used to season it upset her stomach. Resident 28 stated that she would like to have ginger ale, fresh fruit,…

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 its medication error rate was less than five (5) percent (%) for three out of four sampled residents (Resident 50, Resident 23, and Resident 7) when: 1. Licensed Nurse (LN) 1 did not follow the physician's order in administering Resident 50's prescribed medication; 2. LN 2 administered Resident 23's prescribed medication with a wrong dosage (strength of a medication); and 3. LN 2 did not administer a prescribed medication for Resident 7 which was due as ordered. These failures resulted in three medication errors identified out of 30 opportunities during the observation of medication administration; the facility medication error rate was 10%. Findings: 1. During a concurrent observation and interview on 10/10/23, within the medication administration observation started at 8:28 a.m., with LN 1, LN 1 was observed preparing medications for Resident 50. LN 1 used the bottle cap of the Miralax (a medication used to treat difficulty passing stool) container to measure how much Miralax powder to administer 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 medications and supplies were properly labeled and properly stored in accordance with manufacturer guidelines, the facility's policies and procedures, and accepted professional principles for a census of 59 when: 1. Three loose pills and a medication bag with prescription label were found on the bottom of medication cart two; 2. A used insulin medication (a medication used to treat high blood glucose) vial (a glass container used for holding liquid medicines) was found in the medication cart two without a resident label; and, 3. An expired vial of an opened insulin medication was found in medication cart two. These failures had the potential for diversion of the loose medications, risk for breach of resident's personal information, medication could be given to the wrong resident, and for residents to receive medications that were expired or with unsafe or reduced potency. Findings: 1. During a concurrent observation and interview on 10/10/23 at 10:36 a.m. with Licensed Nurse (LN) 1 of medication cart…

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 food to accommodate resident allergies, intolerances, and preferences for three out of 59 residents (residents 3, 12, and 38). These failures had the potential for allergic reactions, food intolerance and weight loss for these three residents. Findings: 1. Resident 12 was admitted in the fall of 2023 with diagnoses including type 2 diabetes (inability to process sugar), hypertensive heart disease (high blood pressure), and vitamin D deficiency. During an interview on 10/10/23 at 3:27 p.m., Resident 12 reported that he does not tolerate bell peppers and intake will lead to an upset stomach. Resident 12 stated this intolerance had been reported to the dietary department, but he continued to receive food with bell peppers such as stir-fried vegetables (in which he counted 12 slices of bell pepper). Resident 12 further explained that he doesn't understand many of the menu item's names so was unsure when to order an alternative, and if a food contains red, green, or yellow items he would not eat it fearing…

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

Based on observation, interview, and record review, the facility failed to ensure food was safely stored and prepared under sanitary conditions for a census of 59 when: 1. Items stored in the reach-in-refrigerator and walk-in-freezer were not properly dated; 2. The can opener tip was found chipped and with brown markings; 3. The steam table-pans were stored wet as well as the blender; 4. Uncooked bacon stored over hard cooked eggs; and, 5. [NAME] streaks were observed running down the sides of the kitchen stove, which were also rusted. The pipes behind the kitchen stove were rusted and covered in a dark fuzzy substance. These failures had the potential to cause foodborne illness (illness caused by consuming contaminated food) to residents receiving food from the kitchen. Findings: 1. During the initial kitchen tour on 10/10/23 at 8:18 a.m., a jar of Maraschino cherries was dated 10/20 in the reach-in-refrigerator. An opened bag of diced ham chunks dated 10/10 with no use by date. A box of cheese & garlic biscuit dough dated 10/9, a box of 12 wheat round top bread dated 10/5, and a…

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

Based on observation, interview, and record review, the facility failed follow and maintain an effective infection prevention and control program for a census of 59 when: 1. Residents' non-pharmaceutical personal belongings were found stored in the medication carts with pharmaceutical products; 2. Resident 38's used oxygen masks and tubing (used to deliver oxygen to patients who need supplemental oxygen) and nebulizer (device used to deliver medicine to lungs) masks were not properly stored; and, 3. There was an unsanitary condition in the laundry room. These failures had the potential to spread germs and cause infection among residents, staff, and visitors. Findings: 1. During a concurrent observation and interview on 10/10/23 at 10:20 a.m. with Licensed Nurse (LN) 3 of medication cart 1, a resident's personal electric wrist blood pressure monitor in a white container and a 12-inch wooden handled knife with blade inserted in made-up knife sheath made of brown corrugated paper/cardboard and clear tape were found stored next to the controlled medications (medications with high…

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

Based on observation, interview, and record review, the facility failed to treat their residents with respect and dignity for one of 20 sampled residents when (Resident 8) was not dressed in her own clothing and was left in a hospital gown. This failure had the potential to impact Resident 8's self-esteem and self-worth. Findings: According to the Resident Face Sheet, Resident 8 was admitted to the facility in late 2022, with diagnosis including unspecified dementia (loss of memory, judgement, and intellectual functions), difficulty walking, muscle weakness, pain, and history of falling. Review of Resident 8's Minimum Data Set (MDS- an assessment tool), dated 12/22/22, indicated that for daily preferences, it was very important for Resident 8 to choose the clothes she wanted to wear and indicated Resident 8 required extensive assistance with dressing. Review of Resident 8's care plan, dated 12/15/22, indicated, Self-Care Deficit as evidenced by requiring assistance or is dependent in: bed mobility extensive, eating supervision, transfer extensive, toileting extensive, personal…

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 Minimum Data Set (MDS, an assessment tool) assessment was conducted for one of twenty sampled residents (Resident 57) when a discharge MDS assessment was not done for Resident 57. This failure resulted in Resident 57 to have an incomplete clinical record to reflect his condition upon discharge. Findings: A review of the clinical record indicated, Resident 57 was admitted in April of 2023, with diagnoses that included high blood pressure with chronic kidney disease. A review of the Physician's Discharge summary, dated [DATE] indicated, Resident 57 was discharged to home on 6/14/23. During a concurrent interview and record review with the MDS nurse (MDSN) on 10/12/23 at 1:57 p.m., the MDSN confirmed Resident 57 was discharged on 6/14/23 and he (Resident 57) did not have an MDS discharge assessment. She stated, they (MDSN) are given 14 days to finish an assessment after discharge, it should have been completed on 6/27/23. During an interview on…

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

Based on observation, interview and record review, the facility failed to ensure communication needs were met for two of twenty sampled residents (Resident 3 and Resident 327) when: 1. Resident 3's communication care plan was not followed; and 2. Resident 327 had no care plan for her communication needs. This failure had the potential to negatively impact these resident's ability to communicate their needs to the staff. Findings: 1. A review of the clinical record indicated Resident 3 was re-admitted to the facility early 2018 with diagnoses that included high blood pressure and anxiety disorder. The most recent annual Minimum Data Set (MDS, an assessment tool) indicated Resident 3's preferred language was a non-English language and she needed an interpreter to communicate with a doctor and health care staff. A review of Resident 3's Risk for communication Deficit care plan initiated on 8/9/19 indicated, Goal .Resident's needs will be met through verbal and nonverbal content .Interventions .Provide communication board .assist resident to supplement words with pictures .communication…

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 activities were provided for Resident 29 and Resident 18 for a census of 59. These failures increased Resident 29 and Resident 18's risk for physical and psychosocial isolation. Findings: 1. According to the Resident Face Sheet, Resident 29 was admitted to the facility in late 2022, with diagnoses including acute respiratory failure with hypoxia (impaired gas exchange between blood and lungs causing difficulty in breathing), abnormalities of gait and mobility. Review of Resident 29's active physician's order, dated 11/11/22, indicated, May participate in activity plan if not in conflict with treatment plan. Review of Resident 29's initial activities assessment, dated 11/25/22, indicated that Resident 29's activity preferences were reading books, newspapers, or magazines; keeping up with the news; and doing favorite activities. Review of Resident 29's active care plan, dated 3/12/23, indicated, .Listen to music he/she likes, do…

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 of twenty sampled residents (Resident 66) received necessary treatment to promote healing of her left heel wound when a treatment order was not initiated as ordered. This failure placed Resident 66 at increased risk for delayed wound healing. Findings: A review of the clinical record indicated Resident 66 was re-admitted to the facility late 2023 with diagnoses that included muscle weakness and difficulty in walking. Resident 66's Braden scale assessment (used to evalute the risk for pressure ulcer development) dated 8/24/23, indicated she was confined to bed, and had very limited mobility. Her Braden score was 13 out of 18 which indicated she had moderate risk of developing a pressure ulcer. A review of Resident 66's SPECIALTY PHYSICIAN INITIAL WOUND EVALUATION & MANAGEMENT SUMMARY dated 10/2/23, indicated, .Focused Wound Exam (Site 1) .UNSTAGEABLE DTI [Deep Tissue Injury, a type of pressure ulcer, localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from…

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

Based on observation, interview and record review, the facility failed to provide accurate pharmaceutical services when Resident 73's full antibiotic course was not fully administered. This failure had the potential for Resident 73's infection to not be fully treated or possibly get worse. Findings: A review of Resident 73's clinical record indicated Resident 73 was admitted in mid-September, 2023 and had diagnoses that included chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). During a concurrent observation and interview on 10/10/23 at 10:36 a.m. with Licensed Nurse (LN) 1 of medication cart 2, a bubble pack (a form of packaging where an individual pushes individually sealed tablets through the foil to take the medication) of azithromycin (an antibiotic medication used to treat certain bacterial infections) 250 milligrams (mg- unit…

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

Based on observation, interview and record review, the facility failed to ensure a safe and sanitary condition was maintained when there was pool of water and water damage in the laundry room, for a census of 59 residents. These failures increased the potential to cause major damage to the walls and ceiling and the growth of mold and bacteria. Findings: An observation of the laundry room was conducted on 10/12/23 at 07:37 a.m. with the Housekeeping staff (HS). There were white rolled towels in between the 2 washers, the side of the 2nd washer, behind the 2 washers and a pool of water behind the 2 washers. The HS confirmed the findings and she stated the Maintenance Director (MD) was aware of the leak and the pool of water. A follow-up observation of the laundry room was conducted by 4 State surveyors with the Laundry Staff (LS) on 10/12/23 at 3:24 p.m. The air vent directly above the 2 washers had blackish build up on the metal plates. The ceiling surrounding the vent was sagging and bulging with blackish discoloration on the border and the paint was peeling, bubbling and flaking. 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.

Based on observation, interview and record review, the facility failed to provide adequate supervision to ensure the safety for 1 of 3 sampled residents (Resident 1), when he eloped from the facility unaccompanied and when the Licensed Nurses (LNs) failed to check and document the wanderguard (a door alarming device placed on the ankle) placement consistently every shift as per the care plan. This failure placed Resident 1's life in danger when he left the facility unaccompanied and walked over a mile on a busy street to his friend's house. Findings: According to Resident 1's 'admission Record,' he was recently admitted to the facility with multiple diagnoses which included cardiomyopathy (a disease that affects the heart muscle and may lead to heart failure), difficulties walking and muscle weakness. Resident 1 scored 8 out of 15 in a Brief Interview for Mental Status (BIMS, tests memory and recall) contained in his admission Minimum Data Set (MDS, an assessment tool). A score of 8 indicated he had severe cognitive impairment. The resident was discharged on 9/7/23 in the morning. 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.