Lomita Post-Acute Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow the care plan intervention for monitoring signs and symptoms of psychosis (a severe mental condition in which thoughts and emotions are so affected that contact with reality is lost ) for one of two sampled residents (Resident 25) related to the use of Seroquel (an antipsychotic medication prescribed to treat mental health conditions) by failing to: 1.Document behaviors associated with the use of Seroquel as ordered by the physician. This failure had the potential to prevent staff from determining whether Seroquel was effective in managing Resident 25's psychotic symptoms.Findings:During a review of Resident 25's admission Record, the admission Record indicated Resident 25 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease(a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), delirium(a serious disturbance in a person's mental abilities that results in a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Resident 18's order for lidocaine patch (a medication in patch form used to treat pain) was implemented according to manufacturer specifications and professional standards of practice. The facility failed to:1.Ensure the lidocaine patch applied to Resident 18's left knee was labeled with the date of application on the day it was applied.2.Ensure the lidocaine patch was removed after 12 hours of application, as required by manufacturer instructions.This deficient practice had the potential to result in adverse consequences such as local site reactions including skin irritation, redness, burning, and itching.Findings:During a review of Resident 18's admission Record (a document containing demographic and diagnostic information), the admission Record indicated Resident 18 was admitted to the facility on [DATE] with diagnoses including pain in left knee and bilateral (affecting both sides) primary osteoarthritis (a progressive disorder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that one of six sampled residents (Resident 22) received respiratory care (specialized healthcare focused on the treatment, management, and prevention of respiratory disorders) consistent with professional standards of practice by failing to: 1.Ensure Resident 22's nasal cannula (a small plastic tube that fits into the nostrils to provide supplemental oxygen) was labeled and dated. 2.Ensure the prescribed amount of oxygen ordered by the physician was administered to Resident 22. This failure had the potential to place Resident 22 at risk for respiratory infection (an infection affecting the respiratory tract, including the nose, throat, and lungs, caused by viruses or bacteria) and respiratory distress (a condition where the body struggles to breathe effectively). Findings:During a review of Resident 22's admission Record, the admission Record indicated Resident 22 was admitted to the facility on [DATE] with diagnoses including…

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 nursing staff possessed the necessary knowledge and skill set (a collection of abilities, knowledge, personal traits, and expertise developed to perform tasks) for two of seven nursing staff. The facility failed to: 1.Complete and document a performance review for Licensed Vocational Nurse (LVN) 1.2. To follow its policy and procedure titled cardiopulmonary resuscitation ([CPR] an emergency lifesaving procedure performed when breathing or heartbeat stops) dated 6/2025 which indicated for staff to maintain current CPR certification through a provider whose training includes hands-on practice and in-person skills assessment, and specifically stated that online-only certification was not acceptable. These failures had the potential to place residents at risk of not receiving care in a safe and competent manner. The facility could not determine if LVN 1's job performance was adequate and safe to provide resident care, and whether CNA 4 could…

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

Based on interview and record review, the facility failed to ensure performance evaluations were completed at least once every 12 months for three of five Certified Nursing Assistants (CNAs). This failure had the potential to prevent identification of areas for improvement or weaknesses in the delivery of care and services to residents by CNAs, which could result in unsafe or inadequate care.Findings:During a concurrent interview and record review on 12/11/2025 at 8:15 a.m. with the Director of Staff Development (DSD), the employee files for CNA 3, CNA 4, and CNA 6 were reviewed. The DSD stated that CNA 4 began employment on 3/29/2022 and did not have a performance review for 2025. CNA 3, who started on 8/23/2021, also had no performance review for 2025. CNA 6, who started on 10/12/2022, did not have a performance review for 2025. The DSD stated that failure to conduct performance reviews for CNAs can lead to improper resident care because their performance was not assessed. The DSD stated performance reviews should be conducted to ensure CNAs were proficient in providing care to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide treatment, monitoring, and services for one of five sampled residents reviewed for unnecessary medications (Resident 3) with diagnosis of depression (a mood disorder causing persistent sadness and loss of interest, affecting feelings and thoughts in a person). This deficient practice had the potential to result in suicidal ideation (means thinking about, considering, or planning suicide) and impairment or decline in the resident's mental, physical condition, functional abilities, and psychosocial status.Findings:During a review of Resident 3's admission Record (a document containing demographic and diagnostic information), dated 12/11/2025, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnosis that included but not limited to recurrent major depressive disorder (common and serious mood disorder characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in most…

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 physician orders for medications were complete and accurate per facility policy for two out five sampled residents (resident 11 and 18). The facility failed to: 1. Ensure Resident 18's order for lidocaine patch (a medication in the form of a patch used to treat inflammation and pain) clearly indicated number of patches (dose) to be applied, per facility's policy and procedure (P&P) titled, Physician Orders, dated 5/2007. 2. Ensure Resident 11's order for diclofenac sodium (a medication used to treat inflammation and pain) external gel had a dose, frequency and location for its use, per facility's P&P titled, Physician Orders, dated 5/2007. These deficient practices increased the risk for inappropriate treatments and medication and adverse effects such as local site reactions (skin irritation, redness, burning, and itching). Findings:1. During a review of Resident 18's admission Record (a document containing demographic and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to:1. Ensure Resident 18's lidocaine patch (a medication in the form of a patch used to treat inflammation and pain) applied to Resident 18's left knee was labeled with the date of application on the day it was applied affecting one of five residents observed for medication administration.2. Ensure Resident 38's Fluticasone-Salmeterol (a medication delivered through a device in the form of inhalation powder, used to treat breathing problems ) inhaler was removed from Station A and B Medication Cart 1 after being discontinued, and labeled with an open date in accordance with manufacturer's specifications and facility's policy and procedure (P&P), titled PH 1 Medication Administration, undated, affecting one of two medication carts reviewed (Station A B and Medication Cart 1).These deficient practices placed Residents 18 and 38 at risk for adverse events, including local site reactions such as skin irritation, redness, burning, and itching, as…

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 dietary staff were competent and able to safely perform assigned job duties, including understanding and accurately following meal tickets (a card for residents' meals) and food service instructions, for two of two dietary staff (Dietary Aide #1 and #2). These failures placed residents at risk for receiving incorrect diets, aspiration (choking), allergic reactions, poor nutritional intake, and compromised resident safety. Findings:During an observation on 12/10/2025 at 12:07 p.m. in the kitchen, Dietary Aide (DA) 2 was observed participating in the tray line (is an assembly-line system in the kitchen where staff quickly prepare and assemble individual resident meal trays) assembly. Dietary Aide 2 appeared to pause prior to assembling trays. DA 2 did not verbally communicate with other staff during the observation regarding clarification of diet orders.During a concurrent observation and interview on 12/10/2025 at 2:15 p.m. with the Dietary Aide (1) and the Dietary Supervisor (DS), DA 1 stated she…

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 honor a resident's food preference for one of three sampled residents (Resident 54) by serving beef, despite the resident's stated dislike for it. This failure had the potential to negatively impact Resident 54's dining experience by providing food that did not align with the resident's preferences.Findings:During a review of Resident 54's admission Record, the admission Record indicated Resident 54 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including diabetes mellitus(DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and iron deficiency anemia( condition where the body does not have enough healthy red blood cells due to lack of iron [crucial mineral needed to make hemoglobin which carries oxygen from 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 Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain any progress made after therapy intervention to maintain their function) splinting (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) recommendations and interventions were accurately documented for one of eight sampled residents (Resident 65) in the Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) Evaluation, RNA care plan, and RNA flowsheets (daily record of RNA services provided for each month). This deficient practice had the potential to negatively impact the provision of necessary care and services, cause miscommunication and confusion among staff, cause a decline in range of motion (ROM, full movement potential of a joint), and result in the inappropriate type of splint being placed on Resident 65's left arm potentially leading to pain, discomfort, skin breakdown (tissue…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain informed consent and involve the resident representative (an individual chosen by the resident to act on their behalf in decision-making and to access medical, social, or other personal information) prior to administering the influenza vaccine for one of three sampled residents (Resident 31). Resident 31 influenza vaccine was administered after the resident representative had declined the vaccine.This failure placed Resident 31 at risk for receiving medical treatment without informed consent, violation of resident rights, adverse reactions or side effects, loss of trust between the facility and the resident's representative, legal and regulatory noncompliance.Findings: During a review of Resident 31's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD-progressive disease that makes it hard to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to resolve a grievance indicating a delayed call light response time for one out of three sampled residents (Resident 3).This deficient practice had the potential for Resident 3 to have anxiety (extreme worry).Findings:During a review of Resident 3's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage).During a review of Resident 3's Minimum Data Set ([MDS] a resident assessment tool) dated 5/28/2025, the MDS indicated Resident 3 had mild cognitive impairment (memory and thinking problems), and had the ability to understand and be understood by others. The MDS indicated Resident 3 required substantial assistance (helper does more than half the effort) from staff…

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 manage pain for one out of three residents (Resident 2), when Resident 2 informed the Certified Nursing Assistant (CNA) 1 she had left arm and hand pain. This deficient practice had the potential to cause Resident 2's pain to worsen, become uncontrolled, create discomfort, and cause fear of receiving treatment/services due to anticipated pain. Findings: During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including cerebrovascular accident (CVA - stroke, loss of blood flow to a part of the brain) and left side hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body). During a review of Resident 2's Minimum Data Set (MDS – a resident assessment tool) dated 3/7/2025, the MDS indicated Resident 2 had severe cognitive (ability to think and reason) impairment and was dependent on staff for toileting hygiene, showering/bathing,…

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 contact precaution sign indicating the personal protective equipment (PPE – clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) that needed to be worn prior to visitors entering the room was posted for one of seven sampled residents (Resident 6) who tested positive for clostridium difficile (C. Diff - a highly contagious bacteria that causes severe diarrhea). This deficient practice had the potential to spread C. diff to other residents, visitors, and staff. Findings: During a review of Resident 6 ' s admission Record (Face Sheet), the Face Sheet indicated, Resident 6 was admitted to the facility on [DATE] with diagnoses including encounter for orthopedic aftercare following surgical amputation (a medical visit or series of visits after a limb amputation to focus on healing, recovery, and rehabilitation) and type 2 Diabetes Mellitus (DM- a disorder characterized by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to have an effective pest control program to prevent the infestation of gnats (fruit fly: flying, winged flies) by failing to: 1. Maintain a sanity environment for the residents' shared refrigerator in the dining room. 2. Prevent gnats from flying in Resident 1's room during lunch time. 3. Place UV fly traps throughout the facility and have working UV fly traps in Resident 5's room. 4. Maintain a sanitary environment in the storage room in the kitchen. These deficient practices have the potential to have flies in the food while having lunch and can affect residents that has open wounds prone to infection. Findings: During an observation on 3/11/2025 at 12:05p.m. in shared residents' refrigerator, there were 11 small black gnats with three (3) walking at the bottom of the refrigerator. The refrigerator had a lot of containers that appears to be brought from home with no date or room number, yogurts with the resident's name but no date, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure three of 20 sampled residents (Resident 22, 24 and 13) had a Preadmission Screening and Resident Review (PASARR-a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) assessment done when diagnosed with a mental illness prior to admission. This failure had the potential to result in Resident 22, 24 and 13 not receiving the necessary services and appropriate psychiatric level of treatment and evaluation in the facility. Findings: a. During a review of Resident 22's admission Record, the admission Record indicated Resident 22 was admitted to the facility on [DATE] with diagnoses including major depressive disorder(a mood disorder that causes a persistent feeling of sadness and loss of interest),paraplegia (loss of movement and/or sensation, to some degree, of the legs) and acute transverse myelitis of central nervous system( brief but intense inflammation of the spinal cord which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three residents (Resident 12) Minimum Data Set (MDS- a federally mandated resident assessment tool) was accurately documented to reflect Resident 12 hearing status. This deficient practice had the potential to negatively affect Resident 12's plan of care and delivery of necessary care and services. Findings: During a review of Resident 12's admission Record, the admission Record indicated Resident 12 was admitted to the facility on [DATE] with diagnoses including anxiety (a feeling of fear, dread, and uneasiness) and major depressive disorder (a mood disorder that can cause severe symptoms that affect a person's feelings, thoughts, and daily activities). During a review of Resident 12's MDS, the MDS indicated Resident 12 has adequate (normal) hearing. During a review of Resident 12's Care Plan titled, Resident 12 had a communication problem related to hard of hearing bilateral ear initiated on 1/30/2024, the Care Plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement care plan interventions for one of three residents (Resident 51) who received anti-coagulant therapy (a medication that prevents or treats blood clots in the heart and blood vessels). This failure had the potential to result in complications from the use of anti-coagulant therapy including bruising and bleeding. Findings: During a review of Resident 51's admission Record, the admission Record indicated Resident 51 was admitted to the facility on [DATE] with diagnoses including venous thrombosis (a condition where a blood clot forms in a vein and blocks blood flow) and embolism (blood clots in the veins) and renal dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly). During a review of Resident 51's Minimum Data Set (MDS- a federally mandated assessment tool) dated 10/17/2024, the MDS indicated Resident 51 had moderate cognitive (ability to think, understand, learn, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of six sampled residents (Resident 163) was helped with activities of daily living (ADL- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) when Resident 163 requested to have a shower. This failure resulted in Resident 163 feeling abandoned and neglected. Findings: During a review of Resident 163's admission Record, the admission Record indicated Resident 163 was admitted to the facility on [DATE] with diagnoses including displaced intertrochanteric fracture of left femur (hip breaks between the bumpy parts at the top of the thigh bone), history of falling, polymyalgia rheumatica (inflammatory disorder that causes muscle pain and stiffness especially in the shoulders and hips) and presence of left artificial knee joint. During a review of Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 10/29/2024, the MDS indicated Resident 163 had an intact cognition…

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 six sampled residents (Resident 32) received necessary care and services by failing to: 1.Follow up and ensure venous and arterial doppler (imaging test that uses sound waves test and help diagnose problems that affect the flow of blood) was done in a timely manner as ordered by the physician on 10/28/2024. 2. Monitor and assess the size of hematoma on Resident 32's left leg. This failure had the potential to cause delays in diagnosis, which could lead to delays in appropriate treatment for Resident 32. Findings: During a review of Resident 32's admission Record, the admission Record indicated Resident 32 was admitted to the facility on [DATE], and was readmitted on [DATE] with diagnoses including laceration of popliteal artery of the left leg( cut or tear of popliteal artery which is the main blood vessel that supplies blood for the lower leg and knee area), displaced bicondylar fracture of left tibia ( severe injury 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 one of three residents (Resident 12) received access to hearing services. This failure resulted in Resident 12 having trouble hearing properly. Findings: During a review of Resident 12's admission Record, the admission Record indicated Resident 12 was admitted to the facility on [DATE] with diagnoses including anxiety (a feeling of fear, dread, and uneasiness) and major depressive disorder (a mood disorder that can cause severe symptoms that affect a person's feelings, thoughts, and daily activities). During a review of Resident 12's MDS, the MDS indicated Resident 12 has adequate (normal) hearing. During a review of Resident 12's Care Plan titled, Resident 12 had a communication problem related to hard of hearing bilateral ear initiated on 1/30/2024, the Care Plan interventions for Resident 12 included validate message by repeating aloud and use touch, facial expression, tone, and body language to enhance communication. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide appropriate safety precautions to residents at risk for fall for one of 20 sampled residents (Resident 40). Facility failed to ensure: a. Resident 40, who was on fall risk precaution with landing pads placed on the side of the bed had no bedside table on top of the landing pads. This failure had the potential for injury when Residents 40 would fall out of bed and hit their head on the bedside table placed on top of the landing pads. Findings: During a review of Resident 40's admission Record, the admission Record, indicated Resident 40 was originally admitted to the facility on [DATE] with diagnoses including transient ischemic attack (TIA is a short period of symptoms similar to those of a stroke [(damage to the brain from interruption of its blood supply)]) , cardiac pacemaker ( a small, battery-powered device that's surgically implanted in the chest or abdomen to regulate the heart's rhythm and rate) , dementia (a progressive…

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

Based on interview and record review, the facility failed to ensure employee files were reviewed and kept up to date to ensure an at the time of hire and annual competency skill (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics in performing that an individual need to perform work roles or occupational functions successfully),Tuberculosis ( TB-lung disease) testing, performance evaluation, annual health examinations and background checks were completed for seven employees. The facility failed to: 1.Ensure DSD, Registered Nurse Supervisor (RNS) 1, Licensed Vocational Nurse (LVN) 3, LVN 4, LVN 5, Certified Nurse Assistant (CNA) 5, and CNA 6 had a Tuberculosis (TB- a lung disease) test, (a skin test to check if you have been infected with Tuberculosis) upon hire and annually. 2.Ensure DSD, LVN 3, LVN 4, LVN 5, CNA 5, and CNA 6 had a skills competency checklist at the time of hire and annually. 3. Ensure DSD, LVN 3, LVN 4, LVN 5, CNA 5, and CNA 6 had annual performance evaluation. 4.Ensure health examinations were completed upon hire and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY b. During a review of Resident 32's admission Record, the admission Record indicated Resident 32 was admitted to the facility on [DATE], and was readmitted on [DATE] with diagnoses including laceration of popliteal artery of the left leg( cut or tear of popliteal artery which is the main blood vessel that supplies blood for the lower leg and knee area), displaced bicondylar fracture of left tibia ( severe injury that occurs when both upper and lower parts of shinbone are broken and displaced from their normal position), and heart failure (heart does not pump enough blood to meet body's needs). During a review of Resident 32's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 9/19/2024, the MDS indicated Resident 32 had moderately impaired cognitive skills (ability to think, understand, learn, and remember) and required partial/moderate assistance (helper does less than half the effort) with toileting hygiene, bathing, and lower body dressing. During a review of Resident 32's Physician…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of six sampled residents (Resident 11 and Resident 22) were free of unnecessary psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) by failing to: a. Ensure Resident 11 was provided with non- pharmacological interventions (intervention that does not primarily use medicine) before administering as needed (prn) psychotropic medication. b. Ensure Resident 22's psychotropic medications were reevaluated for appropriateness of medication. These failures placed Resident 11 and Resident 22 at risk for using psychotropic medicines for excessive duration and developing adverse effects from the medicines. Findings: During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was admitted on the facility on 9/17/2024 with diagnoses including major depressive disorder (a serious mood disorder that affects how a person feels, thinks, and acts), cellulitis (skin…

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 medication cart was locked and secure and not left unattended during administration of resident's medication. This failure had the potential to place residents at risk for accidental ingestion of non-prescribed medicines and unauthorized access of the medication cart from anyone in the facility. Findings: During a concurrent observation of medication administration and interview on 10/31/2024, at 8:17 a.m., with Licensed Vocational Nurse (LVN 1), LVN 1 did not lock the cart when he performed handwashing in another room and left the medication cart unattended. Observed medication cart was not locked when LVN 1 entered a room to administer medications to a resident. LVN 1 stated he failed to lock the medication cart after preparation of medication and before administering the medication to residents. During an interview on 11/1/2024, at 3:42 p.m., with Registered Nurse Supervisor (RNS 1), RNS 1 stated medication cart should be locked when unattended to prevent other residents to have access to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to observe infection control measures for two of 10 sampled residents (Resident 17 and 168) by failing to: a.Ensure Resident 17's nasal cannula (a device used to deliver oxygen to a resident) was changed after seven days per facility's policy and procedure. b.Ensure Resident 168's nasal cannula was dated and labeled upon admission. These failures had the potential to result in the transmission of infectious microorganisms and increase the risk of respiratory infection for Residents 17 and 168. Findings: a.During a review of Resident 17's admission Record, the admission Record indicated Resident 17 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure (difficult to breathe on your own) and atrial fibrillation (irregular and often rapid heart rate). During a review of Resident 17's Minimum Data Set (MDS- a federally mandated assessment tool), the MDS indicated Resident 17 had severe cognitive (ability to…

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

Based on interview, and record review, the facility failed to have an Infection Preventionist (IP) on staff with required qualifications and completed specialized training in Infection Control and Prevention. This deficient practice had the potential for failure to monitor and implement Infection Control and Prevention in the facility. Findings: During a record review of the Infection Prevention Nurse (IPN) certification, dated 6/5/2018, the IPN certification indicated it was a 16-hour Boot Camp for Long Term Care Facilities certificate. During an interview on 11/1/2024 at 9:20 a.m., the IPN stated she did not have the correct certificate by the Center of Disease Control (CDC) for 19.75 hours. IPN stated she was unaware she needed a specific infection prevention certificate. During an interview on 11/1/2024 at 4:17 p.m., the DON stated the IPN did not have the correct IP certificate. No policy and procedure regarding what certificate was required for IP. During a review of facility's Infection Preventionist Job Description dated 12/17/202, the Infection Preventionist Job Description…

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

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, distributed, and served in a sanitary manner to prevent foodborne illness (also called food poisoning caused by eating contaminated food or eating food not kept at appropriate temperatures) by failing to: 1) Label canned foods, corn bread powder, butter, meat products, and vegetables with opened date and received date. 2) Ensure damp cloth used by [NAME] 1 did not repeatedly touched the food inside the plate. 3) Ensure [NAME] 2 who handed utensils back and forth to [NAME] 1 wore gloves. 4) Ensure [NAME] 3 wore gloves while reaching inside the food cart and touches the plate inside the food cart. These deficient practices had the potential to result in foodborne illnesses and can lead to other serious medical complications and hospitalization for residents residing in the facility. Findings: During a facility kitchen tour observation on 10/16/2023 at 8:06 am. found soup base beef style with no open date, corn bread powder with no open date, creamy wheat with no open date,…

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 15 sampled residents (Resident 41) were treated with dignity and respect by failing to ensure Resident 41 had a dignity bag (restores the dignity of [catheterized-a procedure used to drain the bladder and collect urine, through a flexible tube patient by concealing urinary drainage bags from public view) for his indwelling catheter ([foley catheter] plastic or rubber tube that is inserted into the bladder to drain the urine) drainage bag (collects urine). This deficient practice had the potential to affect Resident 41's self-esteem, self-worth, and feeling embarrassed. Findings: During a review of Resident 41's admission Record (Face Sheet), indicated Resident 41 was admitted to the facility on [DATE], with diagnoses including infection (occurs when a [microorganism- an organism that is so small it can only be viewed under a microscope] enters a person's body and causes harm) of the right shoulder, urinary tract infection…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility staff failed to ensure call lights was within reach for two of three sampled residents (Residents 33 and 39). This deficient practice had the potential to result in a delay and inability for Resdeint 33 and Resident 39 to obtain necessary care and services. Findings: During a record review of Resident's 39 admission Record (face sheet), the face sheet indicated Resident 39 was admitted to the facility on [DATE] with diagnoses that included hypertension ( high blood pressure) , diabetes mellitus (a condition in which the body fails to metabolize (process) glucose (sugar) correctly ), and hyperlipidemia (high levels of fat particles (lipids) in the blood). During a review of the Resident 39's Minimum Data Sheet ([MDS]- a standardized assessment and care screening tool) dated 8/7/23, indicated, Resident 39 has clear speech, sometimes able to make self-understood or sometimes able to understand others. Resident 39 has a Brief Interview for Mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of 15 sampled residents (Resident 41) received right arm sling (to ease pain, support healing and to protect arm from further injury) This deficient practice had the potential to place Resident 41 at risk for further range of motion (ROM - the extent of movement of a joint) decline, contracture (a condition of shortening and hardening of muscles, leading to deformity and rigidity of joints) and dehiscence (a surgery complication where the incision (surgical wound) reopens). Findings: During a review of Resident 41's admission Record (Face Sheet), indicated Resident 41 was admitted to the facility on [DATE], with diagnoses including infection of the right shoulder, urinary tract infection (infection in any part of the urinary system), and neuropathic bladder (lack of bladder control). During a review of Resident 41's History and Physical (H/P), dated 10/9/23, the H/P indicated, Resident 41 had the capacity to understand and make…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure it was free of not greater than 5 percent (%) or below medication error rate, as evidenced by eleven medications errors out of 42 opportunities for error, which yield a 26.19% medication error rate. This deficient practice resulted in a 26.19 percent (%) medication error rate for Resident 6. Findings: During a review of Resident 6's admission Record (face sheet), the face sheet indicated Resident 6 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including aphasia ( inability to speak ) dysphagia ( inability to swallow ) and hypertension ( high blood pressure). During a review of Resident 6's history and physical (H&P) report dated 2/2/2023, the H&P indicated Resident 6 does not have the capacity to understand and make decisions. During a review Resident 6's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/7/2023 indicated Resident 6's requires extensive assistance 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Cross Reference F759 Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 6) was free from significant medication errors by failing to ensure crushed medications were not mixed before medication administration according to facility's policy and procedure. This deficient practice had the potential to affect medication efficacy, compatibility and can have drug interactions for Resident 6. Findings: During a review of Resident 6's admission Record (face sheet), the face sheet indicated Resident 6 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including aphasia ( inability to speak ) dysphagia ( inability to swallow ) and hypertension ( high blood pressure). During a review of Resident 6's history and physical (H&P) report dated 2/2/2023, the H&P indicated Resident 6 does not have the capacity to understand and make decisions. During a review Resident 6's Minimum Data Set (MDS, a standardized assessment and care…

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 medication cart and treatment cart were locked when unattended by Licensed Vocational Nurse (LVN 3). This deficient practice had the potential for unauthorized access to medications and medical supplies by residents, staff, and visitors. Findings: During a concurrent observation and interview on 10/16/2023 at 12:18 pm with Licensed Vocational Nurse (LVN) 3, observed medication cart C-D was left unlocked. LVN 3 stated medication cart should be locked when left unattended to prevent potential unauthorized access by resident, staff, and visitors. During an observation on 10/16/2023 at 12:23 pm, observed treatment cart (storage for medical supplies used to treat wounds) was left unlocked in the hallway next to the nursing station. During an interview on 10/18/2023 at 9:11 am with LVN 4, stated residents can steal medical supplies that can be harmful to residents when ingested. During an interview on 10/18/2023 at 10:08 am with Registered Nurse (RN) 1, stated anyone can access the medication cart when left…

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 heparin lock (heplock- locking device on an intravenous catheter [ placed in a vein ] to administer medication) was covered. This deficient practice has the potential to contaminate the intravenous catheter, and risk of infection. Findings: During a record review of Resident 102's admission Record (Face sheet), the Face sheet indicated Resident 102 was initially admitted to the facility on [DATE] with diagnoses including hypertension (high blood pressure), atrial fibrillation (an irregular and often very rapid heart rhythm), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), pneumonia (an infection that affects one or both lungs). During a record review of Resident 102's Minimum Data Set (MDS), a standardize assessment and care-screening tool, dated 9/01/2023, the MDS indicated, Resident 102's needs total assistance on dressing and toilet use and needs extensive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the call system was functional including the audible sounds to alert the staff for one of two sampled Residents (Resident 11). This deficient practice had a potential in a delay in meeting care or services for Resident's 11. Findings: During a review of Resident 11's admission record (face sheet), the face sheet indicated Resident 11 was admitted to the facility on [DATE] with diagnosis of chronic obstructive pulmonary disease (a lung disease that block air flow and make it difficult to breathe), unspecified osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time), muscle weakness (decreased strength in the muscle). During a review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 7/29/2023, indicated Resident 11cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS…

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