Alamitos Belmont Health And Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, failed to follow their policy to replace missing dentures and provide a dentist visit for one of three sampled residents (Resident 15).This Failure had the potential to result in Resident 15 having discomfort while eating or chewing foods that could lead to unintended weight loss and lower self-esteem. Findings:During a review of Resident 15's admission Record, the admission Record indicated, Resident 15 was initially admitted to the facility on [DATE] and last re-admission was on 1/12/2026 with diagnoses including dysphagia (difficulty swallowing), breast cancer ( a disease where cells in the breast grow uncontrollably and form a tumor [abnormal growth]), and dementia (a progressive state of decline in mental abilities).During a review of Resident 15's History and Physical (H&P), dated 1/13/2026, the H&P indicated, Resident 15 had no capacity (ability) to understand and make decisions.During a review of Resident 15's Minimum Data Set (MDS - a resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY During interview and record review the facility failed to ensure safe and appropriate discharge planning for one of three sampled resident (Resident 1) by arranging a transfer to an assisted living facility without verifying that the receiving facility could meet the resident's needs and without confirming the accuracy of the discharge destination.This failure to confirm the appropriateness of the discharge and the receiving facility's capability placed Resident 1 at risk for an unsafe and inappropriate transfer, jeopardizing the resident's health, safety, and continuity of care.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of but not limited to Stage 5 chronic kidney disease (the final stage where kidneys fail requiring dialysis[a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed]) ,…

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 inform one of one sample resident ( Resident 1) that Resident 1's insurance would not cover the cost of a board and care facility ( a small, residential setting that provides housing, meals, and personal care assistance to a limited number of residents). This deficient practice compromised Resident 1's ability to make an informed decision, potentially leading to financial hardship and psychosocial distress. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including hypertension ( high blood pressure) and repeated falls. During a review of Resident 73's History and Physical (H& P) dated 3/13/2025, indicated Resident 1 does have the ability to make own decisions. During a review of Resident 73's Minimum Data Set ([MDS] resident assessment tool) dated 6/6/2025, the MDS indicated Resident 1 required supervision or touching assistance (helper provides…

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

Based on observation, interview, and record review the facility failed to follow the menu and did not meet the nutritional needs of 46 of 81 residents on regular texture diets (diets with no restriction) when the residents did not receive three (3) ounce ([oz] unit of measurement) portions. This failure had the potential to result in decreased intake of nutrients resulting in unintended (not done on purpose) weight loss. Findings: During a review of the facility's daily spreadsheet titled Menus Cycle 4, dated 11/12/2024, the spreadsheet indicated residents on regular diet textures would get 3 oz of Meatloaf. During an observation on 11/12/2024 at 11:03 a.m., at the tray-line area (an area where meals were assembled on the trays), the meatloaf on the steam table varied in portion sizes. During a concurrent observation and interview on 11/12/2024 at 11:13 a.m., with [NAME] 1, [NAME] 1 weighed random pieces of meatloaf using the facility food scale. [NAME] 1 stated the first piece of meatloaf was 2.6 oz, the second piece was 3.6 oz, and the last piece was 2.5 oz. [NAME] 1 stated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor and appearance when: a. The buttered carrots had no butter flavor. b. The mashed potatoes were bland in taste and had no flavor. This failure had the potential to result in 80 of 81 facility residents, getting food from the kitchen including Residents 27, 42,78, and 82 at risk of unplanned weight loss, a consequence of poor food intake. Findings: During a review of Resident 42's admission Record, the admission record indicated the facility admitted Resident 42 on 10/17/2024 with diagnoses including, but not limited to, chronic kidney disease ([CKD] a long term condition where the kidneys are damaged and cannot filter blood properly), chronic obstructive pulmonary disease ([COPD] a common lung disease that makes it difficult to breathe and protein-calorie malnutrition (a nutritional status where the body is lacking nutrients leading changes in the body composition and functions). During 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 prepare foods in a form designed to meet individual needs when residents on puree level four (4) diet (diet consisted of food that are soft with pudding like consistency) received meatloaf that could not hold its shape and puree carrot were weeping water. This failure had the potential to result in coughing, choking (to keep from breathing the normal way) and death for eight (8) of 81 residents on the puree diet. Findings: During a review of the facility's daily spreadsheet titled Menu Cycle 4, dated 11/12/2024, the spreadsheet indicated residents' meals on puree level 4 diet would include the following foods on the tray: Puree meatloaf half (1/2) cup ([c] household measurement) Mashed potato with gravy ½ c Puree buttered carrots 1/3 c Puree bread 1 piece (pc) Margarine 1 pc. Puree winter fruit cup 1/3 c Beverage 8 oz. During a concurrent observation and interview on 11/12/2024 at 10:31 a.m., with [NAME] 1 in the tray-line (an area where foods were assembled on the trays) area, [NAME] 1 stated she already…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: a. Staff improperly labeled food products. 1. Jello was not labeled with product name. 2. Dry potato was improperly labeled. 3. Resident's food from outside was not labeled with the resident's name. b. Three (3) dented cans were stored with non-dented cans. c. There was chipped, cracked, and rusted kitchen utensils and equipment. 1. Chopping boards had scratches and had sauce splatter stored in the clean area. 2. Fruit cutter had rust. 3. Potato container cover had chips. 4. Can opener had chips. 5. 48 of 48 resident's tray were cracked. d. Kitchen equipment and food preparation surfaces were not cleaned and sanitized. 1. Clean area for storing pots and pans had crumbs and food particles. 2. Pans had food residue, spill and burnt surfaces. 3. Toaster had breadcrumbs residue. 4. Tray-line (an area where foods were assembled on the trays) top had rust…

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 dispose of garbage and refuse properly by not ensuring two (2) of the dumpster's (a large trash metal container designed to be emptied into a truck) were not overflowing with trash, and the dumpster lids remained closed. This failure had the potential to result in attracting birds, flies, insects, pest and possibly spread infection to 80 of 81 facility residents. Findings: During an observation on 11/12/2024 at 3:58 p.m., at the dumpster area, 2 dumpsters were overflowing with trash and the lids could not close. During a concurrent observation and interview on 11/12/2024 at 4:02 p.m., with the Dietary Supervisor (DS), the DS stated staff threw all the food trash into those dumpsters. The DS stated the dumpsters were overflowing with trash and were open and it was not okay as it could attract pest and rodents that could come in the facility. The DS stated rodents could carry diseases and could pass the disease to the resident as a potential outcome. During a concurrent observation and interview on 11/12/2024…

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 staff wore personal protective equipment ([PPE], clothing or equipment that protects the wearer from injury or illness) while providing direct resident care for one of three sampled residents (Resident 70) who was on enhanced barrier precaution/protection ([EBP], infection control intervention using gown and gloves during high contact resident care activities designed to reduce the transmission of multi-drug resistant organisms). This failure had the potential to result in the transmission of infectious microorganisms and increase the risk of causing an outbreak in the facility. Findings: During a review of Resident 70's admission Record, the admission Record indicated Resident 70 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of metabolic encephalopathy (a brain disorder that occurs when an underlying condition causes a chemical imbalance in the blood that affects the brain), gastrostomy tube…

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 nursing staff and physician were notified in a timely manner when one out of six residents (Resident 47) presented with decreased range of motion (ROM- full movement potential of a joint) of the bilateral (both) ankles. As a result of this deficient practice, Resident 47 had a delay in services including being seen and evaluated by physical therapy (PT - profession aimed in the restoration, maintenance, and promotion of optimal physical function) to see what services he required. Findings: During a review of Resident 47's admission Record, the admission Record indicated Resident 47 was admitted to the facility on [DATE] with diagnoses of depression (mental illness that causes persistent feelings of sadness and loss of interest), Parkinson's Disease (a chronic brain disorder that causes movement problems, and can also affect mental health, sleep, and pain), and malignant neoplasm of the prostate (prostate cancer). During 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 interview and record review, the facility failed to follow up on a level 2 Preadmission Screening and Resident Review (PASRR, Level 2 Evaluation helps determine the most appropriate placement of an individual, considering the least restrictive setting, and whether specialized services are needed) evaluation for one of six sampled residents (Resident 47) who had a diagnosis of depression (a mood disorder that can affect a person's thoughts, feelings, behavior, and sense of well-being). This deficient practice had the potential to cause a delay in services for Resident 47. Findings: During a review of Resident 47's admission Record, the admission Record indicated Resident 47 was admitted to the facility on [DATE] with diagnoses of depression, Parkinson's Disease (a chronic brain disorder that causes movement problems, and can also affect mental health, sleep, and pain), and malignant neoplasm of the prostate (prostate cancer). During a review of Resident 47's minimum data set (MDS-a resident assessment…

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 8) received her Insulin (a medication that regulates blood sugar levels and is essential for life) as ordered by the physician. This deficient practice had the potential for Resident 8 to become hypoglycemic (occurs when blood sugar level drops too low). Findings: During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes (a common condition that occurs when your body doesn't use insulin properly, resulting in high blood sugar levels) and chronic kidney disease (CKD, a long-term condition that occurs when the kidneys are damaged and can't filter blood properly. This can lead to a buildup of waste and excess fluid in the body). During a review of Resident 8's untitled care plan initiated 8/22/2024, the care plan indicated Resident 8 had diabetes with goals for Resident 8 to be free from any signs or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately assess, monitor the effectiveness of current pain management, and reassess the pain for one of six sampled residents (Resident 47) who was receiving pain medications. This deficient practice had the potential for resident 47 to experience unnecessary pain. Findings: During a review of Resident 47's admission Record, the admission Record indicated Resident 47 was admitted to the facility on [DATE] with diagnoses of depression (a mental illness that causes persistent sadness and loss of interest), Parkinson's Disease (a chronic brain disorder that causes movement problems, and can also affect mental health, sleep, and pain), and malignant neoplasm of the prostate (prostate cancer). During a review of Resident 47's Order Summary Sheet, Resident 47 had an order placed on 11/2/2023 for Percocet (a pain medication that can treat moderate to moderately severe pain) 5-325 milligrams (mg, a unit of measurement) oral tablet give 2 tablets by mouth…

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: F658 Based on interview and record review, the facility failed to ensure one out of six sampled residents (Resident 8) was free from a significant medication error by failing to follow the physician's ordered parameters (specific instructions) when administering insulin (a hormone medication that regulates blood sugar levels and is essential for life). This deficient practice had the potential for Resident 8 to become hypoglycemic (occurs when your blood sugar level drops too low). Findings: During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes (a common condition that occurs when your body doesn't use insulin properly, resulting in high blood sugar levels) and chronic kidney disease (CKD, a long-term condition that occurs when the kidneys are damaged and can't filter blood properly. This can lead to a buildup of waste and excess fluid in the body). During a review of Resident 8's 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide Restorative Nursing Aide program (RNA, nursing aide program that helps residents maintain their function and joint mobility) to one of three sampled residents (Resident 1) when Resident 1 was not discharged home on 2/6/2024 and continued to stay in the facility until 3/6/2024. Resident 1 did not start receiving RNA services until 2/19/2024. This deficient practice placed Resident 1 at risk for a decline in ambulation and range of motion ([ROM] how far you can move or stretch a part of your body, such as a joint or a muscle). Findings During a review of Resident 1's admission Record, the record indicated Resident 1 was admitted on [DATE] with the diagnosis of history of falling and weakness. During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 1/27/2024, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought,…

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 their policy to notify the physician for one of three sampled residents (Resident 2), when the facility did not have Resident 2's ordered medications available and did not administer Amiodarone (drug that works to keep heart rhythm regular), Apixaban (drug used to prevent blood clots), Doxazosin (drug used to keep heart rhythm regular) and Metoprolol (drug used to treat high blood pressure) as ordered. This failure had the potential to cause a delay in needed assessments, services, and treatments for Resident 2. 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 difficulty walking, muscle weakness and atrial fibrillation (condition when heart beats irregularly). During a review of Resident 2's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 1/1/2024, the MDS indicated Resident 2 was cognitively intact (able 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 revise the comprehensive resident centered care plan interventions for one of three sampled residents (Resident 1), who had a history of frequent falls between the hours of 4 am and 8 am due to the need to urinate. This failure resulted in Resident 1 sustaining multiple falls on 12/12/2023, 12/18/2023, 1/10/2024, and 1/16/2024 which had the potential to injury. Findings: During a review of Resident 1's admission Record (face sheet), the face sheet indicated Resident 1 was admitted to the facility on [DATE] with difficulty walking, muscle weakness and aphasia (loss of ability to understand or express speech, caused by brain damage). During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 12/3/2023, the MDS indicated Resident 1 had severe cognitive impairment in attention, orientation, and ability to recall information. According to the MDS, Resident 1 required maximum assistance (helper does more…

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 its medication error rate was less than five (5) percent (%) due to four (4) errors observed out of 25 total opportunities (error rate of 16 %). The medication errors were as follows: 1. Resident 44 received both medications carvedilol (a medication that works by slowing down your heart rate and making it easier for your heart to pump blood around your body) 3.125 mg (unit of measurement) one tablet every twelve hours and nifedipine ER (a medication that works by affecting the movement of calcium into the cells of the heart and blood vessels) 90 mg one tablet by mouth daily and Licensed Vocational Nurse (LVN) 6 did not check blood pressure readings and apical pulse (AP- a pulse point on your chest that gives the most accurate reading of your heart rate). 2. Resident 50 received medication Digoxin (a medication used to manage and treat heart failure and certain arrhythmias) 125 mcg one tablet by mouth daily. 3. Resident 72…

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 FACILITY Based on observation, interview, and record review, the facility failed to ensure a. that its medication error rate was less than five (5) percent (%) due to four (4) errors observed out of 25 total opportunities (error rate of 16 %). The medication errors were as follows: 1. Resident 44 received both medications carvedilol (a medication that works by slowing down the heart rate and making it easier for your heart to pump blood around your body) 3.125 milligram (mg a unit of measurement of weight) one tablet every twelve hours and nifedipine extended release (a medication used to treat high blood pressure) 90 mg one tablet by mouth daily and Licensed Vocational Nurse (LVN) 6 did not check blood pressure readings and apical pulse (AP- a pulse point on your chest that gives the most accurate reading of your heart rate) before administering the medications. 2. Resident 50 received Digoxin (a medication used to manage and treat heart failure and certain irregular heartbeats) 125 micrograms (mcg 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 accommodate and evaluate the food preferences for one of eight sampled residents (Resident 71). This deficient practice had the potential for Resident 71 to have insufficient food intake and significant weight loss. Findings: During a review of Resident 71's admission Record (Face sheet), the admission Record indicated Resident 71 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dysphagia (difficulty swallowing), muscle weakness (lack of muscle strength), and difficulty walking. During a review of Resident 71's History and Physical (H&P), dated 10/18/2023, the H&P indicated, Resident 71 was alert with episodes of confusion. During a review of Resident 71's Minimum Data Set (MDS), a comprehensive screening and assessment tool, dated 10/24/2023, the MDS indicated Resident 71 can be understood and can understand others sometimes. Resident 71 was totally dependent on staff for Activities of Daily Living…

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 staff followed food production recipes and fortified diet (diet to increase caloric intake) guidelines during lunch preparation and tray line observation when: 1.Potatoes and onions prepared for Mechanical soft diet (food texture modified for residents who have chewing or swallowing difficulties) were cut into large pieces and not chopped according to recipe and spreadsheet (food portion and service guide) instruction and mechanical soft diet guidelines. 2.Fortified diets (diet enhanced to increase caloric content) were not prepared and were not served to residents who were on fortified diet. These failures had the potential to result in decreased caloric intake and lead to undesirable weight loss for 15 residents requiring a fortified diet and increased choking risk for the 30 residents required a mechanical sot diet. Findings: 1.During a concurrent observation and interview with Cook1 on 11/6/23 at 12:24PM, Cook1 said potatoes and onions are served as side dish. Cook1 said the potatoes served for 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 ensure standard infection control practices were followed by staff for five of eight sampled residents (Residents 59,71,15, 131 and 279) by failing to: 1. Ensure Resident 59's a gastrostomy tube (G-tube), a tube inserted through the belly that brings nutrition directly to the stomach and dressing (a pad applied to a wound to promote healing and protect from future harm) were applied as indicated in the care plan and physician's order. 2. Ensure Resident 71's and Resident 15's nebulizer (a device used to administer medication in the form of a mist inhaled into the lungs) mask and nasal cannula (a device used to deliver supplemental oxygen placed directly on the resident's nostrils) was properly stored or changed as indicated in the facility's policy and procedure (P&P). 3. Ensure Resident 131's drainage tubes dressing (tubes placed near surgical incisions in the post-operative patient, to remove pus, blood, or other fluid, preventing it…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain and calibrate (process that ensures the reading and functionality of a device is accurate and in full working order) the sit to stand lift (a mechanical device used to assist a resident move from a seated position to a standing position) for resident use in accordance with manufactures guidelines. This deficient practice had the potential to cause injury to any resident who used this equipment as part of their therapy treatment. Findings: During an observation on [DATE] at 9:44 am, in the therapy gym, a sit to stand lift was sitting in the left corner of the rehabilitation gym with a calibration sticker dated 2/2022. During an observation and interview on [DATE] at 10:52 am, in the therapy gym, the Director of Rehabilitation (DOR) confirmed the sit to stand lift in the corner of the therapy gym was last calibrated in 2/2022. The DOR stated she was unsure how often the sit to stand lift was supposed to be calibrated. The DOR…

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's interdisciplinary team (IDT), a coordinated group of experts from several different fields who work together, failed to ensure one of eight residents (Resident 385) was allowed to keep medications at the bedside without a physician's order and without being assessed to determine if the resident was capable to self-administer medications. These deficient practices placed Resident 385 at risk for medication errors and had the potential for unsafe medication administration for other residents. Findings: During a concurrent observation and interview on [DATE] at 11:54 a.m. with Resident 385 in the resident's room, there was a bottle of Refresh (a medication solution applied to the eyes for dryness) eyedrops at Resident 385's bedside table. Resident 385 stated the eyedrops were used when needed and were independently administered. During an interview on [DATE] at 12:03 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated there should be 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 that the call light device was within reach for one of eight sampled residents (Resident 1). This deficient practice had the potential to delay Resident 1 from receiving necessary care and services. Findings: During a record review of Resident 1's admission record indicated the resident was originally admitted to the facility on [DATE] with diagnoses including aphasia (loss of ability to understand or express speech, caused by brain damage), rheumatoid arthritis (chronic autoimmune inflammatory disease that affects the joints) and dementia (decline in mental ability severe enough to interfere with daily life). During a record review of Resident 1's Minimum Data Set (MDS, a comprehensive assessment and care-screening tool) dated 9/4/2023 indicated the resident had impaired vision, difficulty hearing, and severely impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 1 required 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 review and revise the comprehensive care plan for one of eight sampled residents (Resident 1) to address decreased physical mobility and weakness when Restorative Nursing Aide services (RNA, nursing program that uses restorative nursing aides to help residents maintain their function and joint mobility) were discontinued. This deficient practice had the potential to negatively impact the provision of necessary care, treatment, and services for Resident 1 and cause a decline range of motion (ROM, full movement potential of a joint), contracture (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) development, and overall decline in functional ability. Findings: During a record review of Resident 1's admission record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses including aphasia (loss of ability to understand or express…

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 eight sample residents (Resident 70) with a history of urinary retention (a sudden inability to urinate) was provided services to meet the resident needs and make a necessary appointment to see an urologist ( a doctor who specializes in the study or treatment of the function and disorders of the urinary system) as ordered by the physician. This failure put Resident 70 at risk for further urinary retention and had the potential to lead to further urinary complications like urinary tract infection (when bacteria enter the body and infects the urinary tract), benign prostate hypertrophy (enlarged prostate [ the top portion of the tube that drains urine from the bladder]), fever and pain. Findings: During an observation on 11/6/23 at 11:00 a.m., Resident 70 was observed sitting in a wheelchair in his room, with a foley catheter (medical device that helps drain urine from your bladder), draining yellow colored urine attached 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 treat one of two sampled residents (Resident 40) with a diagnosis and verbalizations of depression. This deficient practice resulted in Resident 40 not receiving the proper assessment, necessary treatment and resources for her diagnosis of depression. During a review of Resident 40's admission record, the admission record indicated Resident 40 was admitted to the facility on [DATE] with diagnoses including bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to maniac highs), depression (a mood disorder that causes persistent feelings of sadness and loss of interests in activities such as sleeping, and eating) anxiety (condition that causes nervousness, worry, and dread), dementia (impaired ability to think or make decisions accompanied by behaviors such as agitation and depression), and cataracts (a condition that causes cloudy, blurry vision, double vision, and sensitivity to light). During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide one out of eight sampled residents (Resident 15) with meals that accommodated their food preferences. This deficient practice had the potential to result in decreased meal intake, lead to weight loss and malnutrition. Findings: During a review of Resident 15's admission Record (AR), the AR indicated Resident 15 was admitted to the facility on [DATE] with diagnoses of hypertension (high blood pressure), cervical myelopathy (compression of the spinal cord in the neck) and vitamin D deficiency (not enough vitamin D in your body affecting your bones). During a review of Resident 15's physician order (PO) dated 10/20/23, the PO indicated Resident 15's diet was no added salt regular texture (not cut up or blended). During a review of Resident 15's Nutrition Evaluation dated 10/20/23, the Nutrition Evaluation indicated Resident 15 did not have any chewing or swallowing problems. During a review of Resident 15's care plan (CP) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement their protocol for Antibiotic Stewardship for one of two sampled residents (Resident 428). Resident 428 was prescribed antibiotic drug without meeting the criteria, after being screen for urinary tract infection ([UTI]an infection in any part of the urinary system). This deficient practice had the potential for resident to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use. Findings: During a review of Resident 428's admission Order (Face Sheet) indicated Resident 428 was initially admitted on [DATE] and re-admitted on [DATE] with diagnoses including essential hypertension (high blood pressure), dysphagia (difficulty of swallowing), anemia (a condition in which the body does not have enough healthy red blood cells) and chronic obstructive pulmonary disease ([COPD] a group of diseases that cause airflow blockage and breathing-related problems). During a review of Resident 428'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.