Bay Vista Healthcare & Wellness Centre, LP

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to offer the influenza (a highly contagious viral infection that attacks the nose, throat, and lungs) and pneumococcal (an illness caused by the Streptococcus bacteria [a common bacteria on the nose and throat] immunizations (the process of making your body immune to a specific disease) at the time of admission, for one of five sampled residents (Resident 56).This failure had the potential to result in the resident contracting influenza or pneumococcal and developing a life-threatening infection.Findings: During a review of Resident 56's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with the following but not limited to diagnoses of encephalopathy (damage or malfunction of the brain), epilepsy (a brain disorder that causes repeated, unprovoked seizures) and catatonic schizophrenia (a condition that effects one's movements and speech).During a review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) whose Responsible Party (RP) 1 verbalized a complaint to facility staff, was informed of and helped in completing a Grievance/Complaint Investigation Report. This failure resulted in Resident 1 and RP 1 not receiving timely or formal communication regarding the outcome or resolution of the complaint, which led to distrust toward the facility. This failure had the potential to delay necessary care and services to Resident 1 and could negatively impact Resident 1's mental health and emotional well being.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]. Resident 1's diagnoses included hepatic encephalopathy (a decline in brain function which occurs when the liver cannot remove toxins from the blood), type 2 diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound…

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 three sampled residents (Resident 1), who had recommendations to have referrals and/or consultations with the cardiologist (medical doctor specializing in diseases of the heart) and neurologist (medical doctor specializing in diseases of the brain, spinal cord, nerves and muscles), were implemented. These failures resulted in Resident 1's referrals being delayed for more than nine months. These failures also had the potential to delay necessary specialty assessments, interrupted continuity of care, and increased the risk that changes in Resident 1's medical condition would go unrecognized which could affect Resident 1's health, safety, and overall, well being.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]. Resident 1's diagnoses included hepatic encephalopathy (a decline in brain function which occurs when the liver cannot remove toxins…

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 Restorative Nurse Assistant (RNA 1) accurately documented for one of three sampled residents (Resident 1), indicating Resident 1 received RNA services when there was no order and when those services were not provided. This deficient practice resulted in RNA 1 documenting Resident 1 was provided passive range of motion ([PROM] the movement of a joint when an outside force, such as a person or machine, moves the body part while the person is relaxed) exercises, to her bilateral lower ([BL] both legs) and bilateral upper extremities ([BLE] both upper arms), a splint (a rigid material or apparatus used to support in impaired joint) was applied to his right knee, and pressure relief ankle foot orthosis boot ([PRAFO] a specialized orthopedic boot designed to position the foot and ankle correctly, relieve pressure on the heel, and prevent complications such as pressure ulcers and contractures [permanent and painful tightening of the muscles 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 interview and record review the facility failed to ensure a Registered nurse (RN) worked eight consecutive hours a day seven days a week on 2/1/25, 2/2/25, 2/8/25, 2/9/25, 2/15/25, 2/23/25, 3/9/25 and 3/23/25. This failure had the potential to affect the residents' quality of care and not be able to provide advanced care activities such as resident assessments, developing and evaluating care plans, and consulting with physicians. Findings: During a concurrent interview and record review on 6/25/25 at 4:08 p.m. with the Director of Staff Development (DSD). The facility's Census and Direct Care Service Hours Per Patient Day (DHPPD) dated 1/1/2025 through 6/24/25 were reviewed. The DHPPD indicated on 2/1/25, 2/2/25, 2/8/25, 2/9/25, 2/15/25, 2/23/25, 3/9/25 and 3/23/25 there was no RN coverage on those days. The DSD stated there needs to be an RN in case of an emergency because the RN has more knowledge in assessing the residents. During a concurrent interview and record review on 6/25/25 at 4:08 p.m. 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 2.During a review of Resident 38's admission Record, the admission Record indicated Resident 38 was initially admitted on [DATE] and was readmitted on [DATE] to the facility with diagnoses including paranoid schizophrenia( a pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly), schizoaffective disorder bipolar type(a mental illness that can affect thoughts, mood, and behavior) depression( a serious mental health condition characterized by persistent sadness and a loss of interest in activities, impacting how a person feels, thinks and handles daily tasks), and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations). During a review of Resident 38's History and Physical (H&P) dated 2/8/2025, the H&P indicated Resident 38 can make needs known but cannot make medical decisions. During a review of Resident 38's Minimum Data Set (MDS- resident screening tool) dated 4/30/2025, the MDS indicated Resident 38 had severely impaired…

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

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and preparation practices when the facility failed to: 1.Ensure an open bag of frozen salisbury steak was stored in a sealed plastic bag in the freezer. 2.Ensure an open box of hot rice cereal was dated, labeled and stored in a sealed bag or container. These failures had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to food borne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins ). Findings: During an initial kitchen observation and interview on 6/23/2025, at 8:11 a.m. with Dietary Manager (DM),observed an open plastic bag of frozen salisbury steaks in an open carton box was stored in the freezer. Observed DM took another plastic bag , placed the frozen salisbury steak in the plastic bag and returned the frozen steaks in the freezer. Observed an open box of rice hot cereal sitting on the kitchen countertop without an open date label.…

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

Based on interview and record review, the facility's Quality Assessment and Assurance Committee ([QAA] develop and implement appropriate plans of action to correct identified quality deficiencies) and the Quality Assurance Performance Improvement ([QAPI] a group who takes a systemic, interdisciplinary, comprehensive, and data driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families) failed to ensure effective oversight of the facility and implementation of the facility's plan of correction (POC) of the deficient practices identified during the previous recertification survey. This failure resulted in the facility having repeat deficiencies in the areas of activities of daily living care provided for dependent residents, formulating advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate), infection prevention, Quality Assurance and Performance Improvement, food storage, free of medication error rates of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents' medical records were updated to show documentation that advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate) were discussed and written information was provided to the residents and/or responsible parties for two of six sampled residents (Resident 2 and 16). These deficient practices violated the residents' and/or the representatives' right to be fully informed of the option to formulate an advance directive and had the potential to cause conflict with the residents' wishes regarding health care. Findings: A. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) and depression (a mental health…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview , and record review, the facility failed to ensure one of four sampled residents (Resident 21) was free of chemical restraints (use of medication to control a patient's behavior or restrict the patient's movement and not required to treat the medical symptom) by failing to: 1.Ensure Resident 21 was provided non-pharmacological interventions (interventions that does not primarily use medicine ) before administering a as needed) (prn) psychotropic medication(any drugs that affects the brain activities associated with mental processes and behavior). This failure put Resident 21 at risk for adverse reactions (unintended, harmful events attributed to the use of medication) due to unnecessary prolonged use of psychotropic medication. Findings: During a record review of Resident 21's admission Record, the admission Record indicated Resident 21 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including unspecified dementia (a progressive state…

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 two sampled residents (Resident 22 and Resident 11) had a Level II Preadmission Screening and Resident Review (PASARR-a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) assessment done when diagnosed with a mental illness prior to admission. This failure had the potential to result in Resident 22 and Resident 11 not receiving the necessary services and appropriate psychiatric( relating to mental illness or its treatment) level of treatment and evaluation in the facility. 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 diabetes mellitus, (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) paranoid schizophrenia(a mental illness that is 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 and interview, the facility failed to ensure one of two residents' (Resident 2) was provided with personal hygiene care. This deficient practice resulted in Resident 2's facial hair being too long to shave with a razor, requiring the use of an electrical razor and had the potential to affect Resident 2's dignity. Findings: During an observation on 6/23/2025 at 10:27 a.m., in the hallway outside of Resident 2's room, Resident 2 was observed with long unkempt facial hair. Resident 2 was observed asking the staff to shave him. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) and depression (a mental health condition that causes persistent sadness and loss of interest in activities that were once enjoyable). During a review of Resident 2's Minimum Data Set (MDS- a resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure two of two sampled residents (Resident 11 and Resident 60) were provided with a bowel and bladder retraining and/or toileting program (scheduled toileting, prompted voiding or bladder training [help to regain at least some control over patient's bladder]), to regain normal bowel and bladder function as much as possible and received appropriate treatment and services to restore continence. This failure had a potential risk for Resident 11 and Resident 60 to lose their ability to regain control of bowel and bladder function, which could result in loss of dignity. Findings: 1. During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including urinary tract infection, (UTI- an infection in the bladder/urinary tract) acute cystitis (a sudden inflammation of the urinary bladder caused by a bacterial 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 failed to ensure one of six sampled residents (Resident 48) received respiratory care (specialized healthcare field that focuses on the treatment , management and prevention of respiratory disorders) consistent with professional standards of care by failing to: 1.Ensure Resident 48 's nasal cannula (medical device used to deliver supplemental oxygen to a person's nose) was not left on the floor and oxygen concentrator ( medical device that provides a concentrated source of oxygen) were turned off when not in use. These failures had the potential to put Resident 48 for respiratory infection (an infection that affects respiratory tract which includes the nose, throat, and lungs caused by viruses or bacteria). Findings: During a review of Resident 48's admission Record, the admission Record indicated Resident 48 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including dependence on supplemental oxygen…

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 necessary behavioral care and treatment on one of three sample residents ( Resident 167) by failing to: 1.Assess and monitor Resident 167's behavior after verbalization of wanting to die. 2.Follow up physician's notification about Resident's 167 suicidal ideation (thoughts of self-harm or ending one's life). 3.Provide psychiatric (study and treatment of mental, emotional, and behavioral disorders ) evaluation after Resident 167's verbalization of wanting to die. These failures had the potential to put Resident 167 at risk of committing suicide due to delays in care and services. Findings: During a review of Resident167's admission Record, the admission Record indicated Resident 167 was admitted to the facility on [DATE] with diagnoses including hemiplegia partial ( paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction affecting left dominant side, diabetes mellitus…

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 a medication error rate of less than 5% (percent) during medication pass for one of the four sampled residents (Residents 46 ) The facility failed to: a. Administer Resident 46's Onglyza (medication for DM), Sitagliptin (medication for DM) and Risperdal (antipsychotic medication [used to treat schizophrenia and bi-polar]) within 60 minutes of its scheduled time as per facility's policy and procedure (P&P) titled, Medication Administration dated 1/1/2012. These deficient practices of medication administration error rate of 9.09% exceeded the five (5) percent threshold. Findings: During a review of Resident 46 admission Record, dated 6/25/25, the admission Record indicated Resident 46 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), paranoid schizophrenia (a mental illness that is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure one of four sampled residents (Resident 46) was free from significant medication errors by failing to administer Onglyza for diabetes mellitus 2 (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), Sitagliptin for DM 2 and Risperdal (antipsychotic medication) used to treat schizophrenia (a mental illness that is characterized by disturbances in thought) as prescribed by the physician. These failures had the potential to place Resident 46 at risk for hyperglycemia (high blood sugar) and angry outbursts. Findings: During a review of Resident 46 admission Record, dated 6/25/25, the admission Record indicated Resident 46 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), paranoid schizophrenia (a mental illness that is characterized by disturbances in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility failed to ensure transmission-based precautions (set of infection control measures designed to prevent the spread of infectious diseases in healthcare settings) were implemented for one of one sampled resident (Resident 22) who had an order to rule out Clostridium difficile (C. diff- a highly contagious bacteria that causes severe diarrhea) due to frequent diarrhea. This failure had the potential to expose other residents, staff and visitors to the spread of infection. 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 diabetes mellitus, (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) paranoid schizophrenia(a mental illness that is characterized by disturbances in thought), major depressive disorder(a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (a feeling of fear, dread, and uneasiness). During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident, who had anxiety (an emotional state that involves feelings of fear, dread and uneasiness), and had Ativan (a medication used to treat anxiety) 1 milligram ([mg] a unit of measurement) to control their anxiety, was provided antianxiety medication, for one of five sampled residents (Resident 1). The facility failed to: 1. Ensure licensed nurses ordered a refill of Ativan 1 mg for Resident 1 ' s anxiety before the medication ' s quantity was depleted. 2. Ensure Resident 1 received Ativan for anxiety, as ordered by Resident 1 ' s physician. 3. Ensure licensed nurses contacted Resident 1 ' s MD 1 to obtain authorization to access the facility ' s emergency kit ([E-Kit] a kit which contains a small quantity of medications which can be dispensed when pharmacy services are not available) containing Ativan 1 mg to administer to Resident 1. 4. Ensure the licensed nurses followed the facility ' s policy and procedure (P&P) titled, Medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident, who lacked the capacity to make decisions, was supervised, and monitored to prevent one of three sampled residents (Resident 1) from eloping (leaving a secured institution without notice or permission) from the facility. Resident 1 was last seen in the facility on 12/12/2024 at approximately 10:30 p.m in his room. Resident 1 was noted missing on 12/12/2024 at approximately 11:30 p.m. As of 12/20/2024, Resident 1 has not been located. This deficient practice resulted in Resident 1 ' s eloping from the facility on 12/12/2024 and his whereabouts being unknown. This deficient practice had the potential for Resident 1 to be exposed to excessive drops in temperature, motor vehicle accidents, hunger, dehydration, and death. Findings During a review of Resident 1 ' s General Acute Care Hospital (GACH) records dated 8/19/2024, the GACH records indicated Resident 1 was admitted to the GACH on 8/9/2024 for aggressive behavior and was put on 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 protect the resident rights to be free from physical abuse for two of six sampled residents (Resident 2 and Resident 4). The facility failed to: 1. Ensure Certified Nursing Assistant (CNA 1) separated Resident 1 and Resident 2 immediately when the two residents were arguing over a wheelchair which resulted to Resident 1 throwing a coffee cup to Resident 2's right side of the head. Resident 1 had a recent history of resident-to-resident altercation last June 2024 and Resident 2 had a known aggressive behavior against staff and residents. 2. Protect and prevent Resident 3 from hitting Resident 4 on the face. These failures resulted in Resident 2 sustained a skin abrasion (superficial skin wound) on the right side of the head and Resident 4 getting hit on the face and fell on the floor. Findings: 1.During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to: 1. Ensure Licensed Vocational Nurse (LVN) 5 documented medication as administered in the Medication Administration Record (MAR) immediately after administering Resident 20's Insulin Lispro (a short acting medication used to treat elevated blood sugar level). 2. Ensure LVN 5 verified Resident 20's identity with the MAR prior to medication administration. These deficient practices increased the risk of medication error, including Resident 20 not receiving the correct medication as ordered. 3. Ensure LVN 5 and LVN 2 performed a change of shift inventory of controlled medication (a term used for medications with high level of abuse and dependence) and documented on the count on the facility's-controlled drug count record (a document indicating perpetual inventory and administration of controlled substances) at the beginning and end of each shift per the facility's policy and procedure (P&P) titled, Controlled Medication Storage. This…

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

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: 1. Dusty fan was located near the dishwasher and a dusty radio was located near the kitchen prep table (workstation for food preparation). 2. Facility freezer and refrigerator were not in safe operating condition. 3. A green substance was observed on the spout of the ice dispenser These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (illnesses contracted from eating contaminated food or beverages) of residents who received food from the facility. Findings: 1. During an observation on 6/28/2024 at 3:12 p.m., of the facility's kitchen, a dietary staff was unloading the newly sanitized dishes from the dishwasher and a dusty fan was situated over the dishwasher equipment blowing air to the newly sanitized dishes. Observed a dusty radio was placed close to the kitchen prep table. 2.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure infection control practices was implemented. The facility failed to: 1. Ensure personal protective equipment (PPE- equipment used to prevent or minimize exposure to hazards) was easily accessible for direct patient care staff on residents with Enhanced Barrier Precaution (EBP- use of a gown and gloves for residents with wounds, and indwelling devices). These deficient practices had the potential for the spread and transmission of multidrug resistant organism (MDROs- microorganisms, predominantly bacteria that are resistant to one or more classes of antimicrobial agents) in the facility. 2. Ensure the facility's Water Management Plan (plan that identifies hazardous conditions and steps to take to minimize the growth and spread of bacteria[germs]) indicated testing protocols (deliberate action to see if something works) for control measures (actions taken to reduce the potential of exposure to the hazard) and documented results of…

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

Based on observation, interview and record review, the facility failed to ensure three freezers and one refrigerator in the facility's kitchen and food pantry were maintain in safe operating condition. This failure had the resident food items stored in an unsafe condition that could potentially place the residents at risk for food-borne illnesses (illness cause by food contaminated with bacteria, viruses, parasites, or toxins). Findings: During an observation on 6/28/2024 at 3:24 p.m., at the facility's food pantry with the Dietary Supervisor (DS), the following were observed: a. Freezer #1 that stored several bags of frozen tortilla have no thermometer to monitor the freezer's temperature. There was an opened bag of tortilla with no opened date tag and another tortilla bag unopened with ice crystals inside the bag. b. Freezer #2 that stored packed bags of vegetables had a temperature of 2 (two) degrees Fahrenheit (°F a temperature scale) and there was an ice build up observed on the upper portion of the freezer. c. Freezer #3 that stored sliced carrots and french fries had 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 residents receiving hemodialysis ([HD], a medical procedure to remove fluid and waste products from the body) provided necessary care and services for two of two sampled residents (Resident 47 and 26). The facility failed to: a. Ensure Resident 47's blood pressure check was not measured using the left arm with the arteriovenous shunt ([AV] a connection that was made between an artery and a vein for dialysis access). This deficient practice had the potential to interrupt the blood flow to the arm and may cause the AV shunt to stop working. b. Accurately measure Resident 47 and 26's intake and output when a full pitcher of water was left and within reach for Resident 47 and Resident 26. This deficient practice had the potential to cause fluid overload (too much water in the body) for Resident 47 and Resident 26. Findings: a. During a review of Resident 47's admission record, the admission Record indicated Resident 47 was admitted 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 obtain informed consent (process by which a healthcare provider educates a resident about the risks and benefits, and alternatives of a given procedure or intervention) prior to the administration of psychotropic drugs (medication that affects brain activities associated with mental process and behavior) for two of four sampled residents (Resident 64 and Resident 41). This deficient practice had the potential to place Resident 64 and 41 at risk of receiving unnecessary psychotropic medication including Lorazepam (brand name Ativan-medication used to treat anxiety [feeling of fear, dread, and uneasiness], Olanzapine (antipsychotic medication that can treat several mental health conditions) and lithium carbonate (a medication used to treat manic episodes of bipolar disorder) and Resident 41 receiving olanzapine, and Ativan without clinical justification for use. Findings: a.During a review of Resident 64's admission Record, the admission…

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 its medication error rate was less than five percent (%). Two medication errors out of 27 opportunities contributed to an overall medication error rate of 7.14 % affecting one of four residents observed (Resident 33) during medication administration. The medication errors were as follows: 1. Calcitonin Salmon Nasal Solution (a medication used to treat osteoporosis [a disease which causes bones to weaken and break more easily]) 200 units ([U] the amount of a medication administered to a resident in a single dose) one spray was administered in Resident 33's right nostril (outer openings of the nose through which one breathes) instead of left nostrils as ordered by Resident 33 physician. 2. Omission of Calcitonin Salmon Nasal Solution 200 U one spray in Resident 33's left nostril. These deficient practices resulted in failing to administer Calcitonin Salmon Nasal Solution in accordance with the physician's orders and increased the…

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

Based on interview and record review, the facility's Quality Assessment and Assurance committee ([QAA] a group of facility staff who identifies, evaluates, and implements measures to improve the quality of care and life for the residents in the facility) and Quality Assurance Performance Improvement ([QAPI] a group who takes a systemic, interdisciplinary, comprehensive, and data driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families, and all nursing home caregivers in practical and creative problem solving) committee failed to ensure continued oversight of the facility's plan of correction (POC) of the deficient practices identified during the previous recertification survey (7/19/2021). This deficient practice resulted in the facility having repeat deficiencies in quality of care, such as pharmaceutical services (procuring, dispensing, distributing, storing, and administering of medications), medication error rate of five percent or more, infection control, and physical environment. Findings: During a review of the…

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

Deficiency Text Not Available

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 38) who had a history of post-traumatic stress disorder (PTSD- a mental health condition that triggered by a terrifying event either experiencing it or witnessing it), and depression (a depressed mood or loss of pleasure or interest in activities for long periods of time) was provided individualized plan of care to address potential trauma triggers This deficient practice has the potential not to provide resident centered behavioral health care services needed for Resident 38. Findings: During a review of Resident 38's admission Record, the admission Record indicated Resident 38 was admitted to the facility on [DATE] with diagnoses including post-traumatic stress disorder, bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs and lows), anxiety disorder (persistent and excessive worry that interferes with daily activities). During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 27), who was prescribed with antipsychotic drug (a type of medication prescribed to treat mental health problem) and an anxiolytic drug (anti-anxiety medications, that treat anxiety symptoms and disorders) were monitored for behaviors of bipolar (a mental health condition that causes extreme mood swings) and anxiety episodes every shift. This deficient practice has the potential for Resident 27's behavior of psychosis and anxiety to be unmonitored and has the potential for an inaccurate information necessary for gradual dose reduction ([GDR] tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued. and/ or readjustment) of Resident 27 psychotropic (any drug that affects brain activities associated with mental processes and behavior) medications. Findings: During a review of Resident 27's admission Record, the admission…

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 one sampled resident (Resident 30) Responsible Party (RP) was notified when the dentist recommended the need for dentures (an artificial placement of one or more teeth). This deficient practice had the potential to cause a delay in dental treatment for Resident 30. Findings: During a review of Resident 30's admission Record, indicated Resident 30 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (damage or disease which affects the brain), Alzheimer's disease (a progressive disease which destroys memory and other important mental functions), and unspecified dementia (loss of cognitive functioning [thinking, remembering, and reasoning]). During a review of Resident 30's History and Physical (H&P) dated 2/1/2024, indicated Resident 30 did not have the capacity to understand and make medical decisions. During a review of Resident 30's MDS dated [DATE], the MDS indicated Resident 30 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to report an allegation of sexual abuse to the California Department of Health (CDPH) Licensing and Certification Program (L&C), State Long Term Care Ombudsman ([LTC] public advocate) and the local Police Department (PD) within the regulated time frame of two hours for one of five sampled residents (Resident 1). This deficient practice resulted in a delay in the investigation of the sexual abuse allegation and had the potential for pertinent data to be lost and/or forgotten. Findings: A review of Resident 1 ' s admission Record (Face Sheet), indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including Parkinsonism (brain condition which causes slowed movements, rigidity [stiffness] and tremors), dementia (impaired ability to remember, think, or make decisions which interferes with doing everyday activities), schizophrenia (a mental health condition which causes hallucinations [when a person hears, sees, smells, tastes or feels…

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 complete one of one resident's (Resident 1) Preadmission Screening and Resident Review ([PASRR] a federal requirement to help ensure that individuals were not inappropriately placed in nursing homes for long term care), when Resident 1 was newly diagnosed with Schizophrenia (mental disorder affecting thoughts and perceptions) and started on Risperdal (medication used to treat Schizophrenia). This deficient practice has the potential to result in a lack of specialized care and services. Findings: During a review of Resident 1's the admission Record (face sheet-FS), the FS indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of sepsis (severe infection), pneumonia (infection that affects one or both lungs), Chronic Obstructive Pulmonary Disease (COPD-group of diseases that cause breathing problems) and muscle weakness. During a review of Resident 1's History and Physical (H/P), dated 2/27/2023, the H/P indicated Resident 1 has the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure the interdisciplinary team (IDT) was involved in developing a discharge plan for one of three sample residents (Resident 1), that reflects Resident 1's discharge concerns, needs, goals and treatment preferences. This deficient practice resulted in Resident 1 feeling angry and distrustful of the staff and the failures had the potential to result in an ineffective discharge planning leading to lack of necessary care and services for Resident 1 after discharge. Findings: During a review of Resident 1's the admission Record (face sheet-FS), the FS indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of sepsis (severe infection), pneumonia (infection that affects one or both lungs), Chronic Obstructive Pulmonary Disease (COPD-group of diseases that cause breathing problems) and muscle weakness. During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 9/4/2023, 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.