Bel Vista Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to implement their Enhanced Barrier Precaution (EBP: infection control practices to prevent the spread of multidrug-resistant organisms (MDRO's) control measures for one of three sampled residents (Residents 21 ) by failing to wear proper Personal Protective Equipment (PPE: to protective clothing, helmets, gloves, face shields, goggles, face masks and/or respirators or other equipment designed to protect the wearer from injury or the spread of infection or illness) when coming in contact with /administering Resident 21's Lidocaine Patch (medication that numbs specific area of the body by blocking pain signals to the brain) and when handling the indwelling catheter (known as Foley catheter, a tube that allows urine to drain from the bladder into a bag that is usually attached to the thigh) drainage bag. These deficient practices had the potential to transmit infectious microorganisms and increase the risk of infection for the residents.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation interview and record review the facility failed to ensure a banana was not placed on Resident 194's breakfast tray when the diet tag indicated Resident 194 was allergic to bananas. This deficient practice had the potential to subject Resident 194 to have an allergic reaction( an unpleasant or dangerous immune system reaction after a certain food is eaten. Findings: During a review of Resident 194's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] with diagnoses including dysphagia (difficulty swallowing) , oropharyngeal phase (swallowing difficulty related to mouth and throat), asthma (when a person's airway became inflamed , narrow, swell and becomes difficult to breathe) and repeated falls. During a review of Resident 194's Minimum Data Set (MDS), a resident assessment tool, dated 5/6/2025, the MDS indicated Resident 194's cognition was moderately impaired. The MDS indicated Resident 194 was dependent (helper does all the effort.…

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: committee that focuses on identifying and addressing quality deficiencies in resident care) failed to implement and ensure effective oversight of the facility and implementation of their Quality Assurance and Performance Improvement (QAPI: systemic approach to improve the quality of care and services provided to residents) plan. This deficient practice had the potential to have reoccurring deficient practices that can impact the quality of care for the residents. During a concurrent interview and record review on 5/18/2025 at 6:25p.m., with the Administrator (ADM), the ADM stated they have QAPI meetings monthly and QAPIs are structured to identify potential solutions to yield positive outcomes. The ADM stated they did not have documentation of QAPI meetings prior to March 2025. The ADM stated there were issues regarding call light response time at the end of February 2025, and in March 2025, call light issues were present during the resident council meetings, so a QAPI 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 interview and record review, the facility failed to ensure the status of one of three sample residents (Resident 1)'s alleged abuse allegation was assessed and monitored. These deficient practices had the potential to negatively affect the residents' physical comfort and psychosocial well-being by not receiving the needed and necessary services timely. 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 unspecified sequelae (long term effect) of cerebral infarction (stroke: blockage that disrupts blood flow to the brain leading to brain), slurred speech, and hypertension (high blood pressure). During a review of Resident 1's History and Physical (H&P) dated 4/22/2025, the H&P indicated Resident 1 is not able to make medical decisions. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 4/18/2025, the MDS indicated Resident 1's cognitive skills (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 complete and to provide a written notice of seven-day bed hold (a guaranteed reservation for residents that are transferred out emergently) document when the resident was transferred to the General Acute Care Hospital (GACH) for one of three sampled residents (Resident 1). This failure resulted in Resident 1 and Resident 1's Responsible Party not knowing their rights to a seven-day bed hold. 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 cerebral infarction (loss of blood flow to a part of the brain), sick sinus syndrome (a type of abnormal heartbeat), and dementia (progressive state of decline in mental abilities). During a review of Resident 1 ' s History and Physical (H&P), dated 5/28/2024, the H&P indicated, Resident 1 did not have the capacity (ability) to understand and make decisions. During a review of Resident 1 ' s Minimum…

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) clothing was inventoried prior to being sent out to be laundered by an outside vendor. This deficient practice resulted in the facility not knowing which clothing was being laundered by the outside vendor and resulted in the loss of Resident 1 ' s clothing. Findings: During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted on [DATE] with the diagnosis of hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or the inability to move on one side of the body). During a review of Resident 1 ' s Minimum Data Set (MDS – a federally mandated resident assessment tool) dated 8/29/2024, the MDS indicated Resident 1 cognition was moderately impaired and was dependent (helper does all the effort) on facility staff to complete activities of daily living (ADLs- routine tasks/activities such as bathing,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) Interdisciplinary Team (IDT- a group of professional and direct care staff that have primary responsibility for the development of a plan of care for the patient) Conference Notes accurately reflected the list of concerns and topics discussed during the IDT meeting. This deficient practice has the potential to result in a lack of communication and implementation of Resident 1 ' s plan of care. Findings: During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted on [DATE] with the diagnosis of hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or the inability to move on one side of the body). During a review of Resident 1 ' s Minimum Data Set (MDS- a federally mandated resident assessment too) dated 8/29/2024, the MDS indicated Resident 1 cognition was moderately impaired and was dependent…

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 medication carts (a moveable (a movable piece of equipment used in healthcare facilities to store, transport, and dispense medicines, medical supplies, and emergency equipment) 1, 2, and the facility's intravenous ([IV] giving medicines or fluids through a needle or tube inserted into a vein) medication carts were locked when unattended. This deficient practice resulted in resident's, visitors, and other staff having immediate access to medications and had the potential for theft, loss, and unauthorized consumption of medications. 2. Ensure the medication cart 2 keys were left unattended on top of medication cart 2. These deficient practices resulted in resident's, visitors, and other staff having immediate access to narcotics and had the potential for theft, loss, drug diversion (the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber), and unauthorized consumption 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 assess, care plan, and obtain a physician's order to have the bed against the wall for three of 31 sampled residents (Residents 15, 24 and 28). This deficient practice had the potential to result in unnecessary use of a physical restraint (purposely limiting or obstructing freedom of a person's bodily movement). Findings: a. During a review of Resident 15's admission Record (Face Sheet), the face sheet indicated Resident 15 was admitted to the facility on [DATE] with diagnosis including cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) and dysphagia (difficulty swallowing). During a review of Resident 15's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 4/11/2024, the MDS indicated Resident 15's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 15 had functional limitations in both upper and lower extremities. 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.

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) 11 immediately enters the date and time of a controlled medication [a drug or other substance that is tightly controlled by the government because it may be abused or cause addiction and may cause significant risk to patient safety]) administration, and her initials to Medication Administration Record ( MAR) and the Controlled Medication Sheet (a form used to document and track the administration of controlled substances for one of two sampled residents (Resident 16) per facility's policy and procedure ( P&P). These deficient practices had the potential for increase in pain and/or uncontrolled pain, for Resident 16, medication errors and diversion (illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) of narcotics (a medication used to relieve moderate to severe pain). 2. Ensure LVN's 11 and 12 did not administer Resident 16's Refresh Tears…

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 Medication Administration Record ([MAR] a record of all medications administered to a resident) were accurately documented for the month of 5/2024 for two of two sampled residents (Resident 18 and 139). Licensed nurses documented: 1. For Resident 18, Licensed Vocational Nurse (LVN) 10 documented on Resident 18's MAR as administered for Ipratropium-Albuterol Solution (a medication used to open bronchial tubes [air passages]) every six hours for shortness of breath (unable to breathe normally), on 5/17/2024 at 9 p.m., and on 5/18/2024 at 3 a.m., when the medication was not delivered in the facility. This deficient practice placed Resident 18 at risk for further respiratory complications, change of condition, and unnecessary hospitalization from lack of treatment. 2. For Resident 139, licensed nurses documented on Resident 139's MAR as administered for Refresh Tears Ophthalmic Solution ([Carboxymethlcellulose Sodium]- medications used for dry…

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 staff to resident physical abuse to the California Department of Public Health (CDPH), Local Law Enforcement, and the State Long Term Care Ombudsman ([LTC] public advocate) within the regulated time frame of two hours for one of one sampled resident (Resident 30). This deficient practice resulted in CDPH not being aware of the abuse allegation that occurred in 4/2024 until 5/18/2024 and the inability to investigate the allegation on time. This deficient practice had the potential for pertinent information to be lost and/or forgotten, more allegations of abuse to go unreported and continued abuse to occur. Findings: During a review of Resident 30's admission Record (Face Sheet), the Face Sheet indicated Resident 30 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) and malnutrition (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 interview, and record review, the facility failed to develop and implement an individualized care plan with measurable objectives, timeframes, and interventions t for two of two sampled residents (Resident 24 and Resident 9) when: a. Resident 24's non- compliance on turning and repositioning as part of wound management interventions; and b. Resident 9's prescribed anti-anxiety medication (used to treat anxiety [(a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness) disorders) with subsequent monitoring for episodes of anxiety and the response to medications such as side effects and/ or adverse reactions (harmful or unpleasant reaction to medication). These deficient practices had the potential to negatively affect the delivery of necessary care and services for Resident 24 and 9). Findings: a. During a review of Resident 24's admission Record (Face Sheet), the indicated Resident 24 was admitted at the facility on 2/3/2023 with diagnoses including diabetes mellitus (a condition in which the body fails to metabolize (process) glucose…

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 licensed nursing staff failed to follow professional standards of practice for one of one sampled resident (Resident 29) by: 1. Not flushing (introducing water to the tube) the medication pre and post administration of medication with 30 milliliters ([mL] a unit of measurement) though a gastrostomy ([G-Tube] a surgical opening made into the stomach to provide nutritional support and administer medications to a resident) of water. 2. Not checking gastric residual (the volume of fluid remaining in the stomach) prior to medication administration. 3. Not mixing medication with five to 15 mL of water prior to administration per facility's policy and procedure. These deficient practices had the potential to cause additional health complications such as dislodgement of the G-Tube, aspiration (food, liquid, or other material enters a person's airway and eventually the lungs), abdominal distention (bloating and swelling in the belly area) and discomfort, gastric…

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 31 sampled resident's (Resident 30) got out of bed as ordered and was offered to get out of bed when he requested to attend the facility's Cinco De Mayo Festivities. This deficient practice resulted in Resident 30's not getting out of bed since his admission to the facility on 3/4/024, feeling of sadness, and inability to participate in the Cinco de Mayo Festivities. Findings: During a review of Resident 30's admission Record (Face Sheet), the Face Sheet indicated Resident 30 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (occurs because of disrupted blood flow to the brain due to problems with the blood vessels that supply it), abnormalities of gait (manner of walking) and mobility, and lack of coordination. During a review of Resident 30's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 3/8/2024 the MDS indicated Resident 30's cognitive skills for daily…

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 two of two sampled residents (Resident 9 and Resident 18) were: a. provided assistance in recharging Resident 9's hearing aid; and b. provided assistance for Resident 18 to be scheduled for ancillary services such as Eyes, Ears, Nose and Throat consultation and assessed/ determined for a hearing aid. These failures has caused Resident 9 and Resident 18 to feel frustrated during their care and treatment which could potentially delay the delivery of their care and services that can inadvertently affect their quality of life. Findings: A. During a review of Resident 9's admission Record (face sheet), the Face sheet indicated Resident 9 was admitted at the facility on 3/1/2024 with diagnosis including anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness) and repeated falls. During a review of Resident 9's Minimum Data Set ([MDS] a standardized assessment and care screening tool)…

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

Based on observation, interview, and record review the facility failed to ensure one of one sampled resident (Resident 11) was provided floor mats to both side of her bed, who have a history of falling. This failure has the potential for Resident 11 to incur injury and suffer complications associated with a fall. Findings: During a review of Resident 11's admission Record (face sheet), the face indicated Resident 11 was admitted at the facility on 9/12/2023 with diagnosis including atrial fibrillation (a condition of irregular heartbeat that occurs when the electrical signals in the chambers of the heart fire rapidly at the same time causing the heart to beat faster than normal) with long term use of anticoagulant (also called a blood thinner; a substance that is used to prevent and treat blood clots in the blood vessels and the hearts) medication, dementia (a condition of loss of brain function that affects one or more brain function such as memory, thinking, language, judgment or behavior), and gait (the way a person walks or run) and mobility (ability to move freely)…

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 (Resident 140), who received hemodialysis (process of purifying the blood of a person whose kidneys [one of a pair of organs in the abdomen which remove waste and extra water (as urine) and help keep chemicals balanced in the body] are not working normally) intake and output status was monitored per the physician's orders for one of one sampled resident. This deficient practice had the potential to over and/or underload Resident 140 with fluid. Findings: During a review of Resident 140's admission Record (Face Sheet), the Face Sheet indicated Resident 140 was admitted to the facility on [DATE] with diagnosis including diabetes mellitus (DM) type 2 [a chronic disease characterized by elevated levels of blood glucose (or blood sugar) in a bloodstream] and end stage kidney disease (a condition in which the kidneys lose the ability to remove waste and balance fluids), dependence on renal (kidney) dialysis (a procedure to remove waste…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure resident who has a history of Post traumatic stress disorder (PTSD- a mental health condition that's triggered by a terrifying event either experiencing it or witnessing it) was screen and was assessed for re-traumatization of traumatic experience for one of one sampled resident (Resident 23). This deficient practice has the potential for staff unable to identify fears that can bring back trauma. Findings: During a review of Resident 23's admission Record (Face Sheet), the face sheet indicated Resident 23 was admitted to the facility on [DATE] with diagnosis including Post traumatic stress disorder (PTSD- a mental health condition that's triggered by a terrifying event either experiencing it or witnessing it), depression (a depressed mood or loss of pleasure or interest in activities for long periods of time),unspecified atrial fibrillation (an irregular and often very rapid heart rhythm). During a review of Resident 23's Minimum…

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 proper use of bed rails (are adjustable metal or rigid plastic bars that attach to the bed) for two of three sampled residents (Resident 15, 24, and 28), as indicated in the facility's policy and procedure by failing to: assess, monitor, evaluate, and provide care plan for residents with side rails. These deficient practices had the potential to result in inappropriate use of bed rails for (Resident 15,24 and 28) that can lead to entrapment and/or injuries. Findings: a. During a review of Resident 15's admission Record (Face Sheet), the face sheet indicated Resident 15 was admitted to the facility on [DATE] with diagnosis including cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) and dysphagia (difficulty swallowing). During a review of Resident 15's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 4/11/2024, the MDS indicated Resident 15's cognitive skills for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure resident who has a history of Post traumatic stress disorder (PTSD- a mental health condition that's 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 with individualized approach to care and understand resident's distress for one of one sampled resident(Resident 23). This deficient practice has the potential not to provide behavioral health care services needed for Resident 23. Findings: During a review of Resident 23's admission Record (Face Sheet), the face sheet indicated Resident 23 was admitted to the facility on [DATE] with diagnosis including Post traumatic stress disorder (PTSD- a mental health condition that's triggered by a terrifying event either experiencing it or witnessing it), depression (a depressed mood or loss of pleasure or interest in activities for long periods of…

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

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 9), who was prescribed an anxiolytic (also known as anti-anxiety, a drug used to treat symptoms of anxiety such as feelings of fear, dread, uneasiness that may occur as a reaction to stress) for anxiety disorder was monitored for behavior of anxiety prior to administration of the medication and monitored for side effects and/or adverse reactions to the medication every shift. This failure has the potential for Resident 9 to be unnecessarily medicated with anxiolytic (anti-anxiety medication) which could place Resident 9 high risk for adverse and/ or side effects that could negatively affect her overall health and well-being. Findings: During a review of Resident 9's admission Record (face sheet), the Face sheet indicated Resident 9 was admitted at the facility on 3/1/2024 with diagnosis including anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness). During a review of Resident 9's Medication Administration Record…

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

Based on interview and record review the facility failed to ensure laboratory findings was relayed to medical doctor (MD) when available for one of one sampled residents ( Resident 6). This deficient practice has the potential to miss abnormal laboratory to be relayed to MD and informed for any abnormal findings. Findings: During a record review of Resident 6's admission record, the admission record indicated Resident 6 was admitted to the facility initially on 2/24/2024. Resident 6's diagnosis included dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), generalized muscle weakness (a decrease in muscle strength) and paroxysmal atrial fibrillation (happens when abnormal electrical impulses suddenly start firing in the atria). During a record review of Resident 6's Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 3/1/2024, the MDS indicated Resident 6 supervision on eating at required dependent assistance (helper does all the effort) from the two or more staff for…

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

Based on observation, interview and record review, the facility failed to ensure the walk-in freezer in the facility's kitchen did not have an ice buildup. This failure has the potential for the residents' food supply to be tampered and/or contaminated that could put the residents at risk for food-borne illnesses. Findings: During an observation of the facility's walk-in freezer on 5/18/2024 at 6:48 a.m., the freezer had an ice build-up at the top portion of the freezer. During an interview on 5/18/2024 at 6:48 a.m., [NAME] 1 (CK 1) stated the ice buildup was concerning because it might leak and can destroy the residents' food supply. During an interview on 5/18/2024 at 2:01 p.m., the Maintenance Director (MD) stated the ice condensation in the freezer was normal because it was an old freezer that needed an insulation line to be redone. During an interview and record review on 5/18/2024 at 2:28 p.m., the Registered Dietician (RD) stated the ice buildup in the walk-in freezer has been identified and noted during kitchen audits and was fixed/ resolved by the facility's maintenance…

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 address/ implement facility assessment elements when: a.The facility failed to include the Infection Prevention Nurse (IPN) during the resident's assessment in the facility's assessment dated 01/30/ 2024 for the population of 39 census. b.The facility failed to assess needs for Resident that will be admitted to the facility with trauma experience to be able to provide needs and necessary care needed. These deficient practices had a potential to result in the provision of inadequate care and services to the facility's resident population. Findings: A. During a record review of the facility's assessment provided on 5/18/2024 during entrance conference, the assessment did not indicate that IPN was included in the facility wide assessment that was conducted on 1/30/2024. During a concurrent interview on 5/20/2024 at 9: 46 a.m. with the DON and Admin and record review of the facility assessment, the Admin stated that he forgot to include the IPN on 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 ([QAA] to develop and implement appropriate plans of action to correct identified quality deficiencies) and Quality Assurance Performance Improvement ([QAPI] designated to bring about constant and measurable improvement in the services provided at the facility for continual improvement of quality care) committee failed to: 1.Maintain effective systems in place to obtain and use feedback for facility issues submitted by direct care staff, residents, and resident representatives with regards to trauma informed care. 2. Monitor, review and analyze data for performance improvement of facility issues such as Abuse, use of side rails or bed against the wall, and change of condition. These deficient practices have the potential to not identify systematic approach to improve services to the residents. Findings: During a concurrent interview and record review on 5/20/2024 at 11:06 a.m. with the Administrator (ADMIN) and Director of Nursing (DON), the ADMIN stated the facility does not have any evidence 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 resident that is taking antibiotic vancomycin (can treat infections) 125 mg oral suspension for Clostridioides difficile (c-diff- is a bacterium that causes an infection of the colon, the longest part of the large intestine) was discontinued from contact isolation and was not placed in enhanced precaution for one of one sample Resident (Resident 38) This deficient practice had the potential for other Residents to get infected while Resident 38 is still on antibiotic without precaution. Findings: During a review of Resident 38's admission Record (Face Sheet), indicated Resident 38 was admitted to the facility on [DATE] with diagnosis including type 2 diabetes mellitus, cancer of the kidney (abnormal growth of cells in your body tissue), and gastrostomy tube ([GT] soft flexible tube surgically placed into the stomach through the abdominal wall to provide nutrition and/or medication). During a review of Resident 38's History and Physical (H&P),…

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 two of 20 residents bedrooms measured at least 80 feet square feet (sq. ft) per resident in rooms [ROOM NUMBERS]. The deficient practice resulted in reduced, required bed space per resident in rooms [ROOM NUMBERS], and had the potential for inadequate space during resident's care, or the inability for residents' access and use of personal assistive devices, furniture and providing enough space for visitors. Findings: During an initial tour on 5/18/2024 at 6:45 a.m., during the initial tour of the facility-and during the entrance conference with the Infection Preventionist, the IP stated that she is aware there is a room waiver. During a tour with the Administrator on 5/19/2024 at 11:03 a.m. stated rooms [ROOM NUMBERS] had been granted a waiver (variation) in December 2021. During a review of the facility's Client Accommodation s Analysis form dated 5/18/2024, the form indicated the following: Room: Sq ft. Number of Residents 5…

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

Based on observation, interview and record review, the facility failed to ensure the caregivers of one of one sampled resident (Resident 32) were properly identified through background check, competencies verified and provided orientation of the facility's rules and regulations before allowed to render care for one of one sampled resident (Resident 32). This failure had the potential for Resident 32 to be provided assistance and care not in line with the professional standard of care that could negatively affect her safety and well-being. Findings: During a review of Resident 32's admission Record (Face sheet), the face sheet indicated Resident 32 was admitted at the facility on 4/9/2024 with a diagnosis including anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness) and senile degeneration of the brain (a condition when older individuals suffer from cognitive decline particularly memory loss). During a review of Resident 32's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 4/12/2024, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure 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 them to a doctor) for three of eight sampled residents (Residents 13, 33 and 16) was offered and/or initiated. This deficient practice had the potential to cause conflict with Resident 13, 33, and 16's wishes regarding health care. Findings: During a review of Resident 13's admission Record, the admission record indicated the resident was admitted to the facility on [DATE]. Resident 13's diagnoses included acute myeloma in relapse (relapsed, or recurrent, acute myelogenous leukemia [AML] means the leukemia has come back after treatment and reaching remission), palliative care, unspecified protein-calorie malnutrition. During a review of Resident 13's Minimum Data Set (MDS), a standardized assessment and screening tool, dated 10/10/2021, the MDS indicated the resident 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 assess, care plan, and obtain a physician's order for having the bed against the wall for ten of 31 sampled residents (Residents 7, 14, 137, 138, 27, 25, 22, 12, 26, and 34). This deficient practice had the potential to result in unnecessary use of a physical restraint (purposely limiting or obstructing freedom of a person's bodily movement). Findings: a. During a record review of Resident 12's admission Record (face sheet), dated 12/19/2021, the face sheet indicated the facility admitted Resident 12 on 9/10/2021. Resident 12's diagnoses included a left foot injury, essential hypertension (abnormally high blood pressure [force it takes for blood to pump in the body]), history of falling, and sciatica (nerve pain originating in the lower back which travels down the leg). During a review of Resident 12's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 12/8/2021, the MDS indicated Resident 12 was cognitively…

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 an accurate assessment was conducted for three of eight sampled residents (Residents 23, 31, and 35). 1. Resident 23's limited range of motion was coded incorrectly. 2. Resident 35's skin condition during the assessment reference date (ARD) was not coded. 3. Resident's 31's assessment was coded incorrectly for therapeutic diet (meal plan that controls the intake of certain foods or nutrients). This deficient practice had the potential to result in an inaccurate reflection of Residents 23, 31, and 35's medical status and functional abilities. Findings: a. During a review of Resident 23's admission Record, the admission record indicated the resident was admitted to the facility on [DATE]. Resident 23's diagnoses included traumatic brain injury ([TBI] brain dysfunction caused by an outside force, usually a violent blow to the head), atrial fibrillation (irregular, often rapid heart rate), and anemia (condition in which the blood…

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 develop a comprehensive and resident centered care plan for three of eight sampled residents (Residents 20, 33, and 34). This deficient practice had the potential to result in a delay in delivery of care and services. Findings: a. During an initial tour of the facility on 12/18/2021 at 8:42 a.m., Resident 20 stated he had dementia and that the medicine he was given was making him shake a lot. Resident 20's feet were observed to be shaking. During a review of Resident 20's admission Record, the admission record indicated Resident 20 was admitted to the facility on [DATE]. Resident 20's diagnoses included dementia (progressive memory loss that affects a person's ability to carry out daily activities and that may cause changes in mood and personality), anxiety (excessive worry or fear), major depressive disorder (causes severe symptoms that affect how you feel, think, and handle daily activities, such as sleeping, eating, or working), and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure there was sufficient nursing staff to provide care for two of 31 sampled residents (Residents 16 and 22). Resident's 16 and 22's call lights (device used by residents to signal his or her need for assistance from healthcare staff) were not answered in a timely manner. This deficient practice resulted in Residents 16 and 22's needs not being met, and resulted in Resident 16's accidental defecation (the act of pooping) on the floor which impacted Resident 16's dignity. Findings: a. During a review of the Resident 22's admission Record (face sheet), the face sheet indicated the facility admitted Resident 22 on 6/1/2021. Resident 22's diagnoses included chronic obstructive pulmonary disease ([COPD] breathing problem), gout (painful condition causing joints to swell), morbid obesity (weight more than 80 to 100 ponds above ideal weight), muscle weakness, type 2 diabetes (body unable to regulate glucose [sugar] as fuel), and abnormalities of gait and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store food in a sanitary manner to prevent growth of microorganisms that could cause food borne illness (any illness resulting from the food spoilage of contaminated food) for 33 out of the 55 residents in the facility by: a. Storing staff food together with resident food. b. Discarding frozen fruit and ground meat on the labeled discarded date. These deficient practices had the potential to cause food borne illness for 33 out of the 55 residents in the facility. c. Facility failed to maintain dish washer temperature of 120 degrees Fahrenheit (F) as outlined in the facility policy and failed to ensure the chemical in the dishwasher used for sanitizing was at the proper level of 100 parts per million (PPM) to ensure dishes were cleaned. This deficient practice placed residents at increased risk for food borne illness related to improper sanitation of dishes. Findings: a. During an initial kitchen tour with the [NAME] (CK) on 12/17/2021 at…

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

Based on observation, interview, and record review, the facility failed to maintain an infection control program which prevented the spread of infection and COVID-19 (a respiratory disease caused by a coronavirus called SARS-CoV-2) when: a. Staff failed to complete a self-screen for temperature and symptoms of COVID-19 prior to starting their shift. b. Staff failed to properly doff (remove) personal protective equipment ([PPE] protective clothing to prevent the spread of infections). c. Staff wearing appropriate PPE. These deficient practices could potentially spread and expose residents and staff to COVID-19. Findings: a. During a concurrent observation on 12/18/2021 at 11:25 a.m., in Resident 32's room, observed Certified Nursing Assistant 2 (CNA) 2 remove her gown first then remove her gloves before exiting the room. During an interview on 12/18/2021 at 1:32 p.m., with Infection Preventionist Nurse (IP) stated, proper doffing should be gown first, fold it and discard in the trash, then removal of the gloves. IP showed the poster posted outside resident room which indicated that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure facility staff wore name badges to identify themselves to residents and families. This deficient practice had the potential to negatively affect Resident 16's sense of self-esteem, self-worth and felt his rights was violated. Findings: During a review of Resident's 16 admission record (Face Sheet), the face sheet indicated Resident 16 was admitted to the facility on [DATE]. Resident 16's diagnoses included hemiplegia (paralysis [inability to move] of one side of the body) and hemiparesis (muscle weakness), hypertension (high blood pressure), and migraines (recurring type of headache). During a review of Resident 16's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 10/13/2021, the MDS indicated Resident 16 had intact cognitive (ability to learn, remember, understand, and make decision) skills for daily decision making. The MDS indicated Resident 16 required limited assistance with bed mobility,…

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 two of 31 sampled residents (Residents 25 and 16) dignity by failing to: a. Ensure Resident 25 was provided with a dignified dining experience. b. Ensure Resident 16 did not accidentally defecate (pooping) on the floor. These deficient practices did not preserve Resident 25 and Resident 16's dignity thus impeding on the realization of the resident's highest attainable practicable well-being. Findings: a. During a review of Resident 25's admission Record (face sheet), the face sheet indicated the resident was admitted to the facility on [DATE]. Resident 25's diagnoses included cerebral infarct (blockage of blood vessel in the brain), anxiety (constant feeling of worry, fear, dread, or uneasiness), history of falling, heart failure, dysphagia (difficulty swallowing), and encounter for palliative care (medical care for people with serious illness focused on medical, emotional and spiritual support needed). 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 eight sampled resident's (Resident 33) pre-admission screening and resident review (PASARR) assessment screening was followed up to determine the facility's ability to provide for the special needs of the resident. This deficient practice placed Resident 33 at risk for not receiving the necessary care and services required and needed. Findings: During a review of Resident 33's admission Record, the admission record indicated the resident was admitted to the facility on [DATE]. Resident 33's diagnoses included acute kidney failure (sudden loss of kidney function), atrial fibrillation (irregular heart beat), renal dialysis (process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). During a review of Resident 33's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 11/1/2021, the MDS indicated the resident was able to make…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure nursing staff met professional standards of quality and competency, for proper medication administration technique of one of two licensed nurses observed administering medications, as evidenced by the facility's failure to ensure that two (2) medications were administered to Resident 6 during medication administration (med pass) and licensed staff did not sign the Medication Administration Record (MAR) without giving the medication for Resident 6. This deficient practice resulted in Resident 6 complaining of pain and the potential for harm to Resident 6 due to not receiving medications indicated for nutritional supplement and pain caused by their individual medical conditions. Cross referenced F759 Findings: During a review of the Resident's 6 admission Record (Face Sheet), the face sheet indicated Resident 32 was admitted to the facility on [DATE]. Resident 6's diagnoses included encephalopathy (damage or disease that affects the…

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

Based on observation, interview, and record review, the facility failed to provide feeding assistance for one of 31 sampled residents (Resident 25). This deficient practice resulted in Resident 25's inadequate nutritional intake thus putting the resident at high risk for malnutrition. Findings: a. During a record review of Resident 25's admission Record (face sheet) dated 12/18/2021, the face sheet indicated the facility admitted Resident 25 on 8/25/2020. Resident 25's diagnoses included cerebral infarct (blockage of blood vessel in the brain), anxiety (constant feeling of worry, fear, dread, or uneasiness), history of falling, heart failure, dysphagia (difficulty swallowing), and encounter for palliative care (medical care for people with serious illness focused on medical, emotional and spiritual support needed). During a record review of Resident 25's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 11/8/2021, the MDS indicated Resident 25 rarely had the ability to express ideas and wants, and rarely had the ability to understand others. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident, who was at risk for aspiration (when food, drink, or foreign objects are breathed into the lungs) and was noncompliant with her nothing per mouth ([NPO] to withhold food and fluids)) order, did not have a pitcher of water and enteral formula at the bedside (Resident 31). This deficient practice placed Resident 31 at risk for aspiration and choking. Findings: During a review of Resident 31's admission Record (Face Sheet), the face sheet indicated Resident 31 was admitted to the facility on [DATE]. Resident 31's diagnoses included malignant neoplasm (cancer) of the tongue, dysphagia (difficulty swallowing), chronic obstructive pulmonary disease ([COPD] progressive disease that makes it hard to breath), and use of a gastrostomy tube ([G-tube] an artificial opening into the stomach to deliver medication, nutrition, and hydration). During a review of Resident 31's Minimum Data Set (MDS), a standardized assessment and care screening tool,…

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 routine foot care for one of one sampled residents (Resident 11). Resident 11 was observed with long, curved toenails, and was last seen by the podiatrist on 10/8/2021. This deficient practice resulted in complaints of pain and discomfort, and had the potential to cause complications with mobility and foot health. Findings: During a review of the Resident 11's admission record (face sheet), the face sheet indicated Resident 11 was admitted to the facility on [DATE]. Resident 11's diagnoses included hypertension (high blood pressure), dementia (loss of memory, language, problem-solving and other thinking abilities), osteoarthritis (degenerative joint disease) of the knee, and hyperlipidemia (high levels of fat particles in the blood). During a review of Resident 11's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 9/29/2021, the MDS indicated Resident 11 had severe impairment in cognitive (ability…

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 conduct an interdisciplinary team ([IDT] group of different disciplines working together towards a common goal for the resident) meeting, update interventions, perform neurological assessments and rehabilitation assessment status post fall for Resident 13. These deficient practices resulted in Resident 13 suffering multiple falls in three consecutive days. Findings: During a review of Resident 13's admission Record, the admission record indicated the resident was admitted to the facility on [DATE]. Resident 13's diagnoses included acute myeloma in relapse (relapsed, or recurrent, acute myelogenous leukemia (AML) means the leukemia has come back after treatment and reaching remission), and unspecified protein-calorie malnutrition. During a review of Resident 13's Minimum Data Set (MDS), a standardized assessment and screening tool, dated 10/10/2021, the MDS indicated the resident was able to make self-understood and had the ability to…

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

Based on observation, interview, and record review, the facility failed to ensure Resident 137's tube feeding (a way of delivering nutrition directly to the stomach through a surgically inserted tube) formula was running at the prescribed rate ordered. This deficient practice had the potential for decreased nutritional intake. Findings: During a review of Resident 137's admission Record (face sheet) dated 12/19/2021, the face sheet indicated the facility admitted Resident 137 on 12/14/2021. Resident 137's diagnoses included hemiplegia (paralysis [inability to move] on one side of the body), aphasia (loss of ability to understand or express speech caused by brain damage), essential hypertension (abnormally high blood pressure [force it takes for blood to pump in the body]), muscle weakness, syncope (temporary loss of consciousness), and hyperlipidemia (abnormally high levels of lipids or fats in the blood). During a concurrent observation, interview, and record review of Resident 137's enteral feeding formula label, on 12/17/21 at 8:37 a.m., it was noted and visually confirmed by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to monitor the intake and output status for one of one sampled residents (Resident 33) receiving hemodialysis (process of purifying the blood of a person whose kidneys are not working normally). This deficient practice had the potential to over or underload Resident 33 with fluid, which can affect the kidneys. Findings: During a review of Resident 33's admission Record, the admission record indicated the resident was admitted to the facility on [DATE]. Resident 33's diagnoses included acute kidney failure (when your kidneys suddenly become unable to filter waste products from your blood), atrial fibrillation (irregular heart beat), and renal dialysis (process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). During a review of Resident 33's Minimum Data Set (MDS), a standardized assessment and screening tool, dated 11/21/2021, the MDS indicated the 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 observation, interview, and record review, the facility failed to comprehensively assess the root cause of behavioral symptoms and develop measurable goals and interventions to address care and treatment of residents with dementia (a disorder of mental processes caused by brain disease or injury and marked by memory disorder, personality changes, and impaired reasoning) for one of 8 sampled residents (Resident 20). This deficient practice had the potential to negatively affect the delivery of services to Resident 20. Findings: During a review of Resident 20's admission Record, the admission record indicated the resident was admitted to the facility on [DATE]. Resident 20's diagnoses included dementia (progressive memory loss affecting a person's ability to carry out daily activities and that may cause changes in mood and personality), anxiety (excessive worry or feeling of unease), major depressive disorder (causes severe symptoms that affect how you feel, think, and handle daily activities, such as…

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

Based on observation, interview, and record review, the facility failed to ensure adequate amount of emergency drugs to residents by failing to replace oral (PO) medication in the emergency kit ([E-kit] storage receptacle that contains a drug supply that can be used for residents during emergencies) within 72 hours of usage for one of one medication storage rooms in the facility. This deficient practice had the potential to result in the unavailability of medication for the residents during an emergent situation. Findings: During a medication storage inspection and concurrent interview with the Infection Preventionist (IP) Nurse and review of the oral E-kit record for E-kit 148 on 12/17/221 at 9:50 a.m., the IP confirmed that E-kit 148 was used on four different occasions: 1. On 12/9/2021, one Keflex (medication for infection) was removed for Resident 35; 2. On 12/15/221, one Doxycycline (medication for infection) caplet was removed for Resident 29 on two occasions; and 3. On 12/16/221, one Tramadol (pain medication) 50 milligrams was removed for Resident 137. The IP Nurse stated…

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 it was free of a medication error rate of less than five percent as evidenced by the identification of three (3) medication errors based on 27 medication opportunities, that yield a facility medication error rate of 11.11 percent during medication administration. The following three medication errors occurred for: a. The facility failed to remove a lidocaine patch (used to relieve pain and numb the skin) for Resident 6 at 9 p.m. per physician order. b. The facility failed to administer a dose of Ascorbic Acid (Vitamin C) for Resident 6 as ordered. c. The facility failed to administer Aspercream lidocaine cream 4 percent (%) to Resident 6's left hand and left hip as ordered. These deficient practices had the potential to place Resident 6 at risk for discomfort, pain and jeopardizes her health and safety. Findings: During a review of Resident 6's admission Record (Face Sheet), the face sheet indicated Resident 6 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.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals (substance from biological sources) used in the facility was labeled in accordance with professional principles by: a. Failing to indicate the date when the Aplisol (brand name of a solution for Tuberculin Purified Protein Derivative, PPD - used to aid in the detection of infection with mycobacterium tuberculosis, TB - a highly contagious infection of the lungs) vial was opened to readily identify when the vial should be discarded. This deficient practice had the potential to cause inaccurate test results in the detection of TB and can lead to untreated mycobacterium tuberculosis and spread of infection. b. Failing to ensure medications for a discharged resident (Resident 140) and a used normal saline vial were not stored in one (1) of two (2) medication carts in the facility. These deficient practices had the potential to result in an unintentional medication administration of the wrong or contaminated medication to current residents in the facility. Findings: a. 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.