Bixby Towers Post-Acute Rehab

Based on observation, interview, and record review, the facility failed to maintain three of three electrical rehabilitation therapy (therapy given to restore an individual back to their highest possible level of physical, mental, and psychosocial well-being) equipment for resident use. This deficient practice had the potential for injury to any resident using the therapy equipment. Findings:During an observation and interview on 7/28/2025 at 1:21 p.m., with the Rehabilitation Director (RHB), the RHB stated the rehabilitation gym was downstairs on the first floor. The RHB stated the therapy department had three electrical therapy equipment including an ultrasound (equipment used to produce high-frequency sound waves that travel deep into tissue and create therapeutic heat), transcutaneous electrical nerve stimulation (TENS, a machine that uses electrical currents through a device to stimulate the nerves for therapeutic purposes) combination unit, Therapy Equipment (TE 1), an adjustable therapy mat (TE 2), and a bicycle (TE 3). The RHB provided a tour of the therapy gym on the first…

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 one of two residents (Resident 99) foley catheter ( a medical device that helps drain urine from your bladder [drainage bag]- the bag attached to the end of the catheter that collects the urine) was covered with a dignity bag ( a cover or pouch designed to hide the urine collection bag) in accordance with professional standards and the residents' right to dignity.This failure resulted in potential embarrassment, compromised privacy, and a lack of respect for Resident 99's dignity.Findings:During a concurrent observation and interview on 7/29/2025 at 3:57 p.m. with Certified Nurse Assistant (CNA) 4 in room [ROOM NUMBER]A, it was observed that Resident 99's foley catheter drainage bag was not covered by a dignity bag. CNA 4 stated the dignity bag was not in place on the drainage bag. CNA 4 stated that it is all staff's responsibility to maintain the foley catheters and ensure all residents have a dignity bag. CNA 4 stated that she usually places a dignity bag to cover 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 interview and record review, the facility failed to report an abuse allegation to the California Department of Health, the Ombudsman, and the law enforcement agency for one of three sampled residents (Resident 74), when Resident 74 reported to the Assistant Director of Nursing (ADON) that Certified Nurse Assistant (CNA) 1 physically abused her while providing her with personal care. This deficient practice had the potential to place other residents at risk for physical abuse. Findings:During a review of Resident 74's admission Record, the admission Record indicated Resident 74 was admitted to the facility on [DATE] with diagnoses including osteoarthritis (a progressive disorder of the joints, caused by gradual loss of cartilage) and rheumatoid arthritis (a chronic-progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility). During a review of Resident 74's MDS dated [DATE], the MDS indicated Resident 74 had severe cognitive impairment and required maximal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its abuse policy and procedure (P&P) titled Abuse Prevention Program, dated 12/1/2022 by failing to investigate an abuse allegation for one of three sampled Residents (Resident 74).This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect residents from abuse.Findings:During a review of Resident 74's admission Record, the admission Record indicated Resident 74 was admitted to the facility on [DATE] with diagnoses including osteoarthritis (a progressive disorder of the joints, caused by gradual loss of cartilage) and rheumatoid arthritis (a chronic-progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility). During a review of Resident 74's MDS dated [DATE], the MDS indicated Resident 74 had severe cognitive impairment and required maximal (helper does more than half the effort) assistant with activities of daily living (ADLs- activities such…

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 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) was resubmitted and documented correctly for two of two sampled residents (Resident 9 and Resident 52).This failure had the potential to result in Resident 9 and Resident 52 not receiving the necessary care and services they need.Findings:During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was admitted to the facility on [DATE] with diagnoses including depression (serious mood disorder that affects how a person feels, thinks, and behaves, schizoaffective (a mental illness that can affect thoughts, mood, and behavior), anxiety (a feeling of worry, nervousness, or unease) , psychosis (a severe mental condition in which thought, and emotions are so affected that contact 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 interview and record review, the facility failed to develop and implement a comprehensive care plan for one of three sampled residents (Resident 74) when Resident 74 reported to the Assistant Director of Nursing (ADON) that Certified Nurse Assistant (CNA) 1 physically abused her while providing her with personal care. This deficient practice resulted in failure in the delivery of necessary care and services. Findings:During a review of Resident 74's admission Record, the admission Record indicated Resident 74 was admitted to the facility on [DATE] with diagnoses including osteoarthritis (a progressive disorder of the joints, caused by gradual loss of cartilage) and rheumatoid arthritis (a chronic-progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility). During a review of Resident 74's MDS dated [DATE], the MDS indicated Resident 74 had severe cognitive impairment and required maximal (helper does more than half the effort) assistant with activities 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 the sampled residents (Resident 36) was provided with incontinence care in a timely manner.This failure resulted in Resident 36 crying and left wet in urine for an hour.Findings:During a review of Resident 36's admission Record, the admission Record indicated, Resident 36 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), seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), hypertension (HTN-high blood pressure) and muscle weakness.During a review of Resident 36's Minimum Data Set (MDS-a resident assessment tool), dated 6/13/2025, the MDS indicated, Resident 36 rarely was able to express ideas and wants. The MDS indicated Resident 36 was rarely able to understand others. The MDS indicated Resident 36 was dependent on nursing…

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, interviews, record review, the facility failed to ensure the water pitcher was within reach for one of seven sampled residents (Resident 11). This failure had the potential to increase Resident 11's risk of dehydration (a condition that occurs when the body loses more fluids than it takes in, resulting in a depletion of water and electrolytes) and resulted in Resident 11 complaining of feeling thirsty. Findings:During a review of Resident 11's record titled, Face Sheet (front page of the chart that contains a summary of basic information about the resident), dated 7/30/25, the Face Sheet indicated Resident 11 was admitted on [DATE] with diagnoses of dementia (a progressive state of decline in mental abilities), Alzheimer's Disease (disease characterized by a progressive decline in mental abilities), hypertension (high blood pressure), failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, 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 provide a Physical Therapy ([PT] a rehabilitation profession that restores, maintains, and promotes optimal physical function) evaluation and treatment in accordance with a physician's order dated 7/17/2025 for Physical Therapy Evaluation and treatment for one of 10 sampled residents (Resident 21). This deficient practice had the potential to cause a decline in mobility and range of motion ([ROM] full movement potential of a joint) due to a delay in provision of PT services for Resident 21. Findings: During a review of Resident 21's admission Record (AR), the AR indicated Resident 21 initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including hemiplegia , weakness to one side of the body) and hemiparesis (inability to move one side of the body) following unspecified cerebrovascular disease (disease of the blood vessels, especially blood vessels to the brain) affecting left dominant side, aphasia (a disorder…

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

Based on interview and record review the facility failed to correct deficiencies during the prior recertification survey (inspections conducted by the California Department of Public Health (CDPH), Licensing and Certification Division, or its authorized entities, to ensure that healthcare facilities and providers maintain compliance with state and federal regulations and continue to meet the standards for their license or certification) dated 7/12/2024, for Resident Rights, Quality of Care, Food Safety and Infection Control.These failures had the potential to result in a loss of dignity, lack of quality of care, infection and food borne illness (a disease or infection that is transmitted through the consumption of contaminated food or beverages) for all residents in the facility.Findings:During an interview on 8/1/2025 at 3:17p.m. with the Administrator (ADM), the ADM stated the Quality Assurance and Performance Improvement ([QAPI] a fundamental concept in healthcare, particularly in long-term care settings like nursing homes, where it's mandated by federal regulations) program 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 follow infection control precautions for two of three sampled residents (Resident 86 and. Resident 64.). Facility failed to:a. Ensure family members wore appropriate Personal Protective Equipment ([PPE] clothing and equipment that is worn or used to provide protection against hazardous substances and/or environment) while visiting and assisting Resident 86.b. Implement enhanced barrier precautions (EBP - an infection control intervention designed to reduce transmission of multidrug-resistant organisms) for Resident 64.These deficient practiced had the potential to result in cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another) and place residents at risk for the spread of infection.Findings: 1.During a review of Resident 86’s admission Record, the admission Record indicated Resident 86 was admitted to the facility on [DATE] with diagnoses including hypertension (HTN- high…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one of two resident ' s (Resident 1) cell phone was accounted for and kept safe in the facilty. This deficient practice resulted in Resident's1 cell phone missing. Findings During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses including osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of bilateral (both) knees, muscle weakness, dysphagia (difficulty swallowing), metabolic encephalopathy (problem in the brain), and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Minimum Data Set (MDS), (a resident assessment tool), dated 5/26/2025, the MDS indicated Resident 1 ' s cognition was severely impaired. The MDS indicated Resident 1 needed substantial assistance (helper does more than half the effort to complete the task) with oral hygiene, upper body dressing,…

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 did not accommodate one of one resident 's (Resident 1) family member (FM 1) request by failing to ensure Resident 1 was fed and adult disposable diaper were checked prior to the administration of Ativan (medication to treat anxiety- feeling of fear, dread, and uneasiness) dose. These deficient practices had the potential to result in Resident 1's missed feedings and Resident 1 to sit in a soiled adult disposable diaper with urine or feces for extended periods. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses including need of assistance of personal care, osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of bilateral (both) knees, muscle weakness, dysphagia (difficulty swallowing), metabolic encephalopathy (problem in the brain), anxiety disorder, and dementia (a progressive state of decline in mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide toileting hygiene at least every 2 hours and as needed for one of three residents (Resident 1). The deficient practice resulted in Resident 1 to be left in a soiled adult disposable diaper for extended periods and had the potential to cause skin breakdown. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses including osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of bilateral (both) knees, muscle weakness, dysphagia (difficulty swallowing), metabolic encephalopathy (problem in the brain, and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Minimum Data Set (MDS), a resident assessment tool, dated 5/26/2025, the MDS indicated Resident 1's cognition was severely impaired. The MDS indicated Resident 1 was dependent (helper does all the effort to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one of one residents (Resident 1) received an oral gratification diet (therapeutic feeding allows resident to experience limited oral intake while exercising the muscles for swallowing) three times a day as ordered by the physician from 6/1/2025 to 6/4/2025. This deficient practice had the potential to result in poor health outcomes and weight loss. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses including muscle weakness, dysphagia (difficulty swallowing), metabolic encephalopathy (problem in the brain), and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Minimum Data Set (MDS), a resident assessment tool, dated 5/26/2025, the MDS indicated Resident 1's cognition was severely impaired. The MDS indicated Resident 1 needed substantial assistance (helper does more than half 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 observation, interview, and record review the facility failed to ensure three of the five sampled staff (Receptionist 1, Certified Nurse Assistant 1, and Maintenance 1) wore an identification badge as indicated in the facility ' s policy. This deficient practice did not promote a culture of safety and transparency and violated residents ' right to know who was providing care and to be treated with respect. Findings: During an observation and interview on 5/16/2025 at 10:08 a.m., with Receptionist 1, Receptionist 1was not wearing a name badge and Receptionist 1 stated she was new, and she was still waiting for her name badge to be issued. During an observation and interview on 5/16/2025 at 10:10 a.m., with Certified Nurse Assistant 1 (CNA 1), CNA 1 was not wearing a name badge and CNA 1 stated she forgot to wear her name badge today. During an observation and interview on 5/16/2025 at 10:20 a.m., with Maintenance 1, Maintenance 1was not wearing a name badge and Maintenance 1 stated he was not wearing his name badge right now while doing rounds in residents ' rooms. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure one of four sampled resident ' s (Residents 3) call light (device that allows residents to request assistance from nursing staff) was within reach. This deficient practice resulted in a delay of care and services. Findings: During a review of Resident 3 ' s admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (brain disorder) and muscle weakness. During a review of Resident 3's Minimum data Set (MDS), a resident assessment tool, dated 2/20/2025, the MDS indicated Resident 3 ' s cognition was intact. The MDS indicated Resident 3 needed setup assistance with eating, oral hygiene, personal hygiene, and partial assist (helper does less than half the effort) with showering. During an interview and observation 5/16/2025 at 10:30 a.m. with licensed vocational nurse 2 (LVN2), Resident 3's called light was not in reach. LVN 2 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 interview, and record review, the facility failed to ensure an extended floor mattress (a thicker safety mat [a floor pad designed to help prevent injury should a person fall] designed to provide cushion and protection in the event of a fall) was placed on the floor next to the bed for one of three sampled residents (Resident 1) who was assessed at high risk for falls and who had a history of falling, per Resident 1 ' s Care Plan dated 3/5/2025 This deficient practice resulted in Resident 1 experiencing an unwitnessed fall (4/25/2025) and being found on the floor without an extended floor mattress in place as care planned (3/5/2025). This deficient practice had the potential to result in Resident 1 sustaining aninjury. Findings During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (a slight paralysis…

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 all nursing staff were trained on the proper use of the Tilt-in-space wheelchair (a type of wheelchair where the entire seat and backrest tilt backward as a single unit) prior to its use for one out of three sampled residents (Resident 1). This deficient practice had the potential to place Resident 1 at risk for falls and/or injuries due to the nursing staff ' s lack of training. Findings: During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cognitive communication deficit (difficulty with cognitive processes like attention, memory, and reasoning) Alzheimer ' s disease (a progressive disorder that affects memory, thinking, and behavior), and legal blindness (poor vision that interferes with daily activities). During a review of Resident 1 ' s Minimum Data Set (MDS – a resident assessment tool) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1 ' s), Family Member (FM) 1 who was also the appointed Durable Power of Attorney (DPOA - a legal document where an agent is appointed to make financial, medical, and/or legal decisions on behalf of the appointor if they become unable to make rational decisions due to a mental or physical condition) was notified prior to Resident 1 ' s ophthalmology (a medical specialty focused on the medical and surgical care of the eyes and vision) and ear, nose and throat (ENT) appointment. These failures resulted in Resident 1 being seen by the ophthalmologist on 6/10/2024 and by the ENT on 11/14/2024, without the DPOAs knowledge. These failures also resulted in a violation of Resident 1 ' s rights. Findings: During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain the manufacturer ' s guidelines and maintain a Tilt-in-space wheelchair (a type of wheelchair where the entire seat and backrest tilt backward as a single unit) per the manufacturer ' s guidelines for one out of three sampled residents (Resident 1). This deficient practice had the potential place Resident 1 at risk for injury from improperly maintained equipment. Findings: During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cognitive communication deficit (difficulty with cognitive processes like attention, memory, and reasoning), Alzheimer ' s disease (a progressive disorder that affects memory, thinking, and behavior), and legal blindness (poor vision that interferes with daily activities). During a review of Resident 1 ' s Minimum Data Set (MDS – a resident assessment tool) dated 2/21/2025, 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 report an Influenza A (a contagious respiratory illness caused by the influenza virus, commonly known as the flu, that infects the nose, throat and lungs) outbreak (the occurrence of cases of disease in excess of what would normally be expected) to the California Department of Public Health (CDPH) immediately for two of 10 sampled residents (Resident ' s 9 and 10). This deficient practice resulted in CDPH not being aware of the Influenza A outbreak until 2/24/2025 (three days after Resident 10 tested positive for Influenza A) and the inability to investigate the outbreak. These deficient practices had the potential for pertinent information to be lost and/or forgotten, and more resident ' s who tested positive to go unreported. Findings: a. During a review of Resident 9's admission Record (Face Sheet), the Face Sheet indicated Resident 9 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including chronic…

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 ' s rights were upheld for one of three residents (Resident 1) when Resident 1 was transferred to a General Acute Care Hospital (GACH) for evaluation of inappropriate sexual behaviors and cleared to return to the facility on [DATE]. This deficient practice resulted in Resident 1 being denied readmittance to a facility where he had resided for approximately 38 days. 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 schizophrenia (chronic mental illness that affects how person thinks, feels, and behaves), malignant neuroleptic syndrome (life-threatening condition that can occur as a side effect of certain antipsychotic[medication that affects the brain] medications) and diabetes mellitus type 2 (condition when the body cannot regulate blood sugar). During a review of Resident 1's History and Physical (H&P), dated…

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

Based on interview and record review the facility failed to ensure 2 out of 2 staff members Licensed vocational nurse (LVN ) LVN 1 and LVN 2 were provided with abuse training prior to providing direct patient care. This failure had the potential to put the residents of the facility at risk for abuse. Findings: During concurrent interview and record review on 10/12/2024 at 1:15 p.m., with Director of Staff Development (DSD implements educational programs for employees), two employee files were reviewed, Licensed Vocational Nurse (LVN) LVN 1 and LVN 2. The DSD stated employees must have abuse training prior to providing direct resident care. The DSD stated that she could not find that LVN 1 and LVN 2 had been trained on abuse prior to providing direct patient care. The DSD stated residents are at risk for abuse if staff are not trained. During an interview on 10/13/2024 at 12:45 p.m., with the Administrator (Adm), the ADM stated the DSD's role is to maintain the facilities education program and hire the frontline staff. The ADM stated abuse training is provided upon hire and twice 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 ' 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 ensure the facility ' s Medical Director attended the monthly meetings. This deficient practice has a potential for the QAA committee not to identify and to respond on the QAPI program that identifies systemic problems to improve services for the residents. Findings: During an interview on 10/13/2024 at 11:46 a.m,. with the Director of Nursing (DON), the DON stated that they do the monthly QAPI meeting to identify the concerns of the residents to improve the services and care of the residents in the facility. During a concurrent interview and record review of the QAA minutes meeting for the months of 07/2024-09/2024, on 10/14/2024 at 12:00p.m,. with the DON, the DON stated that…

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

Based on interview and record review the facility failed to ensure 2 out of 2 staff members Licensed vocational nurse (LVN ) LVN 1 and LVN 2 were provided with abuse training prior to providing direct patient care. This failure had the potential to put the residents of the facility at risk for abuse. Findings: During concurrent interview and record review on 10/12/2024 at 1:15 p.m., with Director of Staff Development (DSD implements educational programs for employees), two employee files were reviewed, Licensed Vocational Nurse (LVN) LVN 1 and LVN 2. The DSD stated employees must have abuse training prior to providing direct resident care. The DSD stated that she could not find that LVN 1 and LVN 2 had been trained on abuse prior to providing direct patient care. The DSD stated residents are at risk for abuse if staff are not trained. During an interview on 10/13/2024 at 12:45 p.m., with the Administrator (Adm), the ADM stated the DSD's role is to maintain the facilities education program and hire the frontline staff. The ADM stated abuse training is provided upon hire and twice 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 ensure a tracking system was maintained for staff participation and competency in the facilitiy's on- line learning program. This failure had the potential to put the resident ' s safety at risk when not maintaining a tracking system to ensure staff are completing and competent in the assigned on-line learning. Findings: During a concurrent interview on 10/12/2024 at 1:15p.m., with the Director of Staff Development (DSD) and record review of the 2024 in-service binder, the DSD stated she was responsible for managing the education program in the facility. The DSD stated that the facility uses an online continuing education software The DSD stated she also provides in person classroom learning. The DSD stated she does not keep any data regarding the staff's progress for the online learning in her binder. The DSD stated she could not retrieve lesson plans from the online education application software. The DSD stated she needed to learn how to use the software better. The DSD stated the residents' safety is at risk when staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure: 1. The primary care physician (PCP) signed Resident 37's admission orders from the hospital to continue to make sure the facility provided the care needed during the stay in the facility for one of one sampled resident (Resident 37). This deficient practice has the potential to not provide Resident ' s 37 appropriate medical intervention during facility stay. Findings: During a record review of Resident 37 ' s admission Record, the admission Record indicated the resident was admitted on [DATE] with diagnoses including cerebrovascular disease (group of conditions that affect blood flow and the blood vessels in the brain), diabetes mellitus (a chronic disease that occurs when the body doesn't produce enough insulin or use it properly), vascular dementia, unspecified severity without behavioral disturbance (a type of dementia that occurs when blood flow to the brain is interrupted, damaging brain cells and impairing thinking, memory, and behavior).…

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 make a follow up appointment for left leg surgery, with the Orthopedic surgeon (treats injuries and diseases involving muscles, bones, joints, ligaments, and tendons) in a timely manner ensure for one of five sampled residents (Resident 1) so Resident 1 could be cleared to continue receiving Physical Therapy (PT: help strengthen weakened muscle) services under skilled nursing services (medically necessary services such as PT and occupational therapy (OT: improving residents ability to perform activities of daily living). This deficient practice resulted in delayed treatment and services for Resident 1, placing the resident at a higher risk for further decline. During a review of the Resident 1 ' s admission record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including acute osteomyelitis (a serious bone infection) of the left femur, abnormal gait and mobility, spinal stenosis (narrowing 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure for one of three sampled residents (Resident 1), who was prescribed and administered an anti-psychotic medication (a class of medication primarily used to manage psychosis [a condition of the mind that results in difficulties determining what is real and what is not real) (Seroquel), that the medication was prescribed and administered for appropriate indications, detailed evidence of Resident 1's behavior(s) were documented, non-pharmacologic interventions were attempted and evaluated prior to the administration/continuance of the medication, physician, psychiatric and/or psychological and nursing evaluations were conducted and evaluated to determine if continued use of Seroquel was warranted. This deficient practice resulted in Resident 1 receiving an unnecessary anti-psychotic medication and placed Resident 1 at risk for adverse reactions associated with the medication's use, chemical restraints, falls and death. Findings: 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 two of 18 sampled residents (Resident 80 and 30), was treated with respect and dignity when: 1. Resident 80's bedside commode (a piece of furniture that looks like a chair but has a container in the seat) was left with stool (feces). 2. Certified Nursing Assistant (CNA 2) was standing while feeding Resident 30. These failures resulted in Resident 80 feeling sad and had the potential to affect Resident 80 and 20's self-worth. Findings: During a review of Resident 80's admission Record, the admission Record indicated, Resident 80 was admitted to the facility on [DATE] with diagnoses including right below the left knee amputation (removal of the lower leg) muscle weakness and lack of coordination (the ability to use different parts of the body together smoothly and efficiently). During a review of Resident 80's Minimum Data Set [(MDS] a standardized assessment and care screening tool), dated 7/3/2024, the MDS indicated Resident 80 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure four of eleven sampled residents' (Resident 77,85,82,and 45) paper and electronic medical records (eHR) reflected documentation of advance directives (legal documents that allow you to spell out your decisions about end-of-life care ahead of time) and physician orders for life sustaining treatment (POLST, a legal form that records patients' treatment wishes in the event of a medical emergency) were discussed and written information were provided to Resident 77, 85, 82,and 45, and/or responsible parties. These failures violated the residents' rights to be fully inform of the option to formulate an advance directive and/or POLST and had the potential to cause conflict with the residents' wishes regarding health care in the event residents became incapacitated (unable to participate in a meaningful way in medical decisions) or unable to make medical decisions that would not be identified and/or carried out by the facility staff. Findings: 1.During a…

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

Based on interview and record review, the facility failed to provide Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN), form CMS-10055 for two of three sampled residents (Residents 2 and 27) when residents continued to stay at the facility after the Medicare Part A coverage ended. This failure had the potential to result in responsible parties not being able to exercise their right to receive timely and specific notification. Findings: During a concurrent interview and record review on 7/12/2024 at 9:29a.m., with the Director of Nursing (DON), Resident 2's SNF Beneficiary Notification Review form indicated Resident 2's last covered day for Medicare Part A Skilled Services was 1/19/2024. Resident 2 continued to stay after the coverage ending date. The DON stated, the facility did not provide SNF ABN to Resident 2. During a concurrent interview and record review on 7/12/2024 at 9:29 a.m., with the DON, Resident 27's SNF Beneficiary Notification Review Form indicated Resident 27's last covered day for Medicare Part A Skilled Services was 2/5/2024. Resident 27 continued 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 observations, interviews, and record reviews, the facility failed to 1.Ensure an accurate count of a controlled medication (a drug or chemical whose manufacture, possession, or use is regulated by a government,) lorazepam (a medication used to treat mood disorder) for Resident 32 in the medication storage refrigerator on the third floor. 2.Ensure one open foil pack of arformoterol tartrate inhalation solution (a medication used to treat breathing problems) for Resident 447 was stored in accordance with manufacturer's requirements and labeled with an open date in the medication storage refrigerator on the second floor. 3.Ensure the storage of semaglutide (a medication used to treat high blood sugar) for Resident 53 was in accordance with manufacturer's requirements on the second floor. 4.Ensure expired medications for multiple residents were removed from one of the medication carts on the third floor. These failures had the potential to harm residents due to the potential loss of strength 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.

Based on observation, interview and record review, the facility failed to ensure a safe and sanitary food storage practices in the kitchen when: 1. Food items in the walk-in refrigerator had no open date label. 2. Ensure facility staff personal items were not placed near the food in the dry storage room. 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 foodborne illness (illness caused by food contaminated with bacteria, viruses, and parasites). Findings: 1. During an observation on 7/9/2024 at 8:43 a.m. in the walk-in refrigerator, a bag of salad was noted without a received or expiration date. During an interview on 7/9/2024 at 8:46 a.m., with [NAME] 1, [NAME] 1 stated the bag of salad must be labeled so you know when it was received. If you serve it to someone, they could get sick. During an interview on 7/11/2024 at 11:10 a.m., with Dietary Manager 1 (DM 1), DM1 stated food must be labeled to indicate when it was received and when it needs to be discarded.…

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 52) was provided a touch pad call light (enables residents with limited movement to call for help). This failure had Resident 52 to feel frustrated and had the potential for his needs not met which could result to delay of care and services. Findings: During a review of Resident 52's admission Record, the admission Record indicated Resident 52 was admitted to the facility on [DATE] with diagnoses including quadriplegia (paralysis that affects all of the person's limbs and body from neck down), bipolar disorder (a serious mental illness that causes unusual shifts in mood, ranging from extreme highs to lows) and spastic hemiplegia (a type of brain disorder that causes muscle tightness and contractions [shortening] in the limbs and one side of the body). During a review of Resident 52's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 6/8/2024, the MDS indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility staff failed to assess and monitor multiple skin discolorations for one of two sampled resident's (Resident 23), who was identified to be at high risk for bleeding. This failure had the potential for Resident 23 to have unassessed internal bleeding. Findings: During a review of Resident 23's admission Record, indicated the Resident 23 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including abscess (pus-filled mass) of the liver, reduced mobility, and muscle weakness. During a review of Resident 23's Minimum Data Set (MDS), a standardized assessment and care screening tool) dated 5/4/2024, the MDS indicated the Resident 23 had no cognitive (thought process) impairment. The resident was at risk for developing pressure ulcers and had one Stage 1 pressure injury (intact skin with no blanchable redness of a localized area usually over a bony prominence). During a concurrent observation and interview on 7/9/2024 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one of 18 sampled residents (Resident 71) received services and treatment to address hearing loss. This failure had the potential to result in Resident 71 not being able to effectively communicate with staff and understand care and services being given. Findings: During a review of Resident 71's admission Record, the admission Record indicated Resident 71 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses including left leg cellulitis (deep infection of the skin caused by bacteria), ulcerative proctitis (inflammatory bowel disease), and generalized abdominal pain. During a review of Resident 71's, Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 4/24/2024, the MDS indicated Resident 71 had difficulty with the ability to hear. The MDS indicated Resident 71 had the ability to express ideas and wants. The MDS indicated Resident 71 was dependent on nursing staff for toileting.…

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 18 sampled residents (Resident 92) who was assessed as high risk for fall was on the Falling Star Program per facility's Fall Prevention policy and procedure. This failure had the potential to result in Resident 92, sustaining another fall with injury. Findings: During a review of Resident 92's admission Record, the admission Record indicated, Resident 92 was admitted to the facility on [DATE] with diagnoses including fall, neck fracture (broken bone), spinal stenosis (narrowing of the space around the spinal cord), muscle weakness and difficulty walking. During a review of Resident 92's, Physician Progress Notes, dated 6/21/2024, the Physician Progress Notes indicated Resident 92 had a history of frequent falls at home. During a review of Resident 92's Minimum Data Set (MDS a standardized assessment and care screening tool), dated 6/27/2024, the MDS indicated Resident 92 had the ability to understand and express ideas and wants. 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 ensure one of 18 sampled residents (Resident 87) was provided with dental services to ensure Resident 87 could eat adequately. This failure had the potential to result in Resident 87 losing weight. Findings: During a review of Resident 87s admission Record, the admission Record indicated Resident 87 was admitted to the facility on [DATE], with diagnoses including diabetes mellitus (a condition in which the body fails to metabolize (process) glucose (sugar) correctly ), Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements), muscle weakness and gastro-esophageal reflux (when the contents of the stomach persistently move back up into the esophagus). During a review of Resident 87's History and Physical (H&P), dated 5/28/2024, the H&P indicated Resident 87 had the capacity to make decisions. During a review of Resident 87's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated,…

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

Based on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 70) had their food preferences taken into consideration. This failure had the potential to result in Resident 70 having an undesirable weight loss when nutritional preferences were not being considered. Findings: During a concurrent observation and interview on 7/9/24 at 10:04 a.m. with Resident 70, Resident 70 stated she gets chopped meat at mealtimes. Resident 70 stated she does not like the chopped meats. Resident 70 stated she get chopped meats for lunch and dinner and does not want to eat it. Resident 70 stated she wanted regular not chopped meats for lunch and dinner. During a review of Resident 70's Physician Order Summary dated 2/16/24, Resident 70's diet was regular diet, mechanical soft texture (diet designed for resident who have trouble chewing and swallowing) with thin liquid consistency, large portions at breakfast with fortified cereal and with fortified soup at lunch and dinner. During a review on 7/11/24 at 12:09 p.m., of Resident 70's Dietary…

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

Based on observation, interview, and record review, the facility failed to dispose garbage and refuse properly by not closing dumpster (a large trash container designed to be emptied into a truck) completely This failure had a potential to attract flies, insects, cats, and other animals to the dumpster area. Findings: During an observation on 7/11/2024 at 11:30 a.m., outside the kitchen, observed one dumpster to have the lid off. Observed an empty box sitting on top of one of the closed dumpsters. Another dumpster was stuffed with trash preventing the lid from closing completely. During an interview on 7/11/2024 at 11:45 a.m., with Dietary Manager 1(DM 1), DM 1 stated dumpsters should be completely closed to prevent the attraction of flies and mice. DM 1 stated if flies and mice get into the facility, they can contaminate the food. During an interview on 7/11/2024 at 1:40 p.m., with Maintenance Supervisor (MS) 1, MS1 stated the dumpster should be closed at all times so it will not attract rodents that can potentially enter the facility. MS 1 stated that the dumpster should not be…

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 four sampled residents (Resident 28) was free from contracting an infection when the nebulizer (a respiratory [breathing] device that turns the liquid medicine into a mist which is then inhaled through a mouthpiece or mask) tubing was not stored securely in a bag (bag open) and was not on the floor. This failure had the potential to spread germs and bacteria from the floor to Resident 28. Findings: During a review of Resident 28's admission Record, indicated Resident 28 was admitted at the facility on 1/28/2023 with diagnoses including metabolic encephalopathy (a problem of the brain caused by a chemical imbalance in the blood from an illness or body organs that are not working properly as they should), diabetes mellitus (a serious condition where the blood glucose, also knowns as blood sugar is too high) and chronic kidney disease (a long-term condition where the kidneys do not work as well as they should). During an observation on 7/9/2024 at 8:15 a.m., in Resident 28's room, Resident 28's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement their protocol for Antibiotic Stewardship (refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use) for one of 18 sampled residents (Resident 58). This failure had the potential for Resident 58 to develop antibiotic resistance (not effective to treat infection) from prolonged or inappropriate antibiotic use. Findings: During a review of Resident 58s admission Record, the admission Record indicated, Resident 58 was admitted to the facility on [DATE] with diagnoses including end stage renal disease (the gradual loss of kidney function), diabetes mellitus ( a group of diseases that affect the body uses blood sugar), systemic lupus erythematous (a chronic autoimmune disease that affects various parts of the body), and cardiomyopathy (a disease that affects the heart muscles). During a review of Resident 58's History and Physical (H&P), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure the Responsible Party (RP 2) for one of three sampled residents (Resident 2) was notified that Pro-Stat (a protein drink to promote wound healing) was prescribed to Resident 2 and administered to him from 1/1/2024 through 1/11/2024 and when a Change of Condition (COC) in Resident 2 's mental status occurred. These deficient practices resulted in RP 2 being unaware of Resident 2's change in status and the inability for RP 2 to be a full participant in Resident 2's health care decisions, RP 2's distrust, and frustration with the facility staff. This deficient practice had the potential for unwanted changes in Resident 2's health care to be made by the facility. Findings: a. During a review of Resident 2's admission Record (Face Sheet) the Face Sheet indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia (loss of the ability to think, remember and reason), blindness, 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 address the concerns of the resident council during the resident council meeting on 3/27/2024 regarding food being served cold and hard. This deficient practice resulted in food being served to residents with unacceptable temperatures, was distasteful and/or not eaten. This deficient practice had the potential for food borne illness to occur and unplanned weight loss. Findings: During a review of the facility's Resident Council Agenda Minutes, dated 3/27/2024, the Resident Council Agenda Minutes indicated the food was sometimes cold and hard. The Resident Council Agenda Minutes indicated the Dietary Service Supervisor (DSS) was made aware of the resident's food concerns. During a review of the facility's Menu, dated 4/8/2024, the menu indicated the following was to be served: eggplant parmesan, penne pasta, chicken noodle soup, saltine crackers, chocolate éclair bar, beverage of choice, margarine, salt/pepper and parsley sprig. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure grievances filed by the Resident 2's Responsible Party (RP 2) for one of three sampled residents (Resident 2) were investigated and the findings made available to RP 2. This deficient practice resulted in RP 2 becoming frustrated and distrustful towards the facility's administrative staff and had the potential for Resident 2's care needs to go unmet. Findings: During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia (loss of the ability to think, remember and reason), blindness, and glaucoma (a group of eye diseases that can cause loss of vision). During a review of Resident 2's Minimum Data Set ([MDS]) a standardized assessment and care-screening tool), dated 8/22/2023, the MDS indicated Resident 2 had the ability to think, learn, remember, use judgement, and make decisions. During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure care plan interventions for one of three sampled residents (Resident 2) were implemented when the nursing staff did not use two people when turning and repositioning Resident 2 during care. These deficient practices resulted in one staff turning and repositing Resident 2 and had the potential to result in injury while providing care. Findings: During a review of Resident 2's admission Record (Face Sheet) the Face Sheet indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia (loss of the ability to think, remember and reason), blindness, and glaucoma (a group of eye diseases that can cause loss of vision). During a review of Resident 2's Minimum Data Set ([MDS]) a standardized assessment and care-screening tool, dated 8/22/2023, the MDS indicated Resident 2 had the ability to think, learn, remember, use judgement, and make decisions. The MDS indicated 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 resident rights were maintained for one of three sampled residents (Resident 2) when the facility failed to ensure Resident 2 received a shower or bed bath on days a shower was not provided. These deficient practices caused Resident 2 to feel unclean and had the potential to cause a decline in Resident 2's physical and psychosocial well-being. Findings: During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia (loss of the ability to think, remember and reason), blindness, and glaucoma (a group of eye diseases that can cause loss of vision). During a review of Resident 2's Minimum Data Set ([MDS]) a standardized assessment and care-screening tool), dated 8/22/2023, the MDS indicated Resident 2 had the ability to think, learn, remember, use judgement, and make decisions. 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 observation, interview, and record review, the facility failed to obtain a podiatry (foot doctor) consult after one of three sampled resident (Resident 1) was noted with bleeding under the nail bed of the left great toenail on 2/12/2024. As of 3/1/2024, eighteen (18) days after it was first identified, all of Resident 1's toenails were long, and podiatry has not assessed Resident 1's toenails. This deficient practice resulted in a delay of needed foot care services and had the potential to contribute to a negative physical and psychosocial wellbeing. Findings: During a review of Resident 1's admission record, dated 3/5/2024, the admission record indicated Resident 1 was originally admitted on [DATE] and re-admitted on [DATE] with a diagnosis that included open angle glaucoma bilateral (chronic, progressive, & irreversible optic nerve damage that can cause vision loss or changes), legal blindness, and dementia without behavioral disturbance (loss of thinking, remembering, and reasoning to such an extent…

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 maintain clinical records in accordance with accepted professional standards and practices for one of seven sampled residents (Resident 6) by failing to consistently document Resident 6's bowel elimination. There were ten missed opportunities where Resident's 6's bowel movements was not documented, and the entry was left blank. This deficient practice had the potential to negatively impact the delivery of care and services. Findings: During a review of Resident 6's admission Record (face sheet), the face sheet indicated Resident 6 was admitted to the facility on [DATE] with a diagnosis that included liver (organ that removes toxins from the body) cirrhosis (a chronic condition of liver damage from various causes that lead to liver failure), congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should) and Rheumatoid Arthritis (a chronic inflammatory [swelling]disorder affecting many joints, including those…

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 schedule an interdisciplinary care conference, as requested by the responsible party of one of seven sampled residents (Resident 6). The deficient practice made Resident 6 and his responsible party to feel disregarded and disallowed to participate in the plan of care of Resident 6. Findings: During a review of Resident 6's admission Record (face sheet), the face sheet indicated Resident 6 was admitted to the facility on [DATE] with a diagnosis that included liver (organ that removes toxins from the body) cirrhosis (a chronic condition of liver damage from various causes that lead to liver failure), congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should) and Rheumatoid Arthritis (a chronic inflammatory [swelling]disorder affecting many joints). During a review of Resident 6's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 8/25/2023, the MDS indicated Resident 6 was able…

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 seven sampled residents (Resident 6) was assisted by the Restorative Nursing Assistant (RNA) to perform range of motion exercises (activity aimed at improving movement of a specific joints) to his left and right upper extremities three times a week. This deficient practice has the potential for Resident 6 to negatively affect his joint function and integrity. Findings: During a review of Resident 6's admission Record (face sheet), the face sheet indicated Resident 6 was admitted to the facility on [DATE] with a diagnosis that included liver (organ that removes toxins from the body) cirrhosis (a chronic condition of liver damage from various causes that lead to liver failure), congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should) and Rheumatoid Arthritis (a chronic inflammatory [swelling]disorder affecting many joints, including those in the hands and feet). 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 a resident, who resided at the facility for approximately six years, and was transferred to a General Acute Care Hospital (GACH) for evaluation and treatment for confusion, disorientation (state of being confused or having lost your bearings), and an elevated heart rate, was readmitted to the facility after the resident was stabilized and cleared at the GACH to return to the facility for one of two sampled residents (Resident 1). This deficient practice resulted in Resident 1 remaining at the GACH for 7 days after Resident 1 was deemed appropriate for discharge back to the facility by the GACH but was denied readmission by the facility. Resident 1 was subsequently transferred to a different facility (11/9/2023), placing the resident at risk for continued confusion, disorientation and psychosocial harm related to dislocation from a place Resident 1 considered home. Findings: During a review of Resident 1's admission Record (Face Sheet) the Face…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Facility failed to provide information on advance directives (7, 27, 41)and did not obtain the advance directives from family when it was indicated the resident had one (Residents 6 & 19) C- Blessing Resident #7 Findings: A review of Resident 7's admission Record (Face sheet) indicated the resident was initially admitted to the facility admitted on [DATE] with diagnosis including contracture left elbow, major depressive disorder recurrent,(mood disorder that causes a persistent feeling of sadness and loss of interest), type 2 diabetes mellitus with other specified complications (inability to metabolize glucose in the body causing elevated blood sugar levels). use of insulin. A review of Resident 7's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 10/1/20 , indicated the resident had cognitive (ability to make decisions, understand, learn) impairement, with daily decision making. The MDS assessment indicated the resident required extensive assistance for activities of daily living…

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

Based on interview and record review, facility failed to provide at least twelve (12) hours of annual in-services for two of 5 nurse aides. This deficient practice had the potential for a knowledge, training, and certification deficit among the Certified Nursing Assistant (CNA) leading to inadequate resident care. Findings: During a concurrent interview and review of five (5) employees' record, on 10/19/2021 at 3:00 p.m. with Director of Staff Development/Infection Control Preventionist (DSD/IP) stated she does not have a way to track who completed the 12 hours of annual in-services for nurse's aide. DSD/IP stated that she is missing 2020 binder for Dementia training to staff. DSD/IP stated that she gets behind with annual physical and competency of staff. Five CNA records were reviewed, indicated CNA 5 date of hire 01/17/2017, last Skills Competency Review 12/2019, CNA 6 date of hire 09/27/2004, last Skills Competency Review 07/2020. During an interview on 10/20/21, at 9:2., with Director of Nursing (DON) , DON stated, nursing assistant should have twelve (12) hours in-services…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Facility failed to contact the physician following the pharmacist's recommendation for Residents 7 & 26. Findings: A review of Resident 7's admission Record (Face sheet) indicated the resident was initially admitted to the facility admitted on [DATE] with diagnosis including contracture left elbow, major depressive disorder recurrent,(mood disorder that causes a persistent feeling of sadness and loss of interest), type 2 diabetes mellitus with other specified complications (inability to metabolize glucose in the body causing elevated blood sugar levels). use of insulin. A review of Resident 7's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 10/1/20 , indicated the resident had cognitive (ability to make decisions, understand, learn) impairement, with daily decision making. The MDS assessment indicated the resident required extensive assistance for activities of daily living ({ADLs}) such as bed mobility, transfer,locomotion on unit and off unit, dressing, toilet and personal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to: 1. Ensure that eleven (11) external medications had the opened date written on the container. This deficient practice had the potential for harm to residents due to the potential loss of strength of the medications, and the potential for the residents to receive ineffective medication dosages. 2. Ensure that one (1) Thera moisturizing body shield for a resident was not expired and one (1) Aspirin adult low dose enteric coated was not expired This deficient practice had the potential for harm to residents due to the potential loss of strength of the medication, and the potential for the residents to receive ineffective medication dosages. 3. Ensure that one (1) Phytoplex moisturizer nourishing cream had the Resident 19 name identified on the container. This deficient practice had the potential for harm to a resident potentially receiving another resident's medication in error. 4. Ensure that one (1) Desitin for Resident 35 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.

Based on observation, interview, and record review, the facility failed to ensure Dishwasher staff has the competency to check the quaternary sanitizing solution (ammonium solution used for sanitizing surfaces) with the correct quaternary test strip according to manufacturer's instructions for one of three Dishwasher staff observed. This deficient practice had the potential for inaccurate interpretation of the effectiveness of the quaternary solution, which can lead to a potential for not adequately sanitizing pots and pans, and kitchen surfaces to prevent the outbreak of foodborne illness. Findings: During a kitchen observation and concurrent interview with Dishwasher Staff (DS2) on 10/13/2021 at 8:50 a.m. stated that he is responsible in cleaning and sanitizing pots and pans. DS 2 observed taking a white strip and dipping it to sanitizing solution on a three-compartment sink set up. Observed that the strip remains white, DS 2 stated that it needs to be immersed for 30 seconds, DS stated he used a wrong strip to check the sanitizing solution. DS 2 stated that it is important 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 store, prepare, and distribute and serve food in accordance with professional standards for food service safety when: 1. Sweet potato fries, frozen apples, frozen French fries was stored inside the walk-in freezer and milk was stored inside the reach in refrigerator that was not labeled on date opened. 2. Ensure stuffed bell peppers were discarded on the date indicated on the label. These failures placed residents at risk for foodborne illnesses (illnesses caused by consuming contaminated food or drink) from consuming potentially contaminated food (unclean) and exposure to harmful pathogens (bacteria or viruses that can cause illness). Findings: During an initial kitchen observation and concurrent interview with Chef on 10/13/2021 at 8:05 a.m., sweet potato fries, frozen apples, frozen French fries was observed opened and stored inside the walk-in freezer had no label of date opened. Interviewed Chef, stated that food should be labeled with date opened so staff will know when it needs be discarded. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to offer the pneumonia (PNA) (an infection of the lungs) vaccinations (medication to prevent a particular disease) for 5 of 12 sampled residents (Resident 3, 19, 41 and 93) and revaccination for Resident 26. This deficient practice placed Resident 3, 19, 26, 41 and 93 at a higher risk of acquiring and transmitting the pneumonia to other residents in the facility. Findings: During a concurrent interview and record review on 10/19/2021 at 9:00 a.m. with Licensed Vocational Nurse/Medical Records (LVN /MR) 1, LVN1 stated that pneumonia vaccine was not offered to Resident 3, 19, 26 and 41 and revaccination on Residents 26. Record review on facility's Immunization Records dated 10/13/2021, indicated Resident 3, 19, 26, and 41 pneumonia vaccine slots were blank and Resident 26 pneumonia vaccine was last given on 6/19/2021. LVN 1/MR stated that if it is blank it was not given or offered. During an interview on 10/19/2021 at 3:50 p.m. with Director of Staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a patient-centered care plan for the use of oxygen (a colorless, odorless and tasteless gas) developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs for one out 1 resident (Resident 93). This deficient practice placed Resident 93 at risk for not having interventions for the use of Oxygen and interventions for shortness of breath (SOB). Findings: During a review of Resident 93's admission Record(Face Sheet) indicated the resident was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included but were not limited to acute respiratory failure with hypoxia (a state in which oxygen is not available in sufficient amounts at the tissue level to maintain adequate (homeostasis - balance in body temperature and body fluids), hypertension (high blood pressure). During a review of Resident 93's Minimum Data Set (MDS), a standardized…

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 follow Resident 26 diet order and ensure a correct diet was served to Resident 26. These failures have the potential to place residents at risk for Resident 26 not getting the correct nutritive value, micronutrients, and further weight loss. Findings: During a review of the admission record indicated Resident 26 was admitted to the facility on [DATE] with diagnoses that includes chronic pancreatitis (inflammation of the pancreas [ organ lying behind the lower part of the stomach] ) , generalized anxiety disorder ( feeling of worry, nervousness ), major depressive disorder severe ( mood disorder that causes a persistent feeling of sadness ), iron deficiency anemia ( condition in which the blood doesn't have enough healthy red blood cells ). During a review of Resident 26 's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 9/20/2021, indicated that the resident is cognitively intact, able to make self-understood,…

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 implement professional standards of practice by not: 1. Obtaining a physician's order for monitoring pulse oximetry (a noninvasive method for monitoring a person's oxygen saturation). 2. Assessing and monitoring oxygen saturation (blood oxygen levels) and documenting in the resident's chart. These deficient practices had the potential of resident 93 been infected with infected tubing, confusion and irritability due to continuing use of oxygen (oxygen toxicity). Findings: During a review of Resident 93's admission Record(Face Sheet) indicated the resident was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included but were not limited to acute respiratory failure with hypoxia (a state in which oxygen is not available in sufficient amounts at the tissue level to maintain adequate (homeostasis - balance in body temperature and body fluids), hypertension (high blood pressure). During a review of Resident 93's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review the facility failed to ensure the physician assessed Resident 192 after admission to the facility. This deficient practice had the potential of resident's treatment orders and medical services not delivered in an appropriate order. Findings: During a review of Resident 192's admission Record (Face sheet) indicated the resident was initially admitted to the facility on [DATE] with diagnoses including major depressive disorder recurrent,(mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder. pressure ulcer of sacral region (wound on the buttock area). During a review of Resident 192's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 10/1/21 , indicated the resident had cognitive (ability to make decisions, understand, learn) impairment, with daily decision making. The MDS assessment indicated the resident required extensive assistance for activities of daily living ({ADLs}) such as bed…

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

Based on observation, interview, and record review, the facility failed to ensure a correct diet was served and with no deviations from menu of one of two resident (Resident 26). This failure had the potential to result in resident not receiving the correct nutritive value and weight loss. Findings: During a concurrent observation and interview on 10/14/21, at 8:16 a.m., with Resident 26, in her room, observed Resident 26 breakfast tray, she had orange color broth, chocolate ice cream, apple sauce and watery cream of wheat. Resident 26 meal ticket indicated Clear Liquid diet, likes cream of wheat, apple sauce and vanilla ice cream for breakfast. Resident 26 stated that she has been on Clear liquids for three weeks. During concurrent interview and record review of Resident's 26 Physician order, on 10/14/2021 at 10:10 a.m., Registered Nurse Supervisor (RN Sup. 2), stated that Resident 26 is on Regular diet select menu. Physician order dated 9/22/2021, indicated Resident 26 may have clear liquid diet breakfast and lunch for one week until 9/29/2021. RN Sup. 2 stated that any changes…

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's staff failed to develop and present Quality Assurance and Performance Improvement (QAPI) plan that describes the process for conducting QAPI per Quality of Assurance Agency (QAA) activities, such as identifying and correcting quality deficiencies as well as opportunities for improvement, which will lead to improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life, and resident safety. This deficient practice had the potential risk for residents not receiving care and services at acceptable levels of performance for quality of care, quality of life and resident safety. Findings: During an interview with the administrator on 10/18/21 at 2:12 p.m., the administrator stated the facility's QA committee has been following the center for disease's (CDC) guidelines for Covid -19. The administrator further stated the facility is working on all QAPI issues. On 10/18/21, at 3:14 p.m., during an interview with the assistant director of nursing (ADON), the facility QAPI…

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.