Catered Manor Care Center

Based on observation, interview and record review, the facility failed to ensure food service staff was competent in testing the chlorine (deep cleaning and sanitizing agent) of the dishwashing machine for one of two dietary aides (DA)1.This failure had the potential to put residents at risk for food borne illness (any illness resulting from eating contaminated/spoiled foods) due to inability to read and know what the proper range of sanitizer solution for the dishwashing machine.Findings:During a concurrent observation and interview on 5/11/2026 at 8:20 a.m. with Dietary Aide (AD)1, DA 1 used a test strip and dipped it in the water of the dishwashing machine during the final rinse. DA 1 compared the dipped test strip on the color chart found on the canister of the test strip bottle. The test strip read 200 parts per million (PPM- unit of measurement). DA1 stated they used chlorine to disinfect the dishes and follow 200 ppm. DA 1 stated the test strip read 200 PPM.During an interview on 5/13/2026 at 10:43 a.m. with DA1, DA 1 stated she would check the chlorine in the dishwashing…

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 identify and honor cultural food preferences for one of one sampled resident (Resident 76).This failure had the potential to result in weight loss for Resident 76.Findings:During a review of Resident 76's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 76 was admitted to the facility on [DATE] with diagnoses of but not limited to hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) affecting the left side, muscle weakness, hypertension (HTN-high blood pressure) and hyperlipidemia (high levels of fat circulating in the blood).During a review of Resident 76's Minimum Data Set (MDS-a resident assessment tool), dated 3/9/2026, the MDS indicated Resident 76 needed partial to moderate assistance (helper does less than half the effort) from nursing staff with toileting, showering, dressing, and transferring.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.

Based on observation, interview and record review, the facility failed to ensure the quaternary sanitizer solution (disinfectant) in the red bucket used to clean kitchen surfaces was at the 200 parts per million (PPM- unit of measurement) to ensure kitchen surfaces were sanitized properly.This failure had the potential to expose all residents to food borne illnesses (any illness resulting from ingestion of food contaminated with bacteria, viruses, or parasites).Findings:During an observation on 5/11/2026 at 8:14 a.m. in the kitchen, a red bucket filled with a quaternary solution was observed to be in a kitchen sink with a dish towel submerged in the solution.During a concurrent observation and interview on 5/11/2026 at 8:25 a.m. with Dietary Aide 3 (DA 3) in the kitchen, DA 3 was observed to take a quaternary solution test strip and dip it into the red bucket quaternary solution. DA 3 then compared the color of the test strip to the color chart provided with test strip. The test strip color was observed to be teal. DA 3 stated the color should be green. DA 3 stated the quaternary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain complete and accurate clinical records for one of three sampled residents (Resident 11) by not documenting restorative nursing services ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) as ordered.The facility failed to:1 Accurately document restorative nursing services, including passive range of motion ([PROM] movement at a given joint with full assistance from another person) to the bilateral lower extremities and active assistive range of motion ([AAROM]- movement at a given joint with a person's own effort and assistance from an external force or another person) to the bilateral upper extremities, as ordered five times per week.2. Ensure nursing staff recorded the number of minutes of restorative services provided each day, as required by physician orders.3. Follow facility's policy and procedure (P&P) titled, Charting and Documentation, dated 2026, which indicated all 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 Based on interview, and record review, the facility failed to develop and implement comprehensive plan for one of one sample residents (Residents 1) when Resident 1 fell on 7/3/2025 from the wheelchair. This deficient practice increased Resident 1's risk of further falls and injuries. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses including acute respiratory failure (when not enough oxygen passes from your lungs to your blood), muscle weakness (a reduced ability of muscle to generate force, often resulting in difficulty performing daily tasks or feeling fatigued ), type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dependence on renal dialysis (a person's kidney no longer function adequately, and they rely on a dialysis. During a review of Resident 1's Minimum Data Set (MDS-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 the resident environment was free of potential hazard for one of one sample residents (Resident 1). Resident 1 who had an unwitnessed fall from her wheelchair on 7/3/2025. The facility failed to: 1. Ensure Resident 1's wheelchair was locked upon Resident 1's return from dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) machine to filter their blood ) treatment on 7/3/2025. This deficient practice resulted in Resident 1 falling from her wheelchair on 7/3/2025 with no injury and had the potential for increased risk for further falls and injury.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses including acute respiratory failure (when not enough oxygen passes from your lungs to your blood), muscle weakness (a reduced ability…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the physician when one of four sampled resident's (Resident 1) laboratory (lab) result dated 5/22/2025 indicated a high blood glucose (sugar) level, a low sodium (the electrolyte in the body crucial for maintaining fluid balance, nerve and muscle function, and blood pressure) level, and a low chloride (an essential electrolyte that plays a crucial role in body fluids, including blood, sweat and urine) level. This deficient practice resulted in Resident 1's physician being unaware of Resident 1's abnormal lab results and a delay in care and treatment. Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including Chronic Obstructive Pulmonary Disease ([COPD] a progressive lung disease characterized by persistent airflow limitation and breathing problems) and DM. During a review of Resident 1's Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a Care Plan was created one of four sampled residents (Resident 1) who was administered Prednisone (medication used to treat a wide range of conditions that raises b/s levels and can induce hyperglycemia [a condition where there's too much sugar in the bloodstream]) with intervention to monitor Resident 1 for risk, side effects, and adverse reactions related to the use of Prednisone due to this medications ability to increase blood sugar (b/s) levels. This deficient practice resulted in Resident 1's b/s level not being monitored from 4/11/2025 through 5/16/2025 to ensure it was within an acceptable range in order to provide care and treatment accordingly. On 6/22/2025 Resident 1 was transferred to a General Acute Care Hospital (GACH) due to an altered level of consciousness ([ALOC] a person's awareness of themselves and their surroundings is different from their normal state that can range from mild changes like drowsiness to severe changes like…

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 four sampled residents (Resident 1) who had an order for Prednisone (medication used to treat a wide range of conditions that raises b/s levels and can induce hyperglycemia (a condition where there's too much sugar in the bloodstream) 20 milligrams ([mg] a metric unit of measurement, used for medication dosage and/or amount) 2 tablets, twice a day (80 mg), had a stop date and/or duration of administration. This deficient practice resulted in Resident 1 taking Prednisone 20 mg., 2 tablets twice a day (for a total of 80 mg daily), from 4/12/2025 until 6/22/2025. Resident 1 had a change of condition (COC) and was transferred via 911 to a GACH on 6/22/2025, due to an altered level of consciousness (a person's awareness of themselves and their surroundings is different from their normal state that can range from mild changes like drowsiness to severe changes like coma), hypotension (low blood pressure where the normal range is less than 120…

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 Medication Regimen Review (MRR) for one of four sampled residents (Resident 1) was conducted in 6/2025. They failed to ensure a MRR conducted in 5/2025 with a recommendation by the facility's Pharmacist Consultant (PC) to add a duration of time for the use of Prednisone (medication used to treat a wide range of conditions[b/s] levels) was followed, by notifying Resident 1's physician of the PC's recommendation and ensuring Resident 1's physician responded.This deficient practice resulted in Resident 1's use and dosage of Prednisone not being evaluated per the PC's recommendation from 4/12/2025 until 6/22/2025. Resident 1 was transferred to a General Acute Care Hospital (GACH) on 6/22/2025 due to an altered level of consciousness ([ALOC] a person's awareness of themselves and their surroundings is different from their normal state that can range from mild changes like drowsiness to severe changes like coma [a deep state of unconsciousness where…

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 ensure they documented interventions needed to prevent falls and injuries for one of three sampled residents (Resident 1), per the Minimum Data Set ([MDS] a resident assessment tool) assessment. This deficient practice resulted in an incomplete care plan and staff not being aware that Resident 1 was dependent (helper does all the effort, resident does none of the effort to complete the activity, or the assistance of two or more helpers is required for the resident to complete the activity) on nursing staff for toileting hygiene and rolling to the left and right side while lying on his back in bed during care. 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 a diagnosis including a fracture (breaking of a bone) of the left humerus (the upper arm bone), congestive heart failure ([CHF] a heart disorder which causes the heart to not pump the blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to involve one of one resident (Resident 1) and/or responsible party in the Interdisciplinary team (IDT) conference after Resident 1 fell on 4/3/2025. This deficient practice had the potential to result in poor quality of care and a delay of care and services. 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 diagnosis including hypoglycemia (low blood sugar) and type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 1 ' s Minimum Data Set ([MDS] a resident assessment tool) dated 4/1/2025, the MDS indicated Resident 1 ' s cognition (ability to think and reason) was intact. The MDS indicated Resident 1 needed set up assistance when eating and oral hygiene, maximal assistance (helper does more than half he effort) with toileting hygiene, and showering. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide one of one family member (FM)1 medical records of Resident 1 within the required time frame. This deficient practice had the potential to result in poor quality of care and a delay of care and services. 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 diagnosis including hypoglycemia (low blood sugar) and type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 1 ' s Minimum Data Set ([MDS] a resident assessment tool) dated 4/1/2025, the MDS indicated Resident 1 ' s cognition (ability to think and reason) was intact. The MDS indicated Resident 1 needed set up assistance when eating and oral hygiene, maximal assistance (helper does more than half he effort) with toileting hygiene, and showering. During a review of electronic mail (email) correspondence…

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 recheck one of one ' s resident (Resident 1) blood glucose (sugar) levels after insulin (a hormone that removes excess sugar from the blood can be produced by the body or given artificially via medication) was administered as indicated in Resident 1 ' s care plan. This deficient practice had the potential to result in poor quality of care and a delay of care and services. 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 diagnosis including hypoglycemia (low blood sugar) and type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 1 ' s Minimum Data Set ([MDS] a resident assessment tool) dated 4/1/2025, the MDS indicated Resident 1 ' s cognition (ability to think and reason) was intact. The MDS indicated Resident 1 needed set up assistance when eating and oral…

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 observations, interviews, and records review, the facility failed to ensure there were competent staff (Cook) was able to carry out position related duties when: 1. Cook prepared pumpkin pie, without following the recipe. This deficient practice had the potential to result in decreased puree food quality and had the potential to result in wrong meal preparation. Findings: During a concurrent observation and interview on 4/10/25 at 12:05 p.m. with [NAME] 1, [NAME] 1 was observed pouring milk directly into the food processor and continued blending until the mixture was loose consistency. [NAME] 1 validated that she did not follow the recipe, and that milk should not had been added to the pumpkin pie. [NAME] 1 stated that it is important to follow the recipes for all the residents and especially for the residents that are on puree diets because the consistency could be too thin, and the residents could choke and die. During a concurrent observation and interview on 4/10/25 at 12:15 p.m. with Dietary Manager (DM), DM observed pouring loose mixture into the sink. DM validated…

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

Based on observation, interview and record review, the facility failed to ensure staff prepared puree diet (composed of food of a pasty consistency: smooth, with no lumps or pips) was prepared according to the menus and standardized recipes when: 1.Cook added milk to pumpkin pie without following the recipe. This deficient practice had the potential to result in choking for Resident's that has swallowing problem. Findings: During a concurrent observation and interview on 4/10/25 at 12:05 p.m. with [NAME] 1, [NAME] 1 was observed pouring milk directly into the food processor and continued blending until the mixture was loose consistency. [NAME] 1 validated that she did not follow the recipe, and that milk should not had been added to the pumpkin pie. [NAME] 1 stated that it is important to follow the recipes for all the residents and especially for the residents that are on puree diets because the consistency could be too thin, and the residents could choke and die. During a concurrent observation and interview on 4/10/25 at 12:15 p.m. with Dietary Manager (DM), DM observed pouring…

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 assessment entries on the Minimum Data Set (MDS- an assessment and a care screening tool) related to the legal name of Resident 59 was accurately documented and not 120 days overdue. This failure had the potential to negatively affect Resident 59's plan of care and delivery of necessary care and services. Findings: During a review of Resident 59's admission Record, the admission Record indicated Resident 59 was admitted to the facility with diagnoses of but not limited to rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility), diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and presence of a right artificial hip joint. During a review of Resident 21's Minimum Data Set (MDS - a resident assessment tool), dated 10/15/2024, the MDS indicated Resident 59 had the ability to 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 interview and record review the facility failed to ensure one of one sampled resident (Resident 21) level 1 Preadmission and Resident Review (PASRR- a federal regulation to prevent inappropriate placement of individuals with mental illness, intellectual disability, or developmental disabilities in Medicaid-certified nursing facilities) was documented correctly. This failure had the potential to result in Resident 21 not receiving the necessary care and services. Findings: During a review of Resident 21's admission Record, the admission Record indicated Resident 21 was admitted to the facility on [DATE] with diagnoses of but not limited to schizophrenia (a mental illness characterized by disturbances in thought) and dementia (a progressive state of decline in mental abilities). During a review of Resident 21's History and Physical (H&P), dated 1/31/2025, the H&P indicated Resident 21 is not able to make decisions at this time. During a review of Resident 21's Minimum data Set (MDS - a resident assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a comprehensive care plan and a change of condition ([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive (ability to think, understand, learn, and remember) behavioral, or functional status which without immediate intervention, may result in complications or death)) was completed for two of 15 sampled residents ( Resident 49 and 22). The facility failed to: a. Ensure Resident 22 had a COC and plan of care when Resident 22 passed out with unknown cause and regain consciousness on 01/01/2025. b. Ensure Resident 49 had a COC and care plan in place for Resident 49's left big toe infection. These deficient practices had the potential to negatively affect the delivery of necessary care and services to Resident 22 and 49. Findings: a. a. During a review of Resident 22's admission Record, the admission Record indicated Resident 22 was admitted to the facility on [DATE] with diagnoses including acute respiratory…

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 3) referral, appointment and recommendation for ophthalmology (medical specialty focusing on diagnosis and treatment of eye disorders) was arranged to maintain vision. This failure had the potential to result in worsening vision for Resident 3. Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of but not limited to diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), heart failure (a condition when the heart does not pump enough blood) and chronic kidney disease (the kidneys have been damaged and are not properly functioning for at least three months). During a review of Resident 3's History and Physical (H&P), dated 1/23/2025, the H&P indicated Resident 3 was oriented to name, place and time. During a review…

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 15 sampled residents (Resident 49) was seen by a podiatrist (a medical specialty focused on the care and treatment of the foot, ankle, and lower leg) for her left big toe infection. This failure placed Resident 49 at risk for complications related to her left big toe infection. Findings: During a review of Resident 49's admission Record dated 4/11/25 the admission record indicated Resident 49 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dementia (a progressive state of decline in mental abilities) and depression (a mood disorder that affects how a person feels, thinks and behaves). During a review of Resident 49's Medical Doctor (MD) Note dated 12/15/24, the MD Note indicated Resident 49 was oriented to self, place and time. During a review of Resident 49's Minimum Data Set (MDS - a resident assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that a resident received continuous oxygen (a medical treatment to help resident breathe better) as ordered by the physician for one of twenty sampled residents (Resident 19) by: a. Failing to ensure Resident 19 received oxygen at eight liters per minute (lpm unit of measurement) via re-breathable mask (a medical oxygen delivery device where the patient inhales a mixture of oxygen and exhaled air, rather than pure oxygen) as ordered by the physician. This deficient practice had the potential to result in Resident 19 receiving inaccurate amount of oxygen and cause complications associated with oxygen therapy. Findings: During a review of Resident 19's admission Record, the admission Record indicated Resident 19 was admitted to the facility on [DATE], with diagnoses including chronic respiratory failure (a long-term condition where there is not enough oxygen in your body), and congestive heart failure (occurs when the heart cannot…

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 an annual performance evaluation (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics in performing that an individual need to perform work roles or occupational functions successfully) was performed every year for Certified Nursing Assistant (CNA 3). This deficient practice had the potential for the facility not be able to assess the skills necessary for CNA 3 to provide nursing services to assure resident safety and to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Findings: During a interview and record review on 04/10/2025 at 12:06 pm with the Director of Staff Development (DSD), reviewed CNA 3 employee record. DSD stated there was no records of CNA 3 annual competency training for 2022, 2023 and 2024. DSD stated CNA 3 was hired in 2013 and working 11 p.m. to 7 a.m. shift. During a follow up interview on 04/11/25 at 09:45 am with DSD, the DSD stated it was important to do annual competency and skill evaluation 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 the McGeers criteria (a set of guidelines used to define and classify healthcare-associated infections (HAIs) in long-term care facilities) was used for one of 15 sampled residents, when (Resident 49) was prescribed bacitracin (topical antibiotic) ointment for a left big toe infection. This failure had the potential to result in Resident 49 developing antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use. Findings: During a review of Resident 49's admission Record dated 4/11/25 the admission record indicated Resident 49 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dementia (a progressive state of decline in mental abilities) and depression (a mood disorder that affects how a person feels, thinks and behaves). During a review of Resident 49's Medical Doctor (MD)…

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 the Infection Preventionist ([IP]) term used for the person(s) designated by the facility to be responsible for the infection prevention and control program) had specialized training in infection prevention and control. This failure had the potential to lead to inadequate oversight and potential spread of infections within the facility due to poor infection control education training. Findings: During an interview on 1/24/2025 at 10:45 a.m. with Director of Staff Development (DSD), DSD stated that the IP should be fulltime and have an IP certificate to ensure adequate training. DSD stated IP needs to be trained to perform their job duties adequately and train the staff on how to prevent the spread of infections which could lead to the residents becoming sick. During a concurrent interview and record review on 1/24/2025 at 11:05 a.m. with Infection Preventionist (IP), IP stated that she works full time at the facility. IP stated that she is responsible for training and providing in-services for the staff about…

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 three out of 38 sampled residents (Resident 16, 34, and 3) with limited range of motion (ROM - the extent of movement of a joint) and/or limited mobility, received restorative nursing (a program available in nursing homes that helps residents maintain any progress they have made during therapy treatments, enabling them to function at a high capacity) care per Physical Therapist (PT-(a healthcare professional who specializes in helping patients improve their physical function) and Occupational Therapist (OT-a healthcare professional who specializes in helping patient improve ability to perform daily tasks) recommendation and follow through the progress of the residents who received restorative nursing care by : 1. Failing to apply left-hand splint (a rigid or flexible device that maintains in position a displaced or movable part) as recommended by therapist, to assess and evaluate the progress of Restorative Nursing Assistant (RNA)…

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 two cartridges (container) of morphine (controlled medicine used to relieve pain) tablets were stored in the cubex machine (automated medication dispensing system) after delivery by pharmacy to the facility. This failure had a potential to result in the inability to identify drug diversion (illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) and theft. Findings: During a Medication Storage room observation on 4/11/2024, at 9:00 a.m. with Registered Nurse Supervisor (RNS) 2, observed two red containers with plastic locks not labeled were inside the medication storage room. RNS 2 opened the two red containers, and each red container had a cartridge that contained four morphine extended release (ER- medicine was slowly release into the body over a period) 15 milligrams (mgs- unit of measurement) tablets. During an interview on 4/11/2024, at 9:10 a.m. with RNS 2, RNS 2 stated morphine tablets not properly stored could lead to drug diversion. RNS 2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure five of 14 sampled residents (Resident 35, Resident 24, Resident 5, Resident 49, Resident 1 and Resident 3) were informed of the right to develop an advance directive (a legal document prepared by you that expresses what kind of medical care you want, or who was authorized to make decisions for you should you be unable to make or communicate your wishes). This failure resulted in Resident 35, Resident 24, Resident 5, Resident 49, Resident 1, and Resident 3's rights being violated to be fully informed of the option to formulate their advance directives. Findings: a. During a review of Resident 35's admission Record, the admission Record, indicated Resident 35 was admitted to the facility on [DATE] with diagnoses including skull fracture (broken bone), right arm fracture, rib fractures, and hypertension (high blood pressure). During a review of Resident 35's Minimum Data Set (MDS- a standardized assessment and care screening tool) dated 3/9/2024,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of 14 sampled residents (Resident 24 and Resident 5) had a Preadmission Screening and Resident Review (PASARR-a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) assessment done when diagnosed with a mental illness prior to admission. This failure had the potential for Resident 24 and Resident 5 not receiving the necessary services and appropriate psychiatric level of treatment and evaluation in the facility. Findings: During a review of Resident 24's admission Record, the admission Record, indicated Resident 24 was originally admitted to the facility on [DATE] and readmitted to facility on 3/1/2024 with diagnoses including schizophrenia (a serious mental disorder in which people interpret reality abnormally) chronic obstructive pulmonary disease ( [COPD] a chronic inflammatory lung disease that causes obstructed airflow from the lungs), abdominal aortic aneurysm ( 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 two of 14 sampled residents (Resident 24 and 3): 1.Received Restorative Nursing Aide (RNA- helps tide rehabilitative care for residents) services as recommended by the physical therapist (a healthcare professional who specializes in helping patients improve their physical function). This failure had the potential to result in Resident 24 developing contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) and decreased mobility. 2. Provide a communication tools or system to Resident 3 who had aphasia (loss of ability to understand or express speech due by brain damage) to be able to communicate requests and needs. This failure had the potential for Resident 3 to feel isolated, afraid, and upset as she cannot communicate her needs to facility staff. Findings: During a review of Resident 24's admission Record, the admission Record indicated Resident 24 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the consultant pharmacist's recommendation in the Medication Regime Review (MRR- a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication), were communicated to the physician for two of 14 sampled residents (Resident 2, 56, 24, and Resident 1) for unnecessary medications review. This failure resulted in Resident 2, 56, 24, and Resident 1 receiving an unnecessary medication that can lead to adverse side effects and the potential to result in harm. Findings: 1. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses anxiety disorder (mental health disorder characterized by feelings of worry, anxiety or fear that are strong enough to interfere with daily activities), unspecified osteoarthritis (degenerative joint disease), and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: 1.Ensure seven (7) over-the-counter medication were not expired in (1) out of two (2) sampled medication storage rooms. This failure 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.One of five sample residents' (Resident 22) medicines were not left on the bedside table by a Licensed Vocational Nurse (LVN) 1. This deficient practice had the potential for delay or omission (patient did not receive the medicines that had been ordered) of Resident 22's medications affecting the health of the resident. Findings: 1.During a concurrent observation and interview on [DATE] at 8:51 a.m. with Registered Nurse (RNS 2) in Medication Storage Room, the following medications were stored in an open cabinet: a. Five bottles of multivitamin expired on 3/2024. b. One bottle of Vitamin B 12 expired on 3/2024. c. Six bottles of…

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

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage practices in the kitchen when: 1.Banana puree with a label of use by date of 3/16/2024, egg puree with a label of use by date of 4/01/2024, lettuce with a label of use by date of 4/7/2024, and eggs with a label of use by date of 4/7/2024 remains in the kitchen. This failure 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) in 55 out of 55 residents who received food from the facility. Findings: During an observation on 4/9/2024 at 8:24 am in the kitchen, there was banana puree with a use by date on 3/16/2024, egg puree with a use by date on 4/01/2024, lettuce with a use by date on 4/7/2024, and eggs with a use by date of 4/7/2024. During an interview on 4/09/2024 at 8:24 am with Dietary Aide (DA 1) DA1 stated the cooks were responsible for labeling and dating food and all…

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 assess mental capacity (ability to make decisions) and provide information to two of three sampled residents (Resident 60 and Resident 45) and their responsible parties before signing arbitration agreement (a way of resolving a dispute without filing a lawsuit and going to court). This failure had the potential to result in Resident 60 and Resident 45 not fully understand their right to limit opportunity to initiate judicial proceedings that challenge unfavorable decisions. Findings: During a review of Resident 60's admission Record, the admission Record indicated, Resident 60 was admitted to the facility on [DATE] with diagnoses including traumatic brain injury (a sudden, external, physical assault damages the brain), cerebral infarction (a loss of blood flow to part of the brain), muscle weakness, history of falling, and acute respiratory distress syndrome (a life-threatening lung injury that allows fluid to leak into the lungs). 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 observe infection control practices and procedures in the facility by failing to: 1. Ensure dietary staff did not store its personal food items in the kitchen refrigerator. This failure had the potential to result in cross contamination (transfer of harmful bacteria from one place to another) of the resident's food and to cause the spread of food borne illnesses (illness caused by food contaminated with bacteria, viruses, and parasites) to residents. 2.Wear personal protective equipment([PPE] specialized clothing or equipment worn by an employee for protection against infectious materials) properly when providing care for Resident 215. This failure had the potential to spread infection among residents, staff, and visitors. Findings: 1. During a concurrent observation and interview on 4/9/2024 at 8:24 a.m. with Dietary Aide (DA 1) in the kitchen, in the refrigerator there was a silver metal cup filled with a thick brown substance covered…

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 five sample residents (Resident 56) and/or responsible party (RP) was informed in advance, of the risks and benefits of psychoactive medication (a drug that changes brain function and results in alterations in perception, mood, consciousness, or behavior). This failure resulted into violating the residents' right to make an informed decision regarding the use of psychoactive medications. Findings: During a record review of Resident 56's admission Record, the admission Record indicated Resident 56 was admitted to the facility on [DATE] with diagnoses including unspecified dementia( when symptoms and findings do not meet a the criteria for a specific dementia),depression (persistent feeling of sadness), diabetes (a condition in which the body fails to metabolize (process) glucose (sugar) correctly ), and anxiety disorder( mental health disorder characterized by feelings of worry, anxiety or fear that are strong enough to interfere with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure call light was within reach for one of three sampled residents (Resident 60). This failure resulted in Resident 60 feeling lack of self-determination to make decisions, loss of dignity, loss of self-esteem and had the potential to result in Resident 60 not being cable to call staff for help when needed and delay in necessary care and services. Findings: During a review of Resident 60's admission Record, the admission Record indicated Resident 60 was admitted to the facility on [DATE] with diagnosis including traumatic brain injury (a sudden, external, physical assault damages the brain), cerebral infarction (a loss of blood flow to part of the brain), muscle weakness, history of falling, and acute respiratory distress syndrome (a life-threatening lung injury that allows fluid to leak into the lungs). During a review of Resident 60's History and Physical (H&P), dated 3/22/2024, the H&P indicated, Resident 60 was unable to make his…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to accurately assess and code the Minimum Data Set (MDS, a standardized assessment and care-screening tool) assessment for one of 14 sampled residents (Resident 24) by failing to ensure the MDS was coded correctly. This failure had the potential to result in delayed or missed identification of joint range of motion (ROM, full movement potential of a joint) changes, inaccurate care planning, and inadequate provision of services and treatments for Resident 24. Findings: During a review of Resident 24's admission Record, the admission Record, indicated Resident 24 was originally admitted to the facility on [DATE] and readmitted to facility on 3/1/2024 with diagnoses including chronic obstructive pulmonary disease ( [COPD] a chronic inflammatory lung disease that causes obstructed airflow from the lungs), abdominal aortic aneurysm ( an enlarged area in the lower part of the body's main artery), chronic inflammatory demyelinating polyneuritis ( an acquired…

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 care plan interventions for two of three sampled residents (Resident 1's fall on 3/15/2023 and the use of two people during perineal care (cleaning private areas of resident), and repositioning for Resident 2. These deficient Resident 1 and 2) were revised and/or implemented to include the use of floor mats and specifics for visual checks following practices resulted in recommended interventions and interventions that were already in place not being implemented and Resident 2 falling from a bed sustaining abrasions to his face and thumb and had the for additional falls and/or injuries to occur. Findings: a. 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 including hemiplegia (inability to move one side of body), hemiparesis (weakness on one side of body), and aphasia (loss of ability to understand or express speech, caused by brain damage).…

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 notify the physician when one of three sampled residents (Resident 2) continued to refuse to have restorative nurse aide ([RNA] a nurse who provides rehabilitative care to individuals recovering from illnesses or injuries) therapy exercises provided to him because of pain to his left knee. This deficient practice resulted in and had the potential to cause a delay in Resident 2' s assessment and treatment which could lead to a decline in Resident 1's range of motion ([ROM]. Findings: During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis of osteoporosis (brittle bones) During a review of Resident 2's Minimum Data Set ([MDS], a standardized assessment and care-screening tool), dated 12/15/2023, the MDS indicated Resident 2 ' s cognitive skills for daily decision-making were moderately impaired. The MDS indicated, Resident 2 had a functional limitation in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a physician's order for Ivermectin (a drug used to treat parasitic (an organism [an individual animal, plan, or single-celled life form] that lives on or in a host organism and gets its food from or at the expense of its host) infections such as scabies [a parasitic infestation caused by tiny mites that burrow into the skin and lay eggs, causing intense itching and a rash]) was transcribed and administered to one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1 not receiving Ivermectin as ordered by the physician and had the potential for further itching and discomfort to occur. 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 including hemiplegia (inability to move one side of body), hemiparesis (weakness on one side of body), and aphasia (loss of ability to understand or express speech, caused…

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's Interdisciplinary Team (IDT) failed to meet, following one of three sampled residents (Resident 2) fall with injury on 1/13/2024 to determine the cause of Resident 2's fall and recommend interventions to put in place in order to prevent other falls and/or injuries from occurring. This deficient practice resulted in the facility not exploring the root cause of Resident 2 ' s fall and had the potential for other falls to occur. Findings: During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis of osteoporosis (brittle bones). During a review of Resident 2's Minimum Data Set ([MDS], a standardized assessment and care-screening tool), dated 12/15/2023, the MDS indicated Resident 2's cognitive skills for daily decision-making were moderately impaired. The MDS indicated, Resident 2 had a functional limitation in range of motion ([ROM] the direction a joint can move 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 the treatment of one sampled resident (Resident 1) with Permethrin (a medication used to kill scabies) was reported to the Infection Preventionist Nurse ([IPN] a person who is responsible for identifying, investigating, monitoring, and reporting healthcare associated infections) in order to ensure methods such as isolation, monitoring of rashes and proper cleaning and disinfection of linens and equipment used by Resident 1 was implemented. This deficient practice resulted in the IPN nurse being unaware of a possible scabies diagnosis, a delay in implementing infection control methods and had the potential for acquiring and spreading scabies throughout the facility and to the community. 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 including hemiplegia (inability to move one side of body), hemiparesis (weakness on one side 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 three sampled residents, (Resident 1) remained free from verbal abuse by Licensed Vocational Nurse (LVN) 3. This deficient practice had the potential for Resident 1 to experience a decline in psychosocial well-being and degraded self-esteem. 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 osteomyelitis (an inflammation or swelling of bone tissue that is usually the result of an infection) of vertebrae (small bones forming backbone), multiple sclerosis (autoimmune disease in which brain and spinal cord are damaged), and hydronephrosis (upper urinary tract dilation where something keeps urine from flowing from the kidneys to the bladder). During a review of Resident 1's history and physical (H/P), the H/P indicated Resident 1 had the capacity to make medical decisions. During a review of Resident 1's Minimum Data Set…

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 create a care plan for skin integrity for one of three residents (Resident 1) who had a moisture-associated skin damage (MASD- inflammation of the skin) on the sacrum (tail bone). This deficient practice had the potential to place Resident 1 at risk for further skin breakdown. Findings During a review of Resident 1 ' s admission Record, the record indicated Resident 1 was admitted to the facility on [DATE] with the diagnosis including multiple sclerosis (a nervous system disease that affects the brain and spinal cord). During a review of Resident 1 ' s Minimum Data Set ([MDS]- a standardized assessment and care screening tool) dated 10/9/2023, the MDS indicated Resident 1 ' s cognition (thinking and reasoning) was intact, and Resident 1 is dependent on two staff members when repositioning. During a review of Resident 1 ' s skin/wound note dated 8/10/2023, the note indicated Resident 1 was assessed to have a MASD and new orders were received to treat…

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 the facility ' s medication administration policy for one of one resident (Resident 2) when Licensed Vocational Nurse 2 (LVN 2) left three medication pills in a medicine cup on Resident 2 ' s bedside table unattended. This deficient practice had the potential for Resident 2 to have missed medication doses and had the potential to result in other residents getting access to Resident 2 ' s medication which can cause harm when inadvertently consumed. Findings: During a review of Resident 2 ' s admission Record, the record indicated Resident 2 was admitted to the facility on [DATE]. During a review of Resident 2 ' s History and Physical (H &P), dated 11/29/2023, the H & P indicated Resident 2 had the mental capacity for daily decision-making regarding tasks of daily living. The H &P indicated Resident 2 had a history of bipolar disorder (a serious mental illness that causes unusual shifts in mood, ranging from extreme mania or highs 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 Amended:2-13-2025 Based on interview and record review, the facility failed to: 1. Ensure Certified Nursing Assistant (CNA 4) immediately initiated Resident 1's cardiopulmonary resuscitation [(CPR) an emergency procedure that can help save a person's life if their breathing or heart stops] when Resident 1 was found unresponsive, with no pulse (no heartbeat), and not breathing on [DATE] at 7:50 a.m. Resident 1 was Covid-19 (a highly contagious infectious disease that can affect various systems of the body) positive and was on isolation (separation of an infected resident to prevent further infection transmission). 2. Ensure Registered Nurse (RN 1), the Director of Staff Development (DSD 1), Licensed Vocational Nurse (LVN 1), who were summoned by CNA 4 to Resident 1's room, did not delay initiation of Resident 1's CPR while the Director of Nursing (DON) had to verify/confirm Resident 1's code status (Resident's or resident's representative's wishes on the type of resuscitation procedures, if any, they would like…

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 implement infection prevention and control program measures by failing to: a. Ensure Receptionist (RT)1 sanitized the pen after each use and promote hand hygiene to visitors. b. Ensure Certified Nurse Assistant (CNA) 1 washed and /or sanitize (make clean and hygienic; disinfect) after disposal of soiled linens before repositioning a resident. c. Ensure Licensed Vocational Nurse (LVN) 6 washed and/or sanitize hands before and after entering the residents' room to provide care. d. Follow the facility's policy coronavirus disease ([COVID19-is a disease caused by virus called SARs-CoV-2}) mitigation plan when Licensed Vocational Nurse (LVN 1) did not change their N95 mask after leaving the isolation room and proceeded to sit with other facility staff at the nurses' station. e. Implement Long Beach Public Health COVID-19 guidelines for testing residents and staff on Day 1. f. Provide in-services regarding Infection Control after the facility had identified an outbreak of COVID-19 in the facility. This failure…

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.