Colonial Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the nursing staff notified the physician in a timely manner when one out of three residents (Resident 122) refused tube feeding (a method of delivering liquid nutrients, fluids, and medications directly into the stomach or small intestine via a flexible tube) for the day. This deficient practice placed Resident 122 at risk for potential weight loss and malnutrition. Findings:During a review of Resident 122's admission Record, the admission Record indicated Resident 122 was originally admitted to the facility on [DATE], and readmitted on [DATE]. Resident 122's diagnoses included quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), acute respiratory failure (a life-threatening, sudden-onset condition where the lungs cannot adequately oxygenate the blood or remove carbon dioxide), and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse when Resident 96 pushed Resident 44, causing Resident 44 to fall to the ground. This deficient practice resulted in Resident 44 falling and sustaining a traumatic skin tear measuring 1 centimeter (cm unit of measure of length) long by x 0.1 cm wide on the right eyebrow, requiring an emergency visit to a General Acute Care Hospital (GACH) for treatment and management. Findings: During a review of Resident 44's admission record, the admission record indicated Resident 44 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), depression (constant feelings of sadness, and irritability that lasts more than two weeks) and Alzheimer's disease (a disease characterized by a progressive decline in mental abilities). During a review of Residents 44's Minimum Data [MDS)] resident assessment tool), dated 12/26/2025, 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 observation, interview and record review the facility failed to ensure Minimum Data Set (MDS- a resident assessment tool) accurately reflects resident status for two of five sampled residents (Resident 73 and Resident 99). This failure had the potential to result in inaccurate assessment of the resident's condition, leading to inappropriate care planning, monitoring and interventions. Findings: A. During a record review of Resident 73's admission record, it indicated Resident 73 was admitted on [DATE] with a diagnoses of bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities) and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements). During a record review of Resident73's Minimum Data set (MDS- resident assessment tool), dated 1/26/2026 ,…

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 the nursing interventions according to the care plan for one of three sampled residents (Resident 99). This deficient practice had the potential for Resident 99 needs not being met. Findings: During a record review of Resident 99's admission record indicated Resident 99 was admitted on [DATE] with a diagnoses dementia (a progressive state of decline in mental abilities), schizophrenia (a mental illness that is characterized by disturbances in thought), and history of falling. During a record review of Resident 99's MDS dated [DATE] indicated that residents cognitive was impaired. The MDS indicated that Resident 99 needs maximal assistance with toileting, shower, lower body dressing and putting on/taking off footwear. During an observation on 02/09/2026 at 9:49 a.m. in Resident 99's room, Resident 99 was lying in bed facing the door with bilateral siderails up and call light within reach. Resident 99 did not have any floor mats or…

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

Based on interview and record review, the facility failed to follow the care plan and implement nonpharmacological interventions (any healthcare intervention not involving medications) for pain for one of eight sampled residents (Resident 20).This deficient practice had the potential to place the resident at risk for ineffective pain management and untreated pain.Findings:During a review of Resident 20's admission Record (Face Sheet), the admission Record indicated the facility admitted the resident on 11/15/2021 with diagnoses including hypertension (HTN- high blood pressure), schizophrenia (a mental illness that is characterized by disturbances in thought) and low back pain.During a review of Resident 20's History and Physical (H&P) dated 12/21/2025, the H&P indicated the resident did not have the capacity to understand and make decisions.During a review of Resident 20's Minimum Data Set (MDS- a resident assessment tool), dated 11/20/2025, the MDS indicated Resident 20 had moderate cognitive (ability to think and understand) impairment. The MDS indicated Resident 20 was dependent…

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

Based on interview and record review, the facility failed to ensure nursing staff used behavioral signs of pain (observable non-verbal actions that indicate distress such as facial grimacing, moaning, irritability) to assess pain for one of eight sampled residents (Resident 20).This deficient practice had the potential to result in inaccurate pain assessments and untreated pain.Findings:During a review of Resident 20's admission Record (Face Sheet), the admission Record indicated the facility admitted the resident on 11/15/2021 with diagnoses including hypertension (HTN- high blood pressure), schizophrenia (a mental illness that is characterized by disturbances in thought) and low back pain.During a review of Resident 20's History and Physical (H&P) dated 12/21/2025, the H&P indicated the resident did not have the capacity to understand and make decisions.During a review of Resident 20's Minimum Data Set (MDS- a resident assessment tool), dated 11/20/2025, the MDS indicated Resident 20 had moderate cognitive (ability to think and understand) impairment. The MDS indicated Resident 20…

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 three sampled residents (Resident 15) received Restorative Nursing Assistant ([RNA], a certified nursing assistant who works with patients in skilled nursing facilities to help them regain their ability to perform daily tasks) services ordered for the resident.This deficient practice had the potential to negatively have a decline in range of motion and mobility leading to contractures. Findings:During a review of Resident 15's admission Record, the admission Record indicated Resident 15 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 15's diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), dementia (a progressive state of decline in mental abilities), and diabetes mellitus ([DM]-a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 15's history and physical (H&P) dated 7/5/2025,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the tube feeding (a method of delivering liquid nutrients, fluids, and medications directly into the stomach or small intestine via a flexible tube) machine was on and functioning properly to administer the feeding for one of three sample residents (Resident 5) when the tube feeding machine was on but not administering the feeding to Resident 5 for over three hours.This deficient practice placed Resident 5 at risk for weight loss and nutritional deficit. Findings:During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was originally admitted to the facility on [DATE], readmitted on [DATE]. Resident 5's diagnoses included acute respiratory failure (a life-threatening, sudden-onset condition where the lungs cannot adequately oxygenate the blood or remove carbon dioxide), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to store two unopened Humalog insulin pens (a medication used to treat high blood sugar) in the refrigerator per the manufacturer's requirements affecting Residents 160 and 207 in one of five inspected medication carts (Station 3 Cart A.)The deficient practices of failing to store unopened insulin pens in the refrigerator per the manufacturer's requirements increased the risk that Residents 160 and 207 could have received medication that had become ineffective or toxic due to improper storage possibly leading to health complications resulting in hospitalization or death.Findings: During a concurrent observation and interview on [DATE] at 1:25 PM of Station 3 Medication Cart A with the Licensed Vocational Nurse (LVN 5), the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as required by their respective manufacturer'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 ensure one of two sampled residents (Resident 18) who was under hospice care (compassionate care for people who are near the end of life provided at the person's home or within a health care facility) was visited by hospice licensed nurses weekly per hospice care agreement.This failure had the potential to result in Resident 18 not having their hospice needs met, as they agreed upon.Findings:During a review of Resident 18's admission Record, the admission Record indicated, Resident 18 was initially admitted to the facility on [DATE] and last re-admission was on 10/3/2025 with diagnoses including senile degeneration of brain (a neurological disorder that is tied to cognitive decline, memory impairment, and changes in behavior), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), dementia (a progressive state of decline in mental abilities), and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report immediately and not later than two hours after receiving an allegation of physical abuse (any intentional act causing injury or trauma to another person by way of bodily contact) by one of fifteen sampled residents (Resident 4) to officials, including the State Survey Agency and law enforcement. This deficient practice resulted in the inability of The California Department of Public Health (CDPH) to investigate the allegations of abuse in a timely manner and placed Resident 4 at risk for continued physical abuse. Findings: During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses of essential hypertension (high blood pressure) and type 2 diabetes (happens when the body cannot use insulin correctly and sugar builds up in the blood). During a review of Resident 4's Minimum Data Set (MDS, a resident assessment tool) dated 10/9/2025, the MDS indicated Resident 4…

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 three sampled residents (Resident 1) bed was placed in a low position, per the resident's Falling Star Program care plan dated 2/13/2024. This failure has resulted in Resident 1, who was assessed as a high risk for falls, being observed in a bed that was not in a lowered position and placed Resident 1 at risk for falling out of bed and injuries. 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 diagnosis including a diagnosis of generalized weakness. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 2/3/2025, the MDS indicated Resident 1 was forgetful and was not able to make reasonable and consistent decisions, he required one to two person assist to complete activities of daily living ([ADLs] routine tasks/activities]) such as transferring from…

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 they followed their own sanitation and infection control policy to work under sanitary conditions at all times. This deficient practice had the potential to result in cross-contamination (transfer of harmful substances or disease-causing microorganisms to food by hands, food contact surfaces) and increase the risk of infection for 133 of 181 residents. Findings: During a concurrent observation and interview on 2/4/2025 at 11:59a.m. with Regional Registered Dietitian (RRD), RRD was observed grabbing a food thermometer with no hand washing and gloves, grabbed an alcohol swab (clean and disinfect skin or surfaces to prevent infection), swabbed the metal part of the thermometer, and stuck the thermometer into the purred broccoli (cooked food that has been blended to the consistency of a creamy paste). RRD was observed getting another alcohol swab and wiping away the metal part of the thermometer to clean the purred broccoli and attempted to repeat the process without hand hygiene and gloves. RRD stated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure to store food in a sanitary manner to prevent growth of microorganisms that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, and viruses for 133 out of the 181 residents in the facility by not: 1. Facility failed to separately store frozen meats and veggies. 2. Facility failed to store opened sausages and croissants separately in the produce fridge. 3. Facility failed to date and label frozen items, produce, and stored goods. 4. Facility failed to date thickened milk shakes that were already thawed in the fridge. 5. Facility failed to discard molded and expired bread and expired cottage cheese. 6. Facility failed to check chloride levels and have chloride test strips available before running the dishwasher. 7. Facility failed to have a scale to weigh proper portion sizes. These deficient practices had the potential to result in pathogen (germ) exposure 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 dispose garbage and refuse properly by not completely covering two (2) of three (3) blue dumpster (a large trash container designed to be emptied into a truck) for unknown amount of time. This deficient practice had a potential to attract flies, insects, cats, and other animals to the dumpster area placing 180 of 196 facility residents getting food from the kitchen cross-contamination (a transfer of harmful bacteria from one place to another). Findings: During a concurrent observation of the garbage area located outside the facility near the kitchen and interview with Dietary Manager (DM) at 2/3/2025 on 9:43a.m., 2 of 3 blue dumpsters were not completely closed and covered. There were 3 black trash bags between two dumpsters on the floor. DM stated the trash bin lids were not completely closed, and it could attract pests. During a concurrent observation of the garbage area located outside the facility near the kitchen and interview with the Maintenance Supervisor (MS) at 2/7/2025 on 12:20 p.m., 1 of 3 blue…

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 offer, educate, and track coronavirus vaccinations for staff per facility's policy. This failure had the potential to place all residents at risk for infection of coronavirus. Findings: During an interview on 2/6/2025 at 2:50 p.m. with the Infection Preventionist Nurse (IPN), the IPN stated the facility does not have a tracking log or retain records of vaccination education, proof of vaccination, or declinations for coronavirus vaccination of facility staff. During an interview on 2/8/2025 at 6:50 p.m. with the Director of Nursing (DON), the DON stated it is important to educate and document staff coronavirus vaccinations in order to protect residents and staff from the coronavirus. During a review of the facility's policy and procedure (P/P), titled Covid-19 Policy, dated 8/26/2024, the P/P indicated: A. The facility will continue to educate residents, responsibility parties, and staff about the benefits of receiving the vaccination and risks of refusals. B. Covid-19 2024-2025 vaccination will be offered 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 interview, and record review, The facility failed to provide Effective Communications training for direct care staff, including 18 of Registered Nurse (RN), 50 of Licensed vocational nurse (LVN), and 20 of Respiratory Therapist (RT) as required by the facility's policy and procedure (H&P). This deficient practice had the potential to miscommunication, unmet resident needs, and compromised care, particularly for residents who rely on alternative communication methods. Findings: During an interview on 2/8/2025 at 6:56 p.m. with the Administrator, the ADM stated that currently, there were 18 of RN, 50 of LVN, 20 of RT, and 100 of CNA in the facility. During a concurrent interview and record review on 2/8/2025 at 7:55 p.m. with the Director of Staff Development (DSD), the facility's in-service logs, for the year of 2024. The DSD stated that she was unaware that Effective Communications was a mandatory training for direct care staff and stated that the training was not provided in 2024. The DSD also stated that Effective Communications is important to ensure that staff can…

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 Quality assurance and performance improvement (QAPI) training for direct care staff, including 18 of Registered Nurse (RN), 50 of Licensed vocational nurse (LVN), and 20 of Respiratory Therapist (RT) as required by the facility's policy and procedure (H&P). This deficient practice had the potential to result in poor communication among staff, lack of awareness of facility updates, lack of collaborative work, and compromised resident care. Findings: During an interview on 2/8/2025 at 6:56 p.m. with the Administrator, the ADM stated that currently, there were 18 of RN, 50 of LVN, 20 of RT, and 100 of CNA in the facility. During a concurrent interview and record review on 2/8/2025 at 7:55 p.m. with the Director of Staff Development (DSD), the facility's in-service logs, for the year of 2024, were reviewed. The DSD stated that she was unaware that QAPI was a mandatory training for direct care staff, and she did not provide the training to direct care staff in 2024. The DSD also stated that QAPI training is important…

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: a. involve one of 10 sampled residents (Resident 188) and his responsible party, family member (FM 1) in creating a plan of care for significant weight loss. b. ensure one of seven sampled residents (Resident 19) participated in the development and implementation of his care plan by failing to ensure Resident 19 was involved in the care planning process when Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain their function and joint mobility) services for range of motion (ROM, full movement potential of a joint) exercises to both legs were discontinued. These deficient practices caused Resident 188 and FM 1 to not be informed regarding Resident 188's current health condition and Resident 19's right to be active participant in his care. Findings: During a review of Resident 188's admission record, the admission record indicated Resident 188 was admitted to the facility 12/6/2024 with diagnoses of gastrostomy tube (GT, 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 ensure the residents' medical records were updated to show documentation that a resident has an advance directive (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) for four of eight of sampled residents (Resident 37, 343, 55, and 46). This deficient practice had the potential to cause conflict with the residents' wishes regarding health care. 1. During a review of Resident 37's admission record (Face Sheet), the Face Sheet indicated Resident 37 was initially admitted to the facility on [DATE] and was readmitted on [DATE] and with diagnoses including dementia (a progressive state of decline in mental abilities), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and contracture (a stiffening/shortening at any joint, that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: a. Notify one out of 10 sampled residents (Resident 188)'s physician (MD 1) and responsible party (FM 1) when Resident 188 had a change of condition related to significant weight loss of 7.6% (9lbs) in one month on 1/3/2025, and 20.1% (24lbs) weight loss in 2 months on 1/31/2025. b. report a change of condition (COC) for one of seven sampled residents (Resident 19) who was identified as being at high risk for contracture (loss of motion of a joint associated with stiffness and joint deformity) development and had limited range of motion (ROM, full movement potential of a joint) concerns by not Reporting Resident 19's refusal of Restorative Nursing Aide (nursing aide program that help residents maintain any progress made after therapy intervention to maintain their function) services for range of motion (ROM, full movement potential of a joint) exercises to both legs in accordance with the facility's Policy and Procedure (P/P) titled,…

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 facility's policy and procedure by: 1. Failing to find alternative ways to prevent fall before putting the 4 side rails up for Resident 24 and placing lap tray over Resident 161 2. Failing to obtain consents before applying restraints. 3. Failing to conduct a pre-restraining assessment and review to determine the need for restrains. 4. Failing to follow resident's care plan to have IDT meeting to discuss plan of care and to ensure appropriateness of restraint. This failure has the potential to compromise the resident's dignity and safety, create un unsafe environment, and increase the risk of further injury. Findings: 1. During a review of Resident 24's admission Record, the admission Record indicated the facility admitted Resident 24 on 3/5/2013 and readmitted on [DATE] with diagnoses including hemiplegia (paralysis or weakness that affects one side of the body) and hemiparesis (weakness or the inability to move on one side 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 two of three sampled residents (Residents 16 and Resident 55) Preadmission Screening and Resident Review (PASRR) assessment screening was accurate to determine the facility's ability to provide the special need of the residents. This deficient practice placed the residents at risk of not receiving necessary care and services they need. Findings: a. During a review of Resident 16's admission record (Face Sheet), the Face Sheet indicated Resident 16 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) [bipolar type (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs)], and major depressive disorder (MDD: (a mood…

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 nine out of 37 sampled residents (Resident 19, Resident 21, Resident 25, Resident 40, Resident 46, Resident 55, Resident 59, Resident 74, and Resident 188) had a person-centered care plan related to: 1. The facility failed to develop and implement a care plan for Resident 19's refusal of Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain their function and joint mobility) services for passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises to both legs. 2. Facility failed to initiate and update care plans for resident 46 for actual seizures and seizure medications. 3 . Failed to initiate care plans for Resident 55 and Resident 21 for continued weight loss. 4. Resident 188's significant weight loss with meaningful interventions identified to prevent further weight loss 5. Resident 40's,74's and 59's individualized Preadmission Screening and 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 provide treatments and services to five of seven sampled residents (Residents 19, 37, 66, 95, and 109) to prevent and/or limit a decline in joint (where two bones meet) range of motion (ROM, full movement potential of a joint) and mobility (ability to move). 1. For Resident 95, the facility failed to ensure the Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain their function and joint mobility) order for the application of a resting hand splint (RHS, splint secured from the hand to the forearm to position the hand in a functional position) to Resident 95's left hand was written appropriately to include a maximal wear time of two (2) hours. 2. For Resident 19, the facility failed to provide RNA passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises to Resident 19's both arms (shoulder, elbow, wrist, hand), five (5) times a week as ordered. 3. For 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 ensure tube feedings were properly managed for three (3) of four (4) sampled residents (Resident 16, 84, and 37) with a gastrostomy tube (GT or g-tube: a tube that is passed through the abdominal wall to the stomach used to provide nutrition) by failing to: 1. Ensure Resident 16's tube feeding was disconnected after the administration of feeding. 2. Ensure the feedings were replaced in a timely manner for Residents 84 and Resident 37 that were hanging and were not administered for more than 24 hours (hrs) later. These deficient practices had the potential to place Residents 16, 84, and 37 at risk for infection. 1. During a review of Resident 16's admission Record, the admission Record indicated Resident 16 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including GT, chronic obstructive pulmonary disease (COPD: a chronic lung disease causing difficulty in breathing), gastroesophageal reflux disease…

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 1. Ensure Restorative Nurse Assistant (RNA 1) was competent regarding documenting residents' weight in the resident's medical record and licensed nurses (unknown) including Registered Nurses (RN 2 and RN 3) were competent in reporting changes of condition related to weight loss to the registered dietician (RD), physician (MD 1), and the responsible party (Family Member (FM)1) for one of 10 sampled residents (Resident 188). These deficient practices had the potential to cause inaccurate nutrition assessments and the potential for a delay in care and implementation of interventions to prevent further weight loss for Resident 188. Cross reference: F692 Findings: During a review of Resident 188's admission record, the admission record indicated Resident 188 was admitted to the facility 12/6/2024 with diagnoses of gastrostomy tube (GT, a feeding tube), muscle wasting, non-Hodgkin lymphoma (cancer), tracheostomy tube (an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs), 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 Resident 177's physician order for Aspirin [a medication used to prevent heart attack (flow of blood and oxygen is blocked) and stroke (loss of blood flow to a part of the brain)] was administered as a chewable according to manufacturer formulation specifications instead of being swallowed, on 2/5/2025. 2.Ensure the correct medication administration route (is often classified by the location at which the drug is administered) was ordered for one of eight sampled residents (Resident 52) who had a gastrostomy tube (GT, a tube inserted through the wall of the abdomen directly into the stomach. It can be used to give drugs and liquids, including liquid food, to the patient). These deficient practices had to potential for Resident 52 to receive medication orally (by mouth) and aspirate (breathe something in; inhale) and had a potential for Resident 177 to be at risk for stroke. Findings: 1.During a review of Resident 177's admission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to store and label medications in accordance with manufacture guidelines for the following: 1. One opened Budesonide inhalation suspension foil pack (medication used to reduce breathing problems) for Resident 152 2. Four Intravenous (IV - administered thorugh a blood vessel) Lorazepam (sedative medication used to treat anxiety or seizures) vials for Resident 87 3. One IV Torbramycin (antibiotic) bag for Resident 1 4. One opened Ipratopium Bromide foil pack (medication used to treat breathing problems) for Resident 72 5. One opened Tuberculin Purified Protein Derivative (PPD-used in the 2-step process to screen new resident for tuberculosis [TB-an infectious disease that primarily affects the lungs] solution multi-dose vial. This failure had the potential to result in Residents 152, 87, 1, and 72 receiving medications that had become ineffective or toxic due to improper storage or labeling, possibly leading to health complications or…

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

Based on observation, interview, and record review, the facility failed to ensure the Physical Therapy Joint Mobility Screenings (PT JMS, a brief assessment of a resident's range of motion of both legs completed by a Physical Therapist [PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function]), dated 8/19/2024 and 10/15/2024, for one of seven sampled residents (Resident 19) were accurately completed and documented. This deficient practice had the potential to negatively impact the provision of necessary care and services, portray an inaccurate reflection of assessment results, cause miscommunication among staff, and result in missed opportunities to detect declines in joint range of motion (ROM, full movement potential of a joint). Findings: During a review of Resident 19's admission Record, the admission Record indicated the facility initially admitted Resident 19 on 9/10/2003 and re-admitted Resident 19 on 5/20/2023 with diagnoses including C1-C4 quadriplegia (spinal cord injury in the neck region causing weakness or paralysis in both arms…

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 Quality Assessment and Assurance committee ([QAA] a group of facility staff who identifies, evaluates, and implements measures to improve the quality care and life for the residents in the facility) and Quality Assurance Performance Improvement ([QAPI] a group who takes a systemic, interdisciplinary, comprehensive, and data driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families, and all nursing home caregivers in practical and creative problem solving) committee failed to identify concerns related to cardio-pulmonary resuscitation (CPR, it can help save a life during cardiac arrest, when the heart stops beating or beats too ineffectively to circulate blood to the brain and other vital organs) and weight loss in the facility. This deficient practice had the potential for continued weight loss and improper assessment skills for when initiating CPR is indicated for full code (when your heart stops,…

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 measures on 5 of 37 sampled residents (Resident 19, 87,343,16) by failing to: 1. Ensure Restorative Nursing Aide 2 (RNA 2) wore an isolation gown (protective apparel used to protect the wearer from the transfer of microorganisms and body fluids) while providing range of motion (ROM, full movement potential of a joint) exercises to Resident 19 who was on Enhanced Barrier Precautions (EBP, infection control intervention using gown and gloves during high contact resident care activities designed to reduce the transmission of multi-drug resistant organisms). 2. Ensure padded side rails (a padded side fitted to a bed for safety) were not wrapped with foam and paper tape for one of 10 sampled residents (Resident 87). 3. Ensure Resident 343 had an Enhanced Barrier Precaution (EBP: infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) signage posted for having 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 implement the antibiotic stewardship program policy when the antibiotic (a substance used to kill bacteria and to treat infections) did not meet Loeb's or McGeer's Criteria (criteria used to determine appropriate use of antibiotics) for two of three sampled residents: 1. Resident 154 for ceftriaxone (antibiotic used to treat bacterial infections) 2. Resident 29 for cephalexin (another antibiotic used to treat bacterial infections). These deficient practices had the potential to increase antibiotic resistance and provide antibiotics without justification. Findings: 1. During a review of Resident 154's admission Record, the record indicated Resident 154 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including respiratory failure with hypoxia, tracheostomy (an opening surgically created through the neck into the trachea [windpipe] to allow direct access to the breathing tube), and gastrostomy (a surgical opening…

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 respect dignity for one of two residents (Resident 119) who were under hospice care by not providing oral care when resident 119's teeth covered with brown, sticky matters. This failure has the potential to result in aspiration, tooth decay, pain, and infection, compromising Resident 119's comfort, dignity and overall health. Findings: During a review of Resident 119's admission Record, the admission Record indicated the facility admitted Resident 119 on 8/14/2020 with diagnoses including arteriosclerotic heart disease (a condition that occurs when the coronary arteries narrow or become blocked) and Wernicke's encephalopathy (a brain disorder caused by a severe lack of vitamin B1). During a review of Resident 119's History and Physical (H&P), dated 1/26/2025, indicated, Resident 119 did not have the capacity to understand and make decisions. During a review of Resident 119's Minimum Data Set (MDS- a resident assessment tool), dated 11/14/2024, indicated Resident 119's cognitive skills (the mental abilities…

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 the necessary care and services to attain or maintain the highest practicable physical well-being for one of three sampled residents (Resident 55) by failing to: 1. Follow the facility policy and procedure to monitor and document assessments and interventions provided to Resident 55 during change of condition (COC). 2. Not creating and implementing a patient centered care plan for actual weight loss. 3. Assess Resident 55's continued weight loss. These deficient practices resulted in Resident 55 requiring a gastrostomy (g-tube: a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) to prevent further weight loss. Findings: During a review of Resident 55's admission record the admission record indicated Resident 55 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, protein-calorie malnutrition, major…

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

Based on interview and record review, the facility failed to ensure one out of three sampled residents (Resident 188) had an adequate diagnosis and did not receive unnecessary antipsychotic (altering brain chemistry to help reduce psychotic symptoms like hallucinations, delusions and disordered thinking) medications. This deficient practice placed Resident 188 at risk for harmful side effects of antipsychotic medication including sedation (a decrease in awareness and a decrease in response to external stimulation), drowsiness (sleepy), dizziness, weakness, problems with movement, and changes in weight. Findings: During a review of Resident 188's admission record, the admission record indicated Resident 188 was admitted to the facility 12/6/2024 with diagnoses of gastrostomy tube (GT, a feeding tube), muscle wasting, non-Hodgkin lymphoma (cancer), tracheostomy tube (an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs), and multiple pressure ulcers. Resident 188's admission record did not indicate Resident 188 had any diagnosis…

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 follow their policy and procedure (P/P) titled Antipsychotic Medication Use by failing to ensure one out of eight sampled residents (Resident 184) had complete physicians orders for psychotropic medications (any drug that affects behavior, mood, thoughts, or perception) including a specific diagnosis. This deficient practice placed Resident 184 at risk for receiving unnecessary medications (medications without adequate indication for use). Findings: During a review of Resident 184's admission Assessment, the admission Assessment indicated Resident 184 was admitted to the facility 9/16/2024 with diagnoses of unspecified dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain) with behavioral disturbance, unspecified mood disorder (a mental health condition that primarily affects your emotional state), and unspecified psychosis (a severe 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 ensure the registered dietician (RD) was competent regarding assessment and reassessment of residents with severe weight loss for one of ten sampled residents (Resident 188), and the RD failed to attend interdisciplinary (an approach to healthcare that integrates multiple disciplines through collaboration) team meetings at the facility. This deficient practice had the potential to cause continued weight loss for Resident 188. Resident 188 had severe weight loss (a weight loss greater than 5% in one month, greater than 7.5% in 3 months, and greater than 10% in 6 months) of 25.8 lbs. or 21.6% in 60 days since admission on [DATE]. This deficient practice placed all 181 Residents at risk for weight loss. Cross reference: F692 Findings: During a review of Resident 188's admission record, the admission record indicated Resident 188 was admitted to the facility 12/6/2024 with diagnoses of gastrostomy tube (GT, a feeding tube), muscle wasting, non-Hodgkin…

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, cleaning products used by housekeeping staff were effective against Candida auris ([C. auris] a fungus that can cause severe, often multidrug-resistant infections). This deficient practice resulted the facility's use of an ineffective cleaning agent against C. auris during the facility's ongoing C. auris outbreak (two or more linked cases of the same illness). This deficient practice had the potential for C. auris to survive on surfaces in the facility and spread to other residents. Findings: During an observation of the facility's housekeeping closet and a concurrent interview with the housekeeping staff (HK 1) on 12/16/2024 at 1 p.m., two cleaning agents, Virex Plus and One Step Disinfectant Cleaner and Deodorizer were observed in the housekeeping closet. HK 1 stated the two cleaning agents in the housekeeping closet were the cleaners used to clean the rooms on the subacute unit (a unit where a patient requires more intensive licensed skilled nursing care). During an interview on 12/16/2024 at 1:11…

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 care plan and/develop a care plan based on an accurate assessment of for one of three residents (Resident 1) after Resident 1 was found sitting on the floor and following Resident 1's fall and fracture (break of the bone) to his nose. These deficient practices resulted in Resident 1's care needs not being addressed and/or addressed inaccurately and had the potential to result in a delay of 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 diagnoses of dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and schizoaffective disorder (a mental illness which affects a person's mood and behavior). During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 6/12/2024, the MDS indicated Resident 1's cognition (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 Psychiatrist Evaluation Progress notes and General Acute Care Hospital (GACH) records were available in the clinical record for one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1's clinical records being incomplete and had the potential for non-continuity of 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 diagnoses of dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and schizoaffective disorder (a mental illness which affects a person's mood and behavior). During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 6/12/2024, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses)…

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 include one of three residents (Resident 1) and/or his Responsible Party (RP 1) in an Interdisciplinary Team ([IDT] a group of professionals with different areas of expertise who work together to achieve a common goal or meet the needs of a resident) Conference when Resident 1 was found sitting on the floor on 7/1/2024. This deficient practice resulted in RP 1 not being aware of Resident 1's change of condition (COC) or their ability to provide input regarding Resident 1's care. This deficient practice had the potential for Resident 1's care needs to go unmet. 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 dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and schizoaffective disorder (a mental illness which affects a person's mood and behavior). 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 implement their Covid-19 (highly contagious respiratory infection) policy by failing to conduct contact tracing testing (testing those who were close contacts [sharing the same indoor airspace for a cumulative total of 15 minutes or more over a 24-hour period ]on exposed staff for Covid-19 when four of four residents (Resident 2) tested positive for COVID-19 on 5/21/2024 and 5/22/2024. These deficient practices had the potential to result in undiagnosed or delayed diagnosis of Covid-19 within the facility which does not mitigate the spread of Covid-19 in the facility. Findings During a review of Resident 2's admission Record, the record indicated Resident 2 was admitted on [DATE] with the diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a review of Resident 2's Minimum Data Set ([MDS]- a standardized assessment and care screening tool) dated 5/15/2024, the MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow up on missed laboratory (lab) tests for one of three sampled residents (Resident 1) when Resident 1 had lab tests ordered on 5/6/2024 but were not collected by the lab. This deficient practice placed Resident 1 at risk for undiagnosed medical problems due to the lack of monitoring lab test values. Findings During a review of Resident 1's admission Record, the record indicated Resident 1 was admitted on [DATE] with the diagnosis including schizoaffective disorder (a mental health condition where resident has a different perception or reality). During a review of Resident 1's Minimum Data Set ([MDS- a standardized assessment and care screening tool) dated 5/10/2024, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired. During a review of Resident 1's Physician order dated 4/16/2024, the order indicated the following labs to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the gastrostomy tube ([GT] a tube which is inserted through the wall of the abdomen directly into the stomach to give medications, fluid, and liquid food to a patient) dressing (woven cotton fabric used to provide a protective barrier between the GT site and the skin which helps prevent maceration [a softening and breaking down of skin resulting from prolonged exposure to moisture]) was replaced when it fell off for two of three sampled residents (Resident's 1 and 2). These deficient practices resulted in Resident's 1 and 2's dressing not being on the GT site, to protect the skin, as ordered and had the potential for Resident's 1 and 2 to have a decline in skin integrity. 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 diagnosis including acute (sudden) and chronic (over time) respiratory failure (when the lungs can't release…

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 Preadmission Screening and Resident Review (PASRR is guided by federal regulations that require all individuals being considered for admission to a Medicaid-certified nursing facility (NF) level II evaluation was completed for three of five sampled residents (Resident 135,142 and Resident 175) who were diagnosed with mental disorder (MD). This deficient practice had the potential for Resident 135,142 and 175, not receiving appropriate behavioral services. Findings: A . During a record review of Resident 135's admission Record, the admission Record indicated the resident was initially admitted on [DATE] and was readmitted on [DATE] with diagnoses that included major depressive disorder ( mood disorder that causes persistent feeling of sadness, loss of interest which could interfere in normal tasks of daily living), unspecified psychosis( variety of mental health conditions that can cause a person to have a distorted experience of reality),…

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 and interview, the facility failed to have garbage container in sanitary conditions without lids to cover three (3) outside garbage dumpsters for 179 out of 179 sampled residents. This deficient practice had the potential to harbor and feed pests into the entire facility leading to spread of infectious disease and residents feeling ill. Findings: During a concurrent observation and interview on 2/22/2024, at 11:10 a.m., with the Dietary Supervisor (DS), the outside kitchen garbage dumpsters were observed. Two outside garbage dumpsters were observed with overflowing trash without lids on either dumpster. The DS stated that all three garbage dumpsters should be completely covered with lids so that pests like do not get inside of the garbage because the pests can carry diseases. During a review of the facility's policy and procedure (P&P) titled, Waste Control and Disposal, dated 2019, the P&P indicated, outside garbage bin should be kept closed at all times and surrounding area must be kept clean.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain respect and dignity on two of four residents (Resident 65 and Resident 142) by CNA standing over the resident while assisting them during a meal. This failure had the potential to result in decreased self-esteem and self-worth on Resident 65 and Resident 142. Findings: During a record review of Resident 65's admission Record, the admission Record indicated Resident 65 was initially admitted on [DATE] and was readmitted on [DATE] to the facility with diagnoses that included functional quadriplegia (complete immobility due to severe disability or frailty from another medical condition without injury to the brain or spinal cord), palliative care( specialized medical care that focuses on providing relief from pain of a serious illness) and bipolar disorder(mental disorder associated with episodes of mood swings causing unusual shifts in a person's mood , energy and activity level). During a record review of Resident 65's Minimum Data…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 19 and Resident 63) were free of unnecessary physical restraint, as evidenced by: 1. Resident 19 having bilateral upper side rails with two wedge pillows (provides side support, helps to alleviate pressure, and prevent residents from slipping down the bed) underneath the fitted sheets by the leg. 2. Resident 63's bed was against the wall on the right side with bilateral upper side rails on the left side of the bed. These deficient practices placed Resident 19 and 63 at risk for injury and potential for entrapment (event when an individual is trapped or entangles in the spaces of the bed rail). a. During a review of Resident 19's admission Record, indicated the Resident 19 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including unspecified psychosis (disconnection from what is real), major depressive disorder (MDD: decreased or loss of interest in pleasurable…

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 dietary personnel attended scheduled Interdisciplinary Team meetings ([IDT] a group of professional and direct care staff that have primary responsibility for the development of a plan of care for an individual resident receiving services) for two of eight (8) residents (Residents 34 and 160) who were losing weight in the facility by failing to ensure dietary personnel: 1.Collaborate with various team members during IDT weight loss meetings. 2.Provide effective communication and feedback during IDT meetings to staff members for residents who were losing weight in the facility. 3.Address nutritional needs of the residents during the IDT meeting. These deficient practices placed residents at risk for further malnutrition, continued weight loss and feelings of depression and had the potential for a decline in Residents' 34 and 160 overall qualities of life through proper nutrition and personalized care. Findings: A. During a review of Resident 34's admission Record (face sheet) dated 9/4/2020, the face sheet 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 failed to provide the same regular diet that consisted of diced carrots, red beans and rice, and sliced beef as a pureed diet that consisted of pureed carrots, pureed rice, no red beans, and pureed beef for seven (7) Residents 24, 51, 81, 112, 122, 123, and 131 out of 179 sampled residents. This deficient practice had the potential to result in seven residents not receiving the same week 4 pureed diet as the residents who received a regular diet and not receiving the same calories or nutritional value of their diet ordered per physician order. Findings: During a review of Resident 24's, admission Record, dated 2/23/2024, indicated Resident 24 was originally admitted [DATE] and re-admitted [DATE]. Resident 24 diagnosis includes unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and dysphagia (swallowing difficulties). During a review of Resident 24's Order Summary Report…

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 safe, sanitary environment by maintaining proper infection control practices and procedures in the facility by failing to: 1. Ensure residents' clothes were stored in a clean and hygienic (maintaining health and preventing disease, especially by being clean) manner. 2. Ensure boxes were not stored on the floor in the laundry room. 3. Ensure linen and clothes were washed in a safe and sanitized (disinfected) manner. 4. Ensure staffed performed hand hygiene during medication pass for Resident 140. 5. Ensure gloves for resident use were not stored in staff pockets when providing care to Resident 28. 6. Ensure staff performed hand hygiene before and after entering resident's rooms. 7. Ensure staff performed hand hygiene when passing lunch trays. 8. Ensure the licensed nurse clean and sanitized the blood pressure cuff for Resident 119. These deficient practices placed all residents in the facility at risk for infection, cross…

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 accurately assess and code the Minimum Data Set (MDS, a standardized assessment and care-screening tool) assessment for one of seven sampled residents (Resident 59) by failing to ensure the MDS was coded correctly to include impairment of the arm on one side of the body for functional limitations in range of motion ( limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury). This deficient practice 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 59. Findings: During a concurrent observation and interview on 2/20/2024 at 2:33 p.m., in Resident 59's room, Resident 59 was observed sitting upright in the bed with the left ankle crossed over the right knee. Resident 59'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, interview, and record review, the facility failed to initiate a comprehensive person-centered care plan when the physical restraint hand mitten was implemented on 8/18/2023 for Resident 111 who had a hand mitten on right hand. This deficient practice had the potential for the staff not knowing how to care for residents with a physical restraint and Resident 111 sustaining an injury from the hand mitten physical restraint. Findings: During a review of Resident 111's admission Record, dated 2/23/24, the admission record indicated, Resident 111 was originally admitted on [DATE] and readmitted [DATE]. Resident 111's diagnosis includes acute respiratory failure with hypoxia (a condition where you don't have enough oxygen in the tissues in your body), Encounter for attention to tracheostomy (a surgically created hold in your windpipe that provides an alternative airway for breathing), dependence on respirator ventilator status (the need for mechanical ventilation for more than six hours per day…

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 review and revise the comprehensive care plan for four of seven sampled residents (Residents 59, 112, 124, and 140) by failing to ensure the following: a. For Resident 59, the facility failed to update the care plan to remove the intervention for a Restorative Nursing Aide program (RNA program, nursing aide program that uses restorative nursing aides [RNA] to help residents maintain their function and joint mobility) for range of motion (ROM, full movement potential of a joint) exercises for the right arm and right-hand splint (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) application when the RNA order was discontinued. b. For Resident 112, the facility failed to update the care plan interventions to: 1.Include an RNA program for ROM exercises to both legs. 2.Discontinue the Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) plan of care when…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the licensed nursing staff failed to follow professional standards of practice for one of one sampled resident (Resident 140) by: 1.Not flushing (act of cleaning) the medication pre and post administering medication through a gastrostomy (g-tube: surgical opening made into the stomach to provide nutritional support). 2.Mixing each medication using the syringe. These deficient practices have the potential to cause additional health complications such as dislodgement of g-tube or the resident not receiving all the necessary doses for the medications. Findings: During a review of Resident 140's admission Record, indicated the resident was admitted initially on 9/2/2021 and readmitted on [DATE] with diagnoses that included acute and chronic respiratory failure with hypoxia, aphasia (inability to express speech cause by brain damage), tracheostomy (surgical airway to help air and oxygen reach the lungs) and gastrostomy (g-tube), hypertension (high blood pressure),…

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 three sampled residents (Resident 107) was provided an alternate means to communicate with a language that the resident was able to understand. This deficient practice had the potential to place Resident 107 at risk for feeling of frustration, isolation, and not able to communicate with the staff his needs which could lead to a delay on receiving appropriate care and services. Findings: During a record review of Resident 107's admission Record, the admission Record indicated the resident was admitted on [DATE] to the facility with diagnoses that included dementia(loss of cognitive functioning such as thinking, remembering and reasoning which can affect and interfere with daily life and activities), Alzheimer's disease( a brain disorder that slowly destroys memory and thinking skills and eventually the ability to carry out the simplest tasks) and diabetes ( high blood sugar). During a record review of Resident 107's Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure wheelchair bound (unable to walk) resident get up in bed to attend out of the room group activities for one of nine sampled residents (Resident 29) for 60 days. This failure resulted in Resident 29 unable to attend activities of her choice and had the potential to cause psychosocial harm, like depression (feeling of sadness) and feeling of isolation. Findings: During a review of Resident 59's admission Record indicated Resident 59 was admitted to the facility on [DATE] with diagnoses including hemiplegia (a condition caused by brain damage or spinal cord injury that leads to paralysis on one side of the body), anoxic brain syndrome (a restriction on the oxygen being supplied to the brain) and gastro-esophageal reflux disease ([GERD] when stomach acid repeatedly flows back into the tube connecting your mouth and stomach). During a review of Resident 59'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of three sample residents (Resident 65) was properly positioned in the bed during meal assistance. This deficient practice had the potential to place Resident 65 at risk for choking and aspiration (when food, liquid, or other material enters a person's airway and eventually the lungs by accident which could result to serious health issues like pneumonia, infection in the lungs). Findings: During a record review of Resident 65's admission Record, the admission Record indicated the resident was initially admitted on [DATE] and was readmitted on [DATE] to the facility with diagnoses that included palliative care( specialized medical care that focuses on providing relief from pain of a serious illness), dementia(a group of thinking and social symptoms that interfere with daily functioning), and bipolar disorder(mental disorder associated with episodes of mood swings causing unusual shifts in a person's mood , energy and activity…

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 secure a medication in a locked storage area for one of eight (8) residents (Resident 59) by leaving a Protonix (treats heartburn, stomach ulcers, reflux disease, or other conditions that cause too much stomach acid) 40 milligrams ([mg] unit of measurement) before breakfast daily at Resident 59's bedside unattended, This deficient practice placed Resident 59 at risk for medication errors and had the potential for unsafe medication administration to other residents, staff, or visitors. Findings: During an initial tour to the facility on 2/20/2024 at 11:24 a.m. during the initial tour, Protonix 40 mg tablet was observed in a medicine cup, left unattended on the bedside table of Resident 59. During a review of Resident 59's admission Record (face sheet) dated 4/3/2012, the face sheet indicated Resident 59 was admitted to the facility with diagnoses of hemiplegia (a condition caused by brain damage or spinal cord injury that leads to paralysis on one side of the body), anoxic brain syndrome (a process that begins…

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 one of two (Resident 149) sampled resident's allergy preference, resulting in Resident 149 receiving chocolate shake when Resident 149 is allergic to chocolate. This deficient practice had the potential to cause an allergic reaction that could have been detrimental to the resident's well-being. Findings: During a review of Resident 149's admission Record, indicated the resident was admitted initially on [DATE] and readmitted on [DATE] with diagnoses that included dementia (impaired ability to think or make decisions), severe protein-calorie malnutrition, encephalopathy (brain disease that alters brain function), and gastroesophageal reflux disease (GERD: stomach acid repeatedly flows back into the tube connecting the mouth and stomach). During a review of Resident 149's Minimum Data Set (MDS-standardize assessment and care screening tool) dated [DATE], indicated Resident 149 was cognitively (mental action or process of acquiring…

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

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1.A bowl of ground beef was stored on the second shelf from top shelf and a bag of cabbage and bag of broccoli was stored below the raw ground meat. 2.A bowl of sliced sausage on the second shelf and a bowl of onions on the same shelf. 3.A bowl of onions and cabbage stored on the third shelf below the diced sausage in the walk-in refrigerator for 179 out of 179 sampled residents. 4. Dietary cook carried a bowl of sliced sausage covered with plastic stack on top of a bowl of onions while bringing it to the stove area. 5. One box of beans was stored without covering in the dry food storage area. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses, and parasites) in 179 out of 179 residents who received food from the…

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

Based on interview and record review, the facility's Quality Assessment and Assurance ([QAA] to develop and implement appropriate plans of action to correct identified quality deficiencies) and Quality Assurance Performance Improvement ([QAPI] designated to bring about constant and measurable improvement in the services provided at the facility for continual improvement of quality care) committee failed to: 1.Maintain effective systems in place to obtain and use feedback for facility issues submitted by direct care staff, residents, and resident representatives. 2. Monitor, review and analyze data for performance improvement of facility issues such as falls, call lights, Infection Control, and weight loss. 3. Failing to have a QAPI committee meeting December 2023. These deficient practices have the potential to not identify systematic approach to improve services to the residents. Findings: During a concurrent interview and record review on 2/23/2024 at 1:06 p.m. with the Administrator (ADM), the ADM stated the facility does not have any evidence of monitoring facility issues. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement their infection prevention and control program (IPCP) during a Norovirus (contagious virus that spread through touching and eating contaminated surfaces and food and causes vomiting and diarrhea (watery stool) outbreak (OB: sudden increase in occurrences of a disease) by: 1. Not having the contact precaution (procedure used to reduce the spread of infections through direct or indirect contact) signage in front of the isolation rooms. 2. Certified NUrse Assistant (CNA) 1, CNA 2, CNA 3, and CNA 4 not performing hand hygiene before entering and exiting the isolation rooms. These deficient practices resulted in 15 residents and two staff members who exhibits signs and symptoms of Norovirus and two residents (Resident 1 and Resident 7) tested positive. Findings: a. 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,…

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 ensure staffnot wearing an isolation gown while walking in the hallway. This deficient practice had the potential to spread infection throughout the facility. Findings: During an observation of medication pass on 10/31/2023 at 9:16 a.m., Licensed Vocational Nurse (LVN 2) was standing in front of room [ROOM NUMBER] with a contact precaution ( steps that a healthcare facility visitors and staff need to follow before going into a resident's room )sign in front of the doorway, LVN 2 was observed wearing an isolation gown while preparing medications. LVN 2 stopped preparing the medication and walked away to the opposite side of the hallway wearing the same isolation gown, LVN 2 looked around the corner then went back in front of room [ROOM NUMBER] and continue preparing medications still wearing the same isolation gown. During an interview on 10/31/2023 at 09:20 a.m. with LVN 2 , LVN 2 stated I was preparing medication for resident 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.

Based on interview and record review the facility failed to report the Coronavirus disease ([Covid-19] a very contagious infectious disease) outbreak (at least one resident is confirmed positive with Covid-19), with four residents positive for Covid-19 (Resident 6,7,8,9) out of one hundred eighty six (186) total residents, to the California Department of Public Health (CDPH) Licensing and Certification (L&C), within twenty four hours of the start of the outbreak on 10/10/2023. This deficient practice resulted in a delay of the CDPH investigation and potentially increased the risk of further spreading Covid-19 to other residents and staff. Findings: During a review of the facility's Covid-19 Positive Residents October 2023 and the Covid-19 Positive Staff October 2023, the records indicated: a. On 10/10/2023 there were 4 residents (Resident 6,7,8,9) and no staff positive for Covid-19. b. On of 10/23/2023, there was a cumulative total of 18 positive resident and 6 positive staff members positive for Covid-19. During an interview with the Infection Preventionist (IP) on 10/25/2023 at…

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

Based on observation, interview, and record review, the facility failed to ensure safe food preparation practices in the kitchen when: A. Ice machine was not maintained in a sanitary manner and proper sanitation practice not followed to prevent the growth of microorganism resembling mold. This deficient practice had the potential to cross-contaminate food and put 156 Residents, staff, and visitors at risk for food borne illness. B. Multiple flies flying around in the kitchen and overflowing trash bin in the trash area These failures has 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 for medically compromised residents who is receiving food from the kitchen. Findings: A. During a concurrent observation in the kitchen and interview on 8/30/2023 at 9:40a.m., with the Dietary Aide (DA) and Dietary Supervisor(DS)the DS opened the ice machine and there was grime build up on the right and left side corner of the ice bin. The DS stated, he is responsible in cleaning 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.