Coral Cove Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure its residents with or without limited range of motion (ROM - movement of the joints) received appropriate treatment and services to increase, prevent, or maintain the ROM mobility for four of seven residents (Resident 7 , Resident 8, Resident 90, and Resident 54) with physician's orders for Restorative Nursing Assistant (RNA) exercises.These deficient practices placed residents with orders for RNA exercises at risk for decline in physical function and at risk for contractures.Findings: a. During a review of Resident 7's admission Record, the admission record indicated Resident 7 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnosis including quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), rotator cuff (group of muscles and tendons that surround the shoulder joint) tear or rupture of right shoulder, and contracture (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 maintain acceptable nutritional parameters for one of three sampled residents (Resident 77) when:1. The facility failed to notify the physician on 7/29/2025 after Resident 77 had a significant weight loss (weight loss greater than 10 percent [%] in 6 months).2. The facility failed to ensure the Registered Dietician ([RD] a health professional who has special training in diet and nutrition) recommendations made on 7/29/2025 were implemented in a timely manner and not implemented on 8/4/2025, six days after the significant weight loss was identified. Resident 77's order for Ensure Enlive (nutritional supplement) three times a day was not ordered, and Resident 77 did not receive the supplement until 8/5/2025. Resident 77's order for Megestrol Acetate Suspension (appetite stimulant) was placed and carried out on 8/6/2025. 3. The facility failed to ensure Resident 77's amount eaten for every meal was recorded from 7/15/2025 to 8/12/2025, 29 out of 87 meals…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not provide respiratory care and services consistent with professional standards of practice to three of three residents (Resident 8, 63, and 82) when the facility failed to:a. Ensure Resident 8's oral hygiene and tracheostomy (an opening surgically created through the neck into the trachea [windpipe] to allow air to fill the lungs) care was administered as ordered.b. Ensure Resident 63 received 2 liters of supplemental oxygen (element essential for life) as physician ordered.c. Ensure Resident 82's humidifier (medical device used to humidify supplemental oxygen) was labeled with a date to ensure it was changed timely.These deficient practices had the potential to result in a delay in care, infection and unsafe administration of oxygen in the facility.Findings: a. During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was originally admitted to the facility on [DATE] and with diagnosis including chronic…

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

Based on observation, interview and record review, the facility failed to: 1.Ensure food is properly stored with label and open date. 2.Ensure expired food is discarded. 3.Monitor the temperature of the hydration freezer. These failures had the potential to expose all residents to food-borne illnesses (any illness resulting from ingestion of food contaminated with bacteria, viruses, or parasites) and put residents at risk for cross contamination (unintentional transfer of harmful bacteria from one object to another) which could lead to nausea, vomiting or diarrhea. Findings: During a concurrent observation and interview with the Dietary supervisor (DS) in the kitchen on 8/12/2025 at 8:14 a.m., the following were observed: a. Two Italian dressings with a use by date of 6/30/2025 in the dry storage.b. One container of chili oil with a use by date of 8/8/2025 in the refrigerator.c. One shelf of unlabeled popsicles in individual clear packaging and two shelves of unlabeled popsicles in opaque packaging without expiration dates in the hydration freezer. The DS stated the hydration…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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) Ensure to offer the Corona virus disease ([COVID-19] contagious infectious disease) vaccination (medications used to prevent diseases usually given by injection or by mouth) to one of five sampled residents (Resident 95).b) Ensure to provide documented evidence of all employees, including consultants and physicians, COVID-19 vaccination status and the provision of education on benefits and potential side effects and offering of the 2024 to 2025 COVID-19 vaccine. This failure had the potential to result in staff and residents contracting COVID-19 which can cause serious illness, hospitalization, and death. Findings: During a review of Resident 95's admission Record, the admission Record indicated Resident 95 was admitted to the facility on [DATE] with diagnoses including a history of COVID-19 and cerebral infarction (stroke - loss of blood flow to a part of the brain). During a review of Resident 95's Minimum Data Set ([MDS] a resident assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the physician of Resident 62s Electroencephalogram ([EEG] - is a test that measures the electrical activity in the brain, called brain waves, using small metal disks called electrodes that are attached to the scalp) test was incomplete. This deficient practice had the potential for Resident 62 to have a delayed diagnosis and treatment of neurological conditions placing Resident 62 at risk for worsening symptoms.Findings:During a review of Resident 62's admission Record (Face Sheet), the admission Record indicated Resident 62 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses anoxic brain damage (a complete lack of oxygen to the brain, leading to cell death and lasting harm, even if it's only for a few minutes) and dementia (a progressive state of decline in mental abilities). During a review of Resident 62's minimum data set (MDS: a resident assessment tool), dated 6/25/2025, the MDS indicated Resident 62…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Notice of Proposed Transfer and Discharge Form (written notification to the resident or responsible party that included the reason for the transfer or discharge, where the resident will be transferred or discharged to, how to contact the State Long Term Care Ombudsman, and how to appeal the transfer or discharge if necessary) was provided timely to the resident's responsible party (RP) 1 for one of two residents (Resident 90). This deficient practice had the potential to result in the RP 1's ability to contact the State Long Term Care Ombudsman (public advocate) on how to appeal the transfer if needed.Findings: During a review of Resident 90's admission Record, the admission Record indicated Resident 90 was originally admitted to the facility on [DATE] with diagnosis including chronic respiratory failure (a long-term condition where the respiratory system fails to maintain adequate gas exchange), dependent on a ventilator (a medical device…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately document Restorative Nurse Assistant (RNA- a Certified Nurse Assistant (CNA) who received special training to provide range of motion (ROM) and daily activities under the guidance of nurses and therapists) services on the Minimum data set (MDS - a resident assessment tool), for one of three sampled residents (Resident 54). This failure had the potential to result in Resident 54 to have a delay of care. Findings: During a review of Resident 54's admission record, the admission record indicated Resident 54 was initially admitted to the facility on [DATE] with diagnoses including obstructive hydrocephalus (a blockage in the brain causing increased pressure in the skull), anoxic brain damage (the brain does not receive any oxygen resulting in brain cell death), and contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion) of the right elbow and hand. During a review of Resident 54's Minimum Data Set (MDS - 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 update the care plan titled, Nutrition after significant weight loss (weight loss greater than 10% in 6 months) was identified on 7/29/2025 for one of three sampled residents (Resident 77).These deficient practices resulted in a delay in care and services to improve weight loss.Findings:During a review of Resident 77's admission record, the admission Record indicated Resident 77 was admitted to the facility on [DATE] with a diagnosis including chronic respiratory failure (a long-term condition where the respiratory system fails to maintain adequate gas exchange), acquired absence of stomach, tracheostomy (a surgical procedure that creates an opening in the trachea [windpipe] through the neck to allow for breathing) status, mild calorie protein-calorie malnutrition (nutritional status in which reduced availability of nutrients leads to changes in body composition and functions), diabetes mellitus (disorder where the body cannot regulate glucose or sugar…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two sampled residents (Resident 7) received treatment and care in accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial needs by: Failing to follow up with a referral consultation for rheumatology (medical specialty focused on the diagnosis and treatment of disorders affecting connective tissues like bones, muscles, joints, and tendons [tissue connecting muscle to bone]) and neurology (medical specialty focused on diagnosis and treatment of disorders of the brain, spinal cord, and nerves), and a follow-up appointment in six weeks on 10/1/2024 for results.This deficient practice resulted in Resident 7 not being seen by a Rheumatologist since 10/1/2024, and was not informed about his X-ray (type of radiation that creates pictures of the inside of your body) results that was done in 5/22/2025. Findings: During a review of Resident 7s admission Record, the admission record…

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

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 dependent resident's (Resident 90) toenails were not dirty and thick. This deficient practice had the potential to result in infection, a decreased quality of life and negatively impact the residents' self-esteem. Findings:During a concurrent observation and interview on 8/12/2025 at 9:45 a.m. in Resident 90's room, with Registered Nurse (RN)1, Resident 90 was noted with dirty, discolored and thickened toenails. RN 1 stated the Resident 90's toenails were dirty and thickened and the treatment nurse should be looking at it and the wound doctor should be following it up. During a review of Resident 90's admission Record, the admission Record indicated Resident 90 was originally admitted to the facility on [DATE] with diagnosis including chronic respiratory failure (a long-term condition where the respiratory system fails to maintain adequate gas exchange), type 2 diabetes (a disorder characterized by difficulty in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of 14 sampled residents (Resident 98 and Resident 101) who are fed by a gastrostomy tube (GT - a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration) were following appropriate standard of practice by:a. Failing to ensure the tube feeding was disconnected from Resident 98 when the feeding was turned off.b. Failing to follow the care plan and hold the tube feeding while Resident 101 was lying flat. This deficient practice had the potential to cause dislodgement for Resident 98 and result in aspiration (inhalation of foreign materials) which can lead to pneumonia (a lung infection) for Resident 101. Findings: a. During a review of Resident 98's admission Record (Face Sheet), the admission Record indicated Resident 98 was initially admitted on [DATE] and was readmitted on [DATE] with diagnoses including gastrostomy tube (GT – a flexible tube surgically inserted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident who received dialysis (process of removing waste products and excess fluid from the body) received treatment as ordered for one out of one sampled resident (Resident 10). This deficient practice had the potential to delay provision of dialysis treatment. Findings:During a review of Resident 10's admission Record (Face Sheet), the admission Record indicated Resident 10 was initially admitted on [DATE] and was readmitted on [DATE] with diagnoses including dialysis, Type 2 (II) Diabetes Mellitus (DM: a chronic disease that affects how the body processes sugar), and congestive heart failure (CHF: a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling).During a review of Resident 10's history and physical (H&P) dated [DATE], the H&P indicated Resident 10 has the capacity to understand and make decisions.During a review of Resident 10's Minimum Data Set ([MDS] a resident assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a Licensed Vocational Nurse (LVN 3) remained competent in medication administration for one of one residents (Resident 119) by not re-evaluating LVN 3's competency skills when Resident 119 expressed concerns of receiving more pills than her usual medication pass. This failure had the potential to lead to medication errors for Resident 119 and all residents.Findings:During a review of Resident 119's admission Record, the admission Record indicated the facility admitted Resident 119 on 9/6/2022, readmitted on [DATE] and discharged on 5/1/2025. The admission record indicated Resident 119 had diagnoses including hypertension (high blood pressure) and neuropathy (nerve pain). During a review of Resident 119's History and Physical (H&P), dated 4/1/2025, indicated, Resident 119 had the capacity to make a decision.During a review of Resident 119's Minimum Data Set (MDS- a resident assessment tool), dated 5/1/2025, indicated Resident 119'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 medications were administered on time for one of four sampled residents (Resident 7). This failure had the potential to result in Resident 7's pain not being managed or experiencing adverse medication side effects. Findings: During a review of Resident 7s admission Record, the admission record indicated Resident 7 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnosis including quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), rotator cuff (group of muscles and tendons that surround the shoulder joint) tear or rupture of right shoulder, and contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of right and left knee, right and left hand, and left elbow. During a review of Resident 7's history and physical (H&P) dated 1/20/2025, the H&P indicated Resident 7 has the capacity to understand and make decisions.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurate medical records for two of three residents (Resident 30 and 90) when the facility:A. Failed to ensure Certified Nurse Assistant (CNA) 5 accurately documented in Resident 30's chart.B. Failed to ensure Restorative Nurse Assistant (RNA) 2 accurately documented in Resident 90's chart.C. Failed to ensure RNA 2 documented the amount of time spent with the Resident 90, Resident 90's tolerance to service rendered, and signature initial of RNA providing the services in each occurrence.These deficient practices resulted in an inaccurate depiction of services and care rendered and lack of documentation in the medical record.Findings: A. During a review of Resident 30's admission record, the admission record indicated Resident 30 was initially admitted to the facility on [DATE] with diagnoses including cerebral ischemia (reduced blood flow to a part of the brain resulting in brain damage) and benign prostatic hyperplasia (BPH- enlarged prostate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Infection Prevention Nurse (IPN) incorrectly identified residents to receive antibiotics (medication to treat infection) that did not meet Mc Geer's criteria (standardized tools with definitions for infections to aid if antibiotic use was appropriate) for two of three residents (Resident 11 and 47).This deficient practice resulted in the improper implementation of the antibiotic stewardship program (coordinated program that promotes the appropriate use of antibiotics by clinicians).Findings: A. During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was originally admitted to the facility on [DATE] with a gastrostomy tube ([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).During a review of Resident 11's Minimum Data Set ([MDS] a resident assessment tool) dated 8/7/2025, the MDS indicated Resident 11's cognition (ability to think…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to offer a pneumococcal vaccination (protects against pneumococcal disease, a serious infection that can cause pneumonia) for one of five sampled residents (Resident 95).This failure had the potential to result in Resident 95 contracting the pneumococcal disease. Findings: During a review of Resident 95's admission Record, the admission Record indicated Resident 95 was admitted to the facility on [DATE] with diagnoses including a history of COVID-19 and cerebral infarction (stroke - loss of blood flow to a part of the brain). During a review of Resident 95's Minimum Data Set ([MDS] a resident assessment tool) dated 8/6/2025, the MDS indicated Resident 95's cognition (ability to think and reason) was severely impaired. The MDS indicated Resident 95 needed set-up assistance with eating, oral and personal hygiene, needed substantial assistance (helper does more than half the effort to complete the task) with showering.During a concurrent interview and record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to readmit one of three sampled residents (Resident 3) after Resident 3 was transferred to a General Acute Care Hospital (GACH) to evaluate a distended (swollen or enlarged) abdomen with pain on 6/7/2025.This failure resulted in Resident 3 experiencing a prolonged stay at the GACH and frustration from not being able to return the facility which he considered to be his home. Findings: During a review of Resident 3's admission record, the admission record indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including paraplegia (loss of movement and/or sensation, to some degree, of the legs) and hydronephrosis (swollen kidneys due to blockage in the urinary tract). During a review of Resident 3's History and Physical (H&P), dated 1/31/2024, the H&P indicated Resident 3 was able to make decisions for activities of daily living. During a review of Resident 3's Minimum Data Set (MDS - a resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to review and revise a care plan for one of three sampled residents when Resident 2 was readmitted to the General Acute Care Hospital (GACH) on 6/23/2025 after being transferred to the GACH for aggressive behavior on 6/10/2025.This failure resulted in Resident 2 throwing a book at Resident 1 on 6/27/2025. Findings: During a review of Resident 2's admission record, the admission record indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including encephalopathy (damage or disease that affects brain function), schizophrenia (a mental illness that is characterized by disturbances in thought), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 2's History and Physical (H&P), dated 1/31/2024, the H&P indicated Resident 2 had fluctuating capacity and was able to make…

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

Based on interview and record review, the facility failed to ensure two Certified Nursing Assistants (CNAs 1 and 2) were provided training and orientation to work in the Subacute Unit (a specialized unit in a Skilled Nursing Facility [SNF] which offers more intensive care than standard long-term care but less than acute hospital care). The deficient practice had the potential for the lack of appropriate care to residents in the Subacute Unit. Findings: During an interview on 5/9/2025 at 6:48 a.m., CNA 1 stated she did not receive any training to float to the Subacute Unit. CNA 1 stated she does not feel safe providing care for the residents in the Subacute Unit. During an interview on 5/9/2025 at 6:49 a.m., CNA 2 stated she did not receive any training prior to floating to the Subacute Unit. CNA 2 stated when she worked in the Subacute Unit, she was scared and afraid that if she did something wrong, it would have negative effects on the residents. During a review of the facility ' s Staffing Assignment sheet dated 4/14/2025, the Staffing Assignment sheet indicated CNA 2 was assigned…

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

Based on interview and record review, the facility failed to ensure one of three sampled Certified Nursing Assistants (CNA 1) had an active license and/or certificate. The deficient practice resulted in CNA 1 working as a CNA without an active license and/or certificate. Findings: During a review of the California Department of Public Health (CDPH) License and Certification (L&C) Verification Detail Page obtained from https://cvl.cdph.ca.gov/SearchPage.aspx, the L&C website indicated there was no active certification for CNA 1. During a review of CNA 1 ' s California Nurse Aide Assessment Program (NNAAP) Examination Results Report dated 5/20/2024, the California NNAAP Examination Results indicated CNA 1 passed the California Nurse Assistant Skills Evaluation on 5/20/2024. The California NNAAP Results indicated once CNA 1 passed both written (or oral) and skills portion of the NNAAP examination, the results will be reported to the CDPH, and CNA 1 ' s name would be placed on the California Nurse Assistant Registry. The California NNAAP further indicated that the results will appear on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled Certified Nursing Assistants (CNA 1) certification was active and not expired. This deficient practice resulted in the CNA 1 working 10 shifts (from [DATE] to [DATE]) with an expired certification. Findings: During a review of the California Department of Public Health (CDPH) License and Certification (L&C) Verification Detail Page obtained from https://cvl.cdph.ca.gov/SearchPage.aspx, dated [DATE],the L&C page indicated CNA 1 ' s certification expired on [DATE]. During a review of the facility ' s Nursing Staff Assignment Sheets dated [DATE] to [DATE], the assignment sheets indicated CNA 1 worked 10 shifts from [DATE] to [DATE]. During an interview on [DATE] at 10:31 a.m., the Director of Staff Development (DSD) stated CNA 1was functioning as a CNA with her certification expired. The DSD stated after [DATE], CNA 1 was assigned to non-clinical roles because her certification was still expired. The DSD stated working with an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure adequate monitoring of targeted behaviors for the use of psychotropic medications was documented and psychiatry (medical specialty that diagnose, prevent, and teat mental health conditions) was notified when one of four sample residents (Resident 3) refused to take their medications. This deficient practice had the potential to result in delayed provision of necessary care and services. During a review of Resident 3 ' s admission record, the admission Record indicated Resident 3 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) [bipolar type]), violent behavior, and delusional (mental health condition in which a person cannot distinguish what is real and imagined). During a review of Resident 3 ' s History and Physical (H&P) dated 12/28/2024 the H&P indicated Resident 3 had fluctuating capacity 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 and interview, the facility failed to provide a functioning call light and place the call light in a reachable position for two of six sampled residents (Resident 10 and 13). This deficient practice had a potential for a delay in meeting the resident's needs for assistance and can lead to frustration, falls and accidents. During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was admitted to the facility on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body) following nontraumatic (not due to accident or injury) hemorrhage (blood vessel in brain breaks and bleed) affecting left dominant side, contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of muscle of left lower leg and arm, and cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and 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 their front door was alarmed to prevent a resident who was under conservatorship (a legal status in which a judge appoints a person [conservator] to manage the financial and personal affairs of a minor incapacitated person), who wandered (random or repetitive locomotion maybe goal directed, or non-goal directed) around the hallways in the facility, and was assessed incorrectly during her elopement evaluation, did not elope (act of leaving a facility unsupervised and without prior authorization) from the facility for one of three sampled residents (Resident 1). This deficient practice resulted in a care plan not being created for Resident 1 based on an incorrect elopement evaluation (12/24/2024) and no interventions in place to address Resident 1's elopement risk. Resident 1 eloped from the facility on 2/24/2025 between 6 a.m., when she was last seen during a blood pressure check, and 7 a.m., when she was not found in her room during morning…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 uphold residents ' rights. The facility failed to : a.Address and ensure the concerns of the resident council (group of residents who meet to discuss and advocate for improvements in care and quality of life at the facility) which were stated during the meetings held on 1/7/2025 and 2/10/2025 regarding delayed call lights response time occurring during the 11pm-7am shift. b. Ensure the Director of Staff Development (DSD) provided appropriate oversight to staff during the 11pm-7am shift as indicated in the facility job description Director of Staff Development. This deficient practice resulted in residents rights , including dignity not being upheld and placed residents at risk for a delay in care and services. Findings: a. During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including type 2 diabetes (DM-a disorder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents rights were maintained for one of three sampled residents (Resident 1), when the facility failed to notify Resident 1 ' s physician regarding a change of condition. On 12/3/2024, the Minimum Data Set (MDS) nurse witnessed Resident 1 holding Resident 2 hands away from him (Resident 1) and was informed by Resident 1 that Resident 1 was attempting to protect himself from being hit by Resident 2. This deficient practice resulted in Resident 1 ' s physician being unaware of the altercation between Resident 1 and Resident 2, causing a delay in needed assessments and services for Resident 1. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including type 2 diabetes( DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness, and traumatic partial…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a physical altercation between two of three sampled residents (Resident 1 and Resident 2), to the California Department of Public Health (CDPH), within two hours of the incident. On 12/3/2024, the Minimum Data Set (MDS a resident assessment tool) nurse witnessed Resident 1 holding Resident 2 hands away from him (Resident 1) and was informed by Resident 1 that Resident 1 was attempting to protect himself from being hit by Resident 2. The facility reported the incident on 2/6/2025 (65 days after the incident occurred). This deficient practice resulted in CDPH being unaware of the abuse incident and injury to Resident 1 and had the potential for a delay in CDPH ' s investigation and other abuse allegations to go unreported. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including type 2 diabetes(…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident centered comprehensive care plan was developed for one of three sampled residents (Resident 1) when on 12/3/2024, the Minimum Data Set (MDS) nurse witnessed Resident 1 holding Resident 2 hands and was informed by Resident 1 that Resident 1 was attempting to protect himself from being hit by Resident 2. These deficient practices resulted in a delay and care and services for Resident 1 placing Resident 1 at risk for decline in mental and psychosocial well-being. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including type 2 diabetes( DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness, and traumatic partial amputation (loss of foot due to injury or accident) of right foot. During a review of Resident 1's Minimum Data Set…

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

Based on observation, interview, and record review, the facility failed to ensure staffing information including actual number of staff and staff working was posted and placed and readily available to residents and visitors. This failure resulted in residents and visitors not being able to access accurate daily numbers of clinical staff taking care of residents. Findings: During an on observation on 1/29/2025 at 11:20 a.m., at the facility entrance, there was no visible daily staffing information including total number staff and actual hours worked on the receptionist desk. During an interview on 1/29/2025 at 11:26 a.m., with the Assistant Director of Nursing (ADON), the ADON stated the hours posted at the receptionist desk was the projected hours and did not include the actual number of staff hours or how many staff were working. During an interview on 1/29/2025 at 11:30 a.m. with the Director of Staff Development (DSD), the DSD stated the hours posted at the receptionist desk was the projected hours and did not include the actual number of staff hours. The DSD 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 interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was treated with dignity and respect when Resident 1 was not provided incontinence care due to insufficient staffing when Certified Nursing Assistant (CNA 1) was assigned to care for 82 residents. This failure resulted in Resident 1 calling the police (911) when she was not changed on 12/24/2025 from the 11 p.m. to 7 a.m. shift. This failure also had the potential for the other 81 residents in the facility to not receive care and/or a delay of care due to CNA 1 ' s inability to care for 82 residents by herself. 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 the diagnoses including respiratory failure (the respiratory system cannot adequately provide oxygen to the body). During a review of Resident 1 ' s Minimum Data Set (MDS – a federally mandated resident assessment tool) dated 10/22/2024, 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 failed to ensure the water management plan (a program that identifies and addresses hazardous conditions in a water system) was implemented. The facility failed to ensure: 1. The water management plan team (a group of individuals responsible for overseeing and implementing the facility's water management plan) met regularly to discuss issues related to water management in the facility. 2. Control measures (actions taken in the facility's water systems to limit growth and spread of Legionella [bacteria that causes disease such as pneumonia] which could include adding disinfectant, cleaning, and heating) were acceptable and being monitored, logs and documentation were accessible for review and discussed amongst during meetings. This deficient practice resulted in the inability to determine if there were issues related to the facility's water management program that were recognized and addressed. This deficient practice had the potential for undetected water contamination, delayed response to water born disease outbreaks causing risk…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 designate a fulltime infection preventionist nurse ([IPN] a healthcare professional who works to prevent the spread of infections in healthcare facilities) to perform IPN responsibilities and duties as indicated by the facility's job description titled Infection Preventionist (IP). This deficient practice resulted in a lack of oversight to ensure the facility's water management plan team (group of individuals responsible for overseeing and implementing the facility's water management plan [a program that identifies and addresses hazardous conditions in the facility's water system]) met regularly to discuss any issues related to water management in the facility to ensure changes that may lead to legionella growth were not occurring. This deficient practice had the potential for a delay in implementing infection control measures that could lead to the increased risk of infection for all the residents in the facility. Findings: The facility has no designated infection control preventionist and no one is following…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an injury of unknown origin for one of seven sampled residents (Resident 1) was reported to the California Department of Public Health (CDPH) when Resident 1 sustained multiple skin tears on his body. This deficient practice resulted in the inability of the CDPH to investigate Resident 1's injuries in a timely manner and had the potential for facts related Resident 1's injuries to be forgotten by staff. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including atrial fibrillation ([Afib] a heart condition that causes an irregular heartbeat), cirrhosis of the liver (a type of liver damage where the healthy cells are replaced by scar tissue and the liver is not able to perform its vital functions for the body to function normally), right lung malignant neoplasm (a form of cancer that spreads into 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of seven sampled residents (Resident 4), who had a history of falling was provided a one on one sitter (a person who provides constant observation and assistance to a resident at risk for harm), per the physician's order. This deficient practice resulted in Resident 4 not being closely supervised at all times placing Resident 4 at risk for continued falls and subsequent injuries. Findings: During a review of Resident 4's admission Record (Face Sheet), the Face Sheet indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a change in how the brain works due to an underlying condition that causes confusion, memory loss and loss of consciousness), Parkinsonism (a clinical syndrome characterized by tremors, bradykinesia [slow movement], rigidity [a condition where muscles feel stiff and resistant to movement], postural instability and epilepsy (a brain disorder in which a person…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 4 sampled residents (Resident 2) ' s bed was kept clean and bed with piled up blankets. This deficient practice resulted in Resident 2 not having enough bed space to move and be comfortable while in bed. Findings: During a review of Resident 2 ' s admission Records (Face Sheet), the Face Sheet indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including pain in left hip, abnormalities of gait and mobility, and muscle weakness. During a review of Resident 2 ' s Minimum Data Set ([MDS] resident assessment) dated12/6/2024, the MDS indicated Resident 2 ' s daily decision-making skills were cognitively intact (had ability to make decisions and understand others) The MDS indicated Resident 3 required one-person physical assist with activities of daily living ([ADLs] task such as eating, bathing, dressing, grooming and toileting). During a review of Resident 2 ' s History…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Long Beach Department of Health and Human Services (LBDHHS) guidelines were followed during a facility outbreak of Carbapenemase-producing organisms ([CPO] gut bacteria that has become resistant to many antibiotics known as carbanemens), by not posting the correct isolation precaution signs on 8 out of 12 rooms on the facility's sub-acute unit ([SAU] a place that provides short-term intensive care for patients who need more care than what's available at home or in a assisted living facility, but less than what's needed in a hospital). This deficient practice resulted in the facility posting signs to indicate residents on the facility's SAU were on Enhanced Barrier Precautions ([EBP] infection control interventions using gown and gloves during high contact resident care activities designed to reduce the transmission of multi-drug resistant organisms [MDROS]) instead of contact isolation precautions (infection control interventions using gown and gloves before entering a resident's room that are…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents ' right to be free from verbal and physical abuse by Certified Nursing Assistant (CNA 1) for one of three sampled residents (Resident 1). The facility failed to: a. Ensure CNA 1 did not yell at Resident 1 and threw the urinal and bottle of water towards Resident 1. b. Ensure CNA 1 waited for Resident 1 to finish using the bathroom and not enter the bathroom when Resident 1 pleaded for CNA 1 to wait before entering. These deficient practices resulted in Resident 1 feeling emotional , disrespected and a potential psychological distress (a state of emotional suffering that can include symptoms of anxiety ( a mental health condition that involves persistent and excessive feelings of fear or anxiety that can interfere with daily life), and depression [mental health condition that can impact a person's thoughts, feelings, behavior, and sense of well-being ]). Findings: During a review of Resident 1's admission Record , 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, interviews and record review, the facility failed to report an allegation of abuse to the California Department of Public Health (CDPH) no later than two hours for one of one sampled resident (Resident 1) when Resident 2 pulled Resident 1 ' s beanie (small close fitting hat) off her head and had her hair pulled. This failure had the potential to result in unidentified abuse in the facility and the failure to protect residents from abuse. Findings During a review of Resident 1 ' s Face Sheet, the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including multiple sclerosis (nerve damage disrupting communication between the brain and body), heart failure (heart muscle is unable to pump enough blood to meet the body ' s needs for blood and oxygen), and muscle weakness. During a review of Resident 1 Minimum Data Set (MDS a federally mandated resident assessment tool), dated 5/23/2024 indicated Resident 1 was independent in making…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its abuse policy and procedure by failing to submit a five-day investigative report for one of one sampled resident's (Resident 1). This deficient practice resulted in an incomplete investigation and incomplete conclusion of the alleged abuse in the facility. Findings: During a review of Resident 1's Face Sheet, the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including multiple sclerosis (nerve damage disrupting communication between the brain and body), heart failure (heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), and muscle weakness. During a review of Resident 1 Minimum Data Set (MDS a federally mandated resident assessment tool), dated 5/23/2024 indicated Resident 1 was independent in making decisions for herself. During a review of Resident 2's Face Sheet, the Face Sheet indicated Resident 2 was admitted to the facility on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 4) was not restrained, by pushing the right side of her bed against a wall, with pillows on the left side of her bed tucked underneath her sheets, thus preventing Resident 4 from getting up from bed or moving in bed. This deficient practice resulted in Resident 4's inability to get out of bed and restricted her movements in bed. This deficient practice had the potential to result in the further decline in her mobility and function and an undignified existence. Findings: During a review of Resident 4's admission Record (Face Sheet), the Face Sheet indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including delirium (a serious change in the mental abilities of a person and results to confused thinking and lack of awareness of their surroundings) and a recent fall (10/2/2024). During a review of Resident 4's Minimum Data Set ([MDS] a federally mandated 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 interviews and record review, the facility failed to ensure there was a facility policy developed and implemented to verify whether the prescribers of residents ' antipsychotic (medications that treat symptoms that happen with schizophrenia and other conditions that involve psychosis) medications had obtained informed consents prior to administration, for two (2) of 3 sampled residents (Residents 1 and 3). These deficient practices had the potentials of unnecessary medications and residents ' rights issue. Findings: During a review of Resident 1 ' s admission record, the admission record indicated the resident was originally admitted on [DATE] and recently re-admitted on [DATE]. Resident 1 ' s admission diagnoses included urinary tract infection, psychosis (a set of symptoms that affect the mind and make it difficult to distinguish reality from what is not real), and diabetes (high blood sugar). During a review of Resident 1 ' s physician's order dated 9/18/2024 at 10:30 AM, ordered by Physician 1, 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 interviews and record review, the facility failed to ensure there a diagnosis for the use of an antipsychotic medication was consistent in one (1) of 4 sampled residents (Resident 1). These deficient practices had the potentials of unnecessary medications. Findings: During a review of Resident 1 ' s admission record, the admission record indicated the resident was originally admitted on [DATE] and recently re-admitted on [DATE]. Resident 1 ' s admission diagnoses included urinary tract infection (an infection that occures anywhere within the urinary system), psychosis (a set of symptoms that affect the mind and make it difficult to distinguish reality from what is not real), and diabetes (high blood sugar). During a review of Resident 1 ' s psychiatric (a branch of medicine that specializes in the diagnosis and treatment of mental illlness) evaluation notes, dated 7/25/2024 and 9/13/2024, the evaluation notes indicated the assessed diagnoses were bipolar (a mental illness that causes extreme 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 interview and record review, the facility failed to re-admit one of three sampled residents (Resident 1), when Resident 1 due to low oxygen (an element of air breathed in by humans to sustain life) levels of 84 percent ([% part in every hundred] the amount of oxygen [O2] in person ' s blood: reference range is 95% to 100% without the use of supplemental oxygen]) on 9/20/2024. This deficient practice resulted in Resident 1 remaining at the GACH after Resident 1 was deemed appropriate for transfer back to the facility on [DATE] but was denied readmission by the facility. Resident 1 had not been readmitted to the facility as of 10/17/2024, placing the resident at risk for confusion, disorientation and psychosocial harm related to dislocation from a place that was considered Resident 1's home. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated, Resident 1 ' s original admission to the facility was on 2/2/2024 with diagnoses including Alzheimer ' s disease (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 two of two sampled residents (Resident 1 and Resident 2) were not inappropriately touched; Resident 1 on her buttocks twice by a male resident (Resident 3), when Resident 3 and Resident 2 were left unattended on the facility's patio on 10/1/2024, and when Resident 3 was not closely monitored following his inappropriate sexual behavior with Resident 2 on the previous day (10/1/2024), leading to Resident 3 touching Resident 2 on her left thigh and left breast on 10/2/2024. This deficient practice resulted in Resident 1 and Resident 2 feeling unprotected, uncomfortable and/or disrespected when they were touched inappropriately by Resident 3. This deficient practice and had the potential for inappropriate sexual contact to continue with other residents. Findings: During a review of Resident 3's admission Record (Face Sheet), the Face Sheet indicated Resident 3 was admitted to the facility on [DATE] with a diagnosis including unspecified 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 interview and record review, the facility failed to ensure one of two sampled residents (Resident 3) was closely monitored and supervised, following an allegation by a female resident (Resident 1) that she was inappropriately touched by Resident 3 on 10/1/2024. This deficient practice resulted in Resident 3 inappropriately touching another female resident (Resident 2) on 10/2/2024 at 10 a.m. This deficient practice had the potential for Resident 3 to continue his behavior of inappropriately touching other residents. Findings: During a review of Resident 3's admission Record (Face Sheet), the Face Sheet indicated Resident 3 was admitted to the facility on [DATE] with a diagnosis including unspecified mood disorder (a type of mental health condition where there is a disconnect between actual life circumstances and the person's state of mind and feeling), schizophrenia (a mental disorder characterized by disruption in one's thoughts processes, perception, emotional responsiveness and social interactions)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 3), who was transferred to a General Acute Care Hospital's (GACH) emergency room (ER) after two episodes of inappropriately touching two female residents, was readmitted to the facility after the GACH's ER evaluation was completed, and Resident 3 was deemed appropriate for transfer back to the facility. This deficient practice resulted in Resident 3's unnecessary and extended stay in the GACH's ER (as of 10-21-2024 Resident 3 was still at the GACH, 17 days) and had the potential for Resident 3's continued displacement from his residence at the facility. Findings: During a review of Resident 3's admission Record (Face Sheet), the Face Sheet indicated Resident 3 was admitted to the facility on [DATE] with a diagnosis including unspecified mood disorder (a type of mental health condition where there is a disconnect between actual life circumstances and the person's state of mind and feeling), schizophrenia…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one of three residents ' (Resident 2) orthopedic (aim at the treatment of the musculoskeletal system) consult for right shoulder pain after hospitalization in 1/2024 and for left hip dislocation on 6/2024 was completed in a timely manner. The outpatient orthopedic consult was completed on 9/25/2024. The failure resulted in a delay of care which can result in negative health outcomes. Findings During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] with diagnoses including unspecified inflammatory spondylopathy (swelling and tenderness in one or more joints, causing joint pain or stiffness) lumbar region (lower end of back bone), injury at other symptoms of musculoskeletal system, quadriplegia (paralysis that affects all a person's limbs), and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) right shoulder muscle…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one of three residents ' (Resident 4) Oxycodone (strong pain medication) was available to administer to Resident 4 when he was in pain. The failure had the potential to result in unrelieved pain which can result in negative health outcomes. Findings: During a review of Resident 4 ' s admission Record, the admission Record indicated Resident 4 was originally admitted to the facility on [DATE] with diagnoses including rheumatoid arthritis (chronic disorder that affects the joints in the hands and feet and can cause pain), ulcer (sores that can cause pain) of anus (opening where stool exits the body) and rectum (final part of large intestine connect to the anus), muscle spasms (sudden and involuntary contraction of a muscle or group of muscles), age related osteoporosis (bone disease that causes it to be brittle and break easy), and personal history of traumatic fracture (broken bone that occurs when a significant force is applied to the bone, such…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) prior to administering psychotropic (a drug that affects a person ' s mental state) medication on two occasions for one of three sampled residents (Resident 6) who was on quetiapine (a medication used to treat schizophrenia [a serious mental health condition that affects how people think, feel and behave] and bipolar disorder [a mental illness that causes extreme mood swings, which can make it hard to do daily tasks]). This deficient practice had the potential for Resident 6 to be uninformed about the adverse (unwanted or dangerous medication side effects) effects of quetiapine he may experience when receiving the medication . Findings: During a review of Resident 6 ' s admission Record (face sheet), the face sheet indicated Resident 6 was admitted to the facility on [DATE] and re-admitted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 developed a comprehensive plan of care for one of four sampled residents (Resident 1) for the potential of impaired vision in the right eye and the actual vision loss in the left eye due to diagnosis of glaucoma (eye disease that can cause vision loss and blindness) and advanced diabetic retinopathy (complications of diabetes that affects patient ' s eye that can lead to blindness) upon admission. This deficient practice resulted in delay of services for Resident 1 including the need for eye specialist referrals or monitoring for a decline in eyesight. Resident 1 had a decreased vision in the right eye leading to right eye vision loss. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes (a condition in which the body fails to process glucose (sugar) correctly ) with proliferative diabetic retinopathy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 out of four sampled residents (Resident 1) ' s right eye intact vision was not deteriorated, and the resident did not lose right eye vision and became blind. The facility failed to: 1. Ensure licensed nurses acted upon the optometrist ' s (OPT 1) recommendations made on 3/22/2024 and carried out for Resident 1 to see a retina specialist (medical doctor who specialized in disease of the retina) and a glaucoma specialist (medical doctor who specialized in glaucoma [ eye disease that can cause vision loss and blindness]). Resident 1 was not seen by retina specialist (MD 2) until 8/1/2024 (132 days later) and was seen by the glaucoma specialist (MD 3) on 8/27/2024 (158 days later). 2. Ensure Social Services Director (SSD 1), case management (CM 1), and licensed nurses relayed recommendations from ancillary services (diagnostic and supportive measures that help healthcare providers treat residents) to Resident 1 ' s primary physician…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain an informed consent prior to the administration of psychotropic (medications that affect the mind, emotions, and behavior) medications for one out of three sample residents (Resident 16). This failure had the potential to place Resident 16 at risk for avoidable harm from unwanted adverse effects (a harmful and undesired effect resulting from a medication or intervention) related to psychotropic medication use. Findings: During a review of Resident 16's admission Record, the admission Record indicated Resident 16 was admitted to the facility on [DATE] with diagnoses that included schizophrenia (a chronic mental illness that affects how a person thinks, feels, and behaves), altered mental status, and paranoid personality disorder (long-term pattern of distrust and suspicion of others without adequate reason). During a review of Resident 16's Minimum Data Set ([MDS]- a comprehensive resident assessment and care-screening tool), dated 7/5/2024, 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 an adaptive call light system was provided to a resident that was a quadriplegic (paralyzed on all limbs) and was completely dependent on staff to perform activities of daily living (ADLs, daily self-care activities such as grooming, dressing, toileting, and personal hygiene) for one out of out six sampled residents (Resident 101). This deficient practice had the potential for Resident 101 to be unable to make his needs known and placed Resident 101 at risk for harm. Findings: During a review of Resident 101's admission Record, the admission Record indicated Resident 8 was admitted to the facility on [DATE] with diagnoses that included but not limited to quadriplegia, muscle weakness, and muscle wasting and atrophy. During a review of Resident 101's Minimum Data Set ([MDS]- a comprehensive resident assessment and care-screening tool), dated 8/14/2024, the MDS indicated Resident 101's cognition (ability to think and reason) was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide one of one sampled resident (Resident 318) with the opportunity to choose a primary care physician (PCP) of his choice. This deficient practice violated Resident 318's right to choose a care provider of his choice and had the potential to affect Resident 318's quality of life, sense of self-worth and self-esteem. Findings: During a review of Resident 318's admission Record, dated 8/23/2024, the admission record indicated Resident 318 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 318's diagnoses included pneumonia (a serious infection that affects the lungs, causing the air sacs to fill with fluid or pus), pulmonary edema (a condition where too much fluid builds up in the lungs, making it difficult to breathe), type 2 diabetes (a chronic condition resulting in high blood sugar levels), chronic obstructive pulmonary disease (a lung disease that causes breathing problems and restricted airflow),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 its policy and procedure for restraints for one out of one sampled resident's (Resident 52) by failing to: 1. Ensure the order for a right-hand mitten restraint (purposely limiting or obstructing the freedom of a person's bodily movement) specified a duration (time frame) of use for Resident 52, as specified in the facility's policy. 2. Ensure documentation was performed for the assessment of Resident 52's circulation, sensation, movement, and skin integrity for the duration of Resident 52's use of a right-hand mitten restraint. These deficient practices had the potential to cause unnecessary use of a mitten restraint, skin breakdown and impaired circulation (movement of blood throughout the body) for Resident 52. Findings: During an observation, on 8/21/2024, at 10:57 a.m., Resident 52 had a right-hand mitten restraint in place. During a review of Resident 52's admission Record, the admission Record indicated Resident 52 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to revise the nutritional care plan, perform ongoing assessments, and revise the interventions for one of one sampled resident (Resident 317) after returning to the facility from the general acute care hospital (GACH) due to failure to thrive (features of weight loss, exhaustion, weakness, and decreased physical activity) and decreased oral intake. This deficient practice placed Resident 317 at risk for altered nutritional status and weight loss. Findings: a. During a review of Resident 317's admission Record, dated 8/23/2024, the admission record indicated Resident 317 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 317's diagnoses included anorexia nervosa (an eating disorder that involves severe calorie restriction and often a low body weight), protein-calorie malnutrition (a condition that occurs when someone doesn't get enough protein, calories, and other nutrients), anemia (a blood disorder that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure: 1. Medication was not left at the bedside for one out of 5 sampled residents (Resident 24). This deficient practice had the potential to result in medication errors and having another resident possibly take the medication. Findings: During a review of Resident 24's face sheet, the face sheet indicated Resident 24 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 24's diagnoses included restlessness and agitation (a feeling of severe restlessness, crankiness, or uneasiness), type 2 diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy) and mood disorder (a mental health condition that primarily affects your emotional state). During a review of Resident 24's Minimum Data Set Assessment (MDS- a standardized assessment and care screening tool), dated 8/7/2024, the MDS indicated Resident 24 was cognitively intact (ability to think and reason). 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 meet and maintain the nutritional needs of one of three sampled residents (Resident 317) by: 1. Failing to follow the nutritional care plan and interventions. 2. Failing to consistently record Resident 317's oral intake for every meal. 3. Failing to follow the recommendations of the registered dietician (RD, a health professional who specializes in nutrition and diet) to add nutritional shakes three times a day during med pass. This deficient practice placed Resident 317 at risk for altered nutritional status and weight loss. Findings: a. During a review of Resident 317's admission Record, dated 8/23/2024, the admission record indicated Resident 317 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 317's diagnoses included anorexia nervosa (an eating disorder that involves severe calorie restriction and often a low body weight), protein-calorie malnutrition (a condition that occurs when someone doesn't…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a physician order for oxygen administration for one out of 5 sampled residents (Resident 48). This deficient practice had the potential to cause breathing complications as a result of being under oxygenated. Findings: During a review of Resident 48's admission Record (face sheet), the admission record indicated Resident 48 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 48's diagnoses included acute kidney failure (a condition in which the kidney), paraplegia (paralysis [inability to move] of the legs), atelectasis (complete or partial collapse of a lung or a section of a lung) and urinary tract infection (an illness in any part of the urinary tract, the system of organs that makes urine). During a review of Resident 48's Minimum Data Set Assessment, dated 5/3/2024, (MDS- a standardized assessment and care screening tool), the MDS indicated Resident 48 was moderately cognitively impaired (ability…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the adequate storage and disposal of controlled (a drug that is secured under lock and key and has the potential to be misused), and non-controlled medications when the facility failed to ensure the following: 1. Ensure Hydrocodone and Acetaminophen (a controlled medication, used to treat severe pain) 5-325 milligram ([MG]-a unit of measurement) was properly disposed and wasted, and not kept in the medication bubble pack (a special packaging for resident medications) sealed with paper tape located in Medication Cart 2 . 2. Ensure a liquid bottle of Docusate Sodium (stool softener) was disposed in the proper medication disposal bin receptacle in Medication room [ROOM NUMBER]. 3. Ensure the door to Medication room [ROOM NUMBER] was locked and secured. These deficient practices had the potential for medication errors, drug diversion (the transfer of a controlled substance or other medication from a lawful to an unlawful channel of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow up on the missing/lost dentures for one out of six sampled residents (Resident 6). This deficient practice had the potential for Resident 6 to exhibit weight loss due to limited food choices and choking. Findings: During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was admitted to the facility on [DATE], and readmitted on [DATE]. Resident 6's diagnoses included malnutrition (lack of sufficient nutrients in the body), dysphagia (trouble swallowing), and muscle weakness. During a review of Resident 6's Minimum Data Set ([MDS]- a comprehensive resident assessment and care-screening tool), dated 8/15/2024, the MDS indicated Resident 6's cognition (ability to think and reason) was slightly impaired. The MDS indicated Resident 6 required partial assistance (when a person receives hands-on help with an activity but is still able to participate to some degree) with eating and performing oral hygiene,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure: 1. One of four of the facility's trash dumpsters was not overfilled with an open lid. This deficient practice had the potential to result in pest and vermin infestation. Findings: During a concurrent observation and interview upon the initial kitchen inspection, on 8/20/2024 at 8:55 a.m., with the Dietary Supervisor (DS), one of the facility's four outside trash dumpsters was observed to be overfilled with trash with the trash lid open. The DS stated all trash from the kitchen should have been able to fit in the dumpster containers with closed lids. The DS confirmed the trash dumpster was overfilled and the lid was opened. The DS stated the risk of having an opened trash dumpster overfilled with trash could result in an infestation of pests and vermin. During a review of the facility's policy and procedures (P&P), titled Waste Management, revised 11/2017, the P&P indicated food waste will be placed in covered garbage and trash cans.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure effective infection prevention practices were implemented for a resident with suspected scabies (a contagious skin condition caused by the human itch mite) for one out of three sampled residents (Resident 8) when the facility failed to: 1. Obtain an order and perform a scabies skin scraping (a diagnostic procedure for scabies that involves scraping a suspected lesion with a scalpel blade or glass slide to collect a sample that can be examined under a microscope for mites or eggs) for Resident 8 in a timely manner and before treatment for scabies was administered. 2. Ensure Resident 8 remained in contact isolation (a set of measures used to prevent the spread of infectious agents that can be transmitted through direct or indirect contact with a patient or their environment) during the course of Resident 8's second round of treatment for suspected scabies and before Resident 8's second skin scraping. These deficient practices had 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 Licensed Vocational Nurse (LVN) 3, 4, 5, and 6 accurately documented Vimpat, a medication for seizure (a sudden, uncontrolled burst of electrical activity in the brain which can cause changes in behavior, movements, feelings, and level of consciousness) disorder, for one of four sampled residents (Resident 1) on the Medication Administration Record (MAR) and/or the Individual Narcotic Record (a form used to document and track the administration of controlled substances [a drug or other substance that is tightly controlled by the government because it may be abused or cause addiction and may cause significant risk to patient safety]). This deficient practice placed Resident 1 at risk for mismanagement of their medication regimen and had the potential for medication errors and diversion (illegal distribution or abuse of prescription drugs (illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Assurance Performance Improvement ([QAPI] facility team 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 implement the facility ' s plan to monitor and address staff noncompliance (failure to comply with something) with medication administration. This deficient practice resulted licensed nurses continued noncompliance with medication administration and documentation and had the potential to result in poor resident outcomes. Findings: During a review of the facility ' s Summary of Nurse Consultant Services dated 7/5/2024, the Summary of Nurse Consultant Services indicated the following issues were identified: 1. Thirteen medication errors (blood pressure [the pressure of circulating blood against the walls of blood vessels in the body] parameter not followed, omission of medications, excess…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Licensed Vocational Nurse (LVN) 3, administered Vimpat, a medication for seizure (a sudden, uncontrolled burst of electrical activity in the brain which can cause changes in behavior, movements, feelings, and level of consciousness) disorder, in a timely manner as ordered by the physician for one of four sampled residents (Resident 1). This deficient practice placed Resident 1 at increased risk for adverse effects including drowsiness (excessive sleepiness), stupor (state of near consciousness) and/or insensibility (lack of physical sensibility) due to the medication doses taken too close together. 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 diagnosis including epilepsy (a disorder of the brain characterized by repeated seizures) and altered mental status (a change in mental function) and dementia (the loss of memory, language,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 to the state agency (Department of Public Health: DPH) an unwitnessed fall with injury on 4/13/2024 in a timely manner for Resident 1. This resulted in a delay of an onsite inspection by the Department of Public Health to ensure the residents' fall circumstances were investigated and can lead to a delay in prevention of further falls. Findings: During a review of Resident 1's Face Sheet (admission record), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including paranoid schizophrenia (type of brain disorder that makes someone believe they are being harassed or persecuted), bipolar disorder (mental illness that causes extreme mood swings that include heighted emotion like mania or lows such as depression), unspecified psychosis (collection of symptoms that affect the mind without a known cause) not due to a substance of known physiological condition, muscle weakness, and need for assistance with personal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an unwitnessed fall with injury was thoroughly investigated within 5 working days for one of one sampled resident (Resident 1) as indicated in the facility's policy and procedure. This deficient practice had the potential to place other resident at high risk for falls that could sustain injury. Findings: During a review of Resident 1's Face Sheet (admission record), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including paranoid schizophrenia (type of brain disorder that makes someone believe they are being harassed or persecuted), bipolar disorder (mental illness that causes extreme mood swings that include heighted emotion like mania or lows such as depression), unspecified psychosis (collection of symptoms that affect the mind without a known cause) not due to a substance of known physiological condition, muscle weakness. During a review of Resident 1's Minimum Data Set [(MDS) a standardized…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure resident received supervision and assistance to prevent an unwitnessed fall with injury for one of three sampled residents (Resident 1). This failure resulted in Resident 1 fell on the floor and was transferred to general acute care hospital (GACH) on 4/13/2024. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia (type of brain disorder that makes someone believe they are being harassed or persecuted), bipolar disorder (mental illness that causes extreme mood swings that include heighted emotion like mania or lows such as depression), unspecified psychosis (collection of symptoms that affect the mind without a known cause) muscle weakness, hypertension (high blood pressure), chronic obstructive pulmonary disease ([COPD] disease that cause airflow blockage and breathing related problems) with acute exacerbation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure an Interdisciplinary Team ([IDT] team of health care professionals that work together toward and prioritize the resident's needs) meeting was conducted for one of four sampled residents (Resident 2) when Resident 2's tracheostomy (a surgical procedure to create an opening through the neck into the windpipe that provides an air passage to help you breathe when the usual route for breathing is obstructed or impaired) was accidentally dislodged, it was decided Resident 2 no longer required the tracheotomy and Resident 2 was subsequently transferred from the facility's Sub-Acute unit (level of care requiring more intensive licensed skilled nursing services than is typically provided to the majority of residents) to the facility's skilled nursing unit (a unit where lower level of care is required). These deficient practices resulted in Resident 2's Responsible Party (RP 2) being unaware of Resident 2's plan of care, and RP 2's inability to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure one sampled resident (Resident 2) who had a tracheostomy (a surgical procedure to create an opening through the neck into the windpipe that provides an air passage to help you breathe when the usual route for breathing is obstructed or impaired) that became dislodged on 1/22/2024 and again on 3/23/2024, was investigated by the facility to determine why dislodgement was occurring and to prevent it ' s recurrence. This deficient practice resulted in the Resident 2's tracheostomy dislodging more than once and had the potential to interfere with the ability of Resident 2 and other residents with tracheostomies to breathe and possible death. Findings: During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including tracheostomy care and anoxic (a state of total oxygen deprivation within tissues or organs) brain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a comprehensive centered care plan was developed for one of three sampled residents (Resident 1). The facility failed to develop a care plan to address Resident 1 ' s impaired vision. These deficient practices caused Resident 1 to feel frustrated and had the potential to cause a delay in care and services. Findings: During a review of Resident 1's admission Record, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including paraplegia (inability to move part of the body), muscle weakness and rheumatoid arthritis ( swelling in areas where bones meet). During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 12/29/2023, the MDS indicated Resident 1 had the have cognitive ability to think, learn, remember, use judgement, and make decisions. The MDS indicated Resident 1 had moderately…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 revise one of three sampled resident's (Resident 2) comprehensive, resident centered care plan to include the need for direct line of sight (unobstructive view) monitoring for Resident 2. These deficient practices placed Resident 2 at increased risk for harm due to accidents and or resident to resident altercations. Findings: During a review of Resident 2's admission Record, the admission record indicated Resident 2 was originally admitted to the facility on [DATE] with diagnoses including dementia (impaired ability to think, reason, make decisions), muscle weakness and difficulty walking. During a review of Resident 2's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 1/20/2024, the MDS indicated Resident 2 had severe cognitive impairment (ability to think, learn, remember, use judgement, and make decisions). During a review of Resident 3's admission Record, the admission record indicated Resident 3 was…

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

Based on observation, interview, and record review the facility failed to ensure four of seven sampled resident's (Resident 4, 5, 6 and 7) bathroom did not smell like feces and did not have pasty feces on the toilet seat and on the floor. This failure made Resident 5 feel uncomfortable and had the potential for Resident 4, 5, 6, and 7 to be at risk in acquiring infection that can negatively affect his over-all health condition. Findings: During a review of Resident 4's admission Record (Face sheet), the face sheet indicated Resident 4 was admitted at the facility on 1/5/2024 with a diagnosis that included traumatic subarachnoid hemorrhage (bleeding in the space that surrounds the brain), traumatic brain injury (a sudden trauma causing damage to the brain), psychosis (a symptom of a mental illness) and gait and mobility abnormalities (abnormal walking pattern). During a review of Resident 6's admission Record (Face sheet), the face sheet indicated Resident 6 was admitted at the facility on 4/16/2021 with a diagnosis that included parkinsonism (slow movements and tremors), malignant…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain clinical records in accordance with accepted professional standards and practices for one of seven sampled residents (Resident 4) by failing to consistently document Resident 4's activities of daily living (ADLs). This deficient practice had the potential to negatively impact the delivery of care and services. Findings: During a review of Resident 4's admission Record (Face sheet), the face sheet indicated Resident 4 was admitted at the facility on 1/5/2024 with a diagnosis that included traumatic subarachnoid hemorrhage (bleeding in the space that surrounds the brain), traumatic brain injury (a sudden trauma causing damage to the brain), psychosis (a symptom of a mental illness) and gait and mobility abnormalities (abnormal walking pattern and balance). During a review of Resident 4's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 1/12/2024, the MDS indicated Resident 4 was able to make independent decisions, had periods of disorientation, required one person substantial/maximum…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 four of seven sampled residents (Resident 4, 5, 6 and 7) were free from exposure to human waste in their living environment when feces was noted on Resident 4's clothing and bed linen, on the toilet seat and on the floor of the shared the bathroom for Resident 4, 5, 6, and 7, and on the floor of Resident 4,6, and 7's room. This failure increased Resident 4, 5, 6, and 7's risk for infection from a potentially infected human waste. Findings: During a review of Resident 4's admission Record (Face sheet), the face sheet indicated Resident 4 was admitted at the facility on 1/5/2024 with a diagnosis that included traumatic subarachnoid hemorrhage (bleeding in the space that surrounds the brain), traumatic brain injury (a sudden trauma causing damage to the brain), psychosis (a symptom of a mental illness) and gait and mobility abnormalities (abnormal walking pattern). During a review of Resident 5's admission Record (Face sheet), the face sheet indicated Resident 5 was admitted at the facility on 2/12/2024…

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

Based on interview and record review, the facility failed to ensure one of seven sampled residents (Resident 1), who was aphasic (a communication disorder after a stroke) was provided a communication tool necessary for Resident 1 to communicate her needs. This deficient practice had a potential for delay of appropriate care and services to Resident 1. Findings: During a review of Resident 1's admission Record (Face sheet), the face sheet indicated Resident 1 was admitted at the facility on 8/22/2023 with a diagnosis that included sepsis (an extreme reaction of the body to an infection that could lead to organ failure, tissue damage and death), diabetes mellitus (a disease that occurs when the blood glucose, also called blood sugar, is too high), intracranial brain hemorrhage (a brain bleed) with left side hemiparesis (weakness or being unable to move the left side of the body) and aphasia (a language disorder that affects a person's ability to communicate). During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 1/23/2024, 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 failed to ensure the Responsible Party of one of seven sampled residents (Resident 1) was informed of Resident 1's chest x-ray (an imaging test to produce pictures of the organs, tissue, and bones of the body) results when Resident 1 was transferred to General Acute Care Hospital (GACH) on 1/23/2024. This failure resulted in Responsible party (RP 1) feeling concerned of Resident 1's change in condition and the failure had the potential to delay care and services that could negatively predispose Resident 1 to further health complications. Findings: During a review of Resident 1's admission Record (Face sheet), the face sheet indicated Resident 1 was admitted at the facility on 8/22/2023 with a diagnosis that included sepsis (an extreme reaction of the body to an infection that could lead to organ failure, tissue damage and death), diabetes mellitus (a disease that occurs when the blood glucose, also called blood sugar, is too high), intracranial brain hemorrhage (a brain bleed) with left side hemiparesis (weakness or being unable 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 observations, interviews, and record reviews the facility failed to ensure one of seven sampled residents (Resident 4) was supervised while transferring (sitting to standing position and getting out of bed), ambulating (the ability to walk) and toilet use. This failure resulted in Resident 4's fall on 2/6/2024 and had the potential to result in complications that can negatively affect his well-being. Findings: During a review of Resident 4's admission Record (Face sheet), the face sheet indicated Resident 4 was admitted at the facility on 1/5/2024 with a diagnosis that included traumatic subarachnoid hemorrhage (bleeding in the space that surrounds the brain), traumatic brain injury (a sudden trauma causing damage to the brain), psychosis (a symptom of a mental illness) and gait and mobility abnormalities (abnormal walking pattern such as losing and/ or increasing speed, smoothness, and balance). During a review of Resident 4's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 1/12/2024, the MDS indicated Resident 4 was able to make…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the inventory list records were complete and accurate for one out of three sampled resident (Resident 1). This deficient practice had the potential to result in misappropriation of Resident 2's personal property. Findings: During a review of Resident 1 ' s admission record (face sheet), the face sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted [DATE] with a diagnosis of anemia ( a condition in which the body does not have enough healthy red blood cells ), chronic pulmonary edema ( when fluid collects in the air sacs of the lungs, making it difficult to breathe ), and seizures ( sudden, uncontrol body movements and changes in behavior that occurs because of abnormal electrical activity in the brain). During a review of Resident 1 ' s history and physical (H&P) report dated 12/29/2023, the H&P indicated Resident 1 is able to make decision for activities of daily living. During a review of the Resident 1 '…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 three of five sampled Certified Nursing Assistants (CNA 1, 2, and 3) from the registry company (an agency that offers health care related contracts for temporary staff to health care facilities) received abuse training prior to working at the facility. This deficient practice resulted in the facility being unaware of registry staff's knowledge of abuse regulations and placed residents at risk for abuse, neglect, and exploitation. Findings: During a review of CNA 1, 2, and 3's training documents, there was no evidence of abuse training completed. During an interview on 1/4/2024 at 2:54 p.m. with the Director of Staff Development (DSD), the DSD stated that she reviews the documents from the registry company prior to the registry staff work at the facility. The DSD stated CNA 1,2, and 3 did not have abuse training certification in their documents from the registry company. The DSD stated abuse training was important so the staff knows the abuse policy and procedure in the facility, who abuse should be reported to, 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 ensure one of two sampled residents (Resident 2) call light ' s was answered timely. This failure resulted in Resident 2 felt upset, ignored, and anxious for not receiving assistance timely. Findings: A review of Resident 2 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted on [DATE] with diagnoses including diabetes (high blood sugar), dysphagia (difficulty swallowing), muscle weakness (a lack of strength in the muscles), and anxiety (feeling worried). A review of Resident 2 ' s Minimum Data Set ([MDS] - a standardized assessment and care screening tool), dated 10/08/2023, the MDS indicated the cognitive (the ability to think and process information) skills for daily decisions making was intact and Resident 2 was totally dependent on staff for dressing, toilet use, personal hygiene, and bathing. A review of Resident 2 ' s Care Plan for Resident at risk for falls, dated 09/28/2023, indicated to ensure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observe infection control measures for one of three sampled residents (Resident 1). by: 1. Failing to perform hand hygiene after removing the gown from the isolation room. 2. Failing to use the disinfectant correctly by not knowing the contact time of the disinfectant in use. These deficient practices had the potential to spread infection. Findings: During a review of Resident 1's admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE], with diagnoses of, but not limited to, scabies (an itchy skin rash caused by a tiny burrowing mite), cellulitis (bacterial skin infection), type 2 diabetes mellitus (high blood sugar), chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems)and Hemiplegia (paralysis of one side of the body) and Hemiparesis (weakness of one side of the body). During a review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Juice machine tubing connectors were disconnected from the machine and left on the shelving with juice dripping, two gnats were flying around the dirty shelf. One juice tubing connector was down inside the dirty floor drain. 2. Not all foods were dated upon receipt, sealed after opened, labeled to identify prepared food content, and discarded prior to use by date. 3. Personal drink stored inside the reach in freezer and personal portable speaker was hanging on the drying rack by the hand washing sink. 4. Food preparation and storage area were not maintained clean. Gap between reach in freezer and food preparation counter had visible dust and food-like debris buildup in between. Shelving inside reach in freezer was dirty and had ice buildup. Floor in the dry storage area was dirty. 5. Cooked beef patty left over from 7/5/21 in the walk-in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record reviews, the facility failed to ensure hand mittens (a glove covering the whole left hand) were not used on 2 of 3 sampled residents (Residents 66 and 67) as a physical restraint to stop the residents from pulling out the gastrostomy tube (G-tube, a tube inserted through the abdomen that delivers nutrition directly to the stomach) and scratching the staff during care, without first attempting least restrictive measures. a. Resident 66 had no orders, assessment, and care plans for the use of hand mittens/physical restraints. b. Resident 67 had no reassessment to continue the use of restraints and no monitoring was found for the use of the hand mittens for the months of 5/2021 and 6/2021. These deficient practices resulted in an unnecessarily restricting Resident 66 and prevent him from using his right hand and Resident 67 being on physical restraint longer than necessary. Findings: a. During an observation on 7/7/2021 at 9:30 a.m., Resident 66 was observed with a hand…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete and encoded (entering information into the facility minimum data set [MD'S, a federally mandated comprehensive assessment tool used for care planning] software in the computer) residents assessment for eight of 22 sampled residents (Residents 3, 4, 5, 7, 10, 13, 16, and 20). These deficient practices had the potential to prevent the facility from monitoring each resident's decline or progress to be assessed correctly. Findings: During an annual recertification survey on 7/12/2021 the following residents' MDS were reviewed for completion and submission timeframe. Resident 3 MDS was last completed and submitted on 2/9/2021 Resident 4 MDS was last completed and submitted on 2/9/2021 Resident 5 MDS was last completed and submitted on 2/9/2021 Resident 7 MDS was last completed and submitted on 2/15/2021 Resident 10 MDS was last completed and submitted on 2/16/2021 Resident 13 MDS was last completed and submitted on 2/25/2021 Resident 16 MDS was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure it was free of a medication error rate of five percent (5%) or greater as evidenced by the identification of 3 out of 28 medication opportunities for error, to yield a cumulative error rate of 10.71% for one of three sampled residents (Residents 61), during the medication administration facility task by: 1). Not administering the correct dose of oyster shell calcium with vitamin D 2). Not clarifying the dosage before administering Diclofenac Sodium 1% gel (arthritis pain reliever) These deficient practices had the potential to result in harm to Residents 61 Findings: During a review of Resident 61's admission Record (Face Sheet), the face sheet indicated Resident 61 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 61's diagnoses included epilepsy (a neurological disorder causing seizures or periods of unusual behavior and sensations), bipolar disorder (a brain disorder that causes unusual shifts…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 kitchen staffs were routinely trained, monitored and evaluated for competency related to their duties when: 1. Diet Aide 1 (DA 1) and Diet aide 2 (DA 2) stored personal belonging inside the kitchen and unfamiliar with department requirement regarding personal belonging storage. (cross reference F812) 2. DA 2 did not know the difference between regular dessert and controlled carbohydrate (CCHO) diet dessert for 7/6/21 lunch service and served regular desserts to the CCHO diet residents. (cross reference F803) 3. [NAME] 2 did not know how to calibrate manual thermometer and there was no documented training in-service or documented competency skills evaluation for cooks and diet aides. These failures had the potential to result in unsanitary food storage, inaccurate temperature readings and altered nutrition status for 16 out of 94 residents who received CCHO diets from the kitchen. Findings: 1. During a concurrent observation and interview with the DA 1 on 7/6/21 at 8:20 a.m., there was a bottle of Brisk…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dessert portion served to controlled carbohydrate diet (CCHO - diet for blood sugar control) were prepared according to the spreadsheet (food portioning and serving guide) instruction on 7/6/2021 lunch service. This failure could result in increased blood sugar levels for 16 out of 94 residents who were on a CCHO diet. Findings: During a tray-line observation on 7/6/2021 at 11:55 a.m., observed both regular and CCHO diets were served the same size cakes. During a review of the facility's lunch meal spreadsheet (food portioning and serving guide), the spreadsheet indicated lunch dessert was fruit mix crumble cake, and CCHO diet should receive 1/2 of regular serving cake. During an interview 7/6/2021 at 12 p.m., the Dietary Aide 2 (DA 2), who served the desserts and side items during tray-line on 7/6/2021 at 11:57 a.m., stated there was no difference in the desserts today. DA 2 stated both regular and CCHO diets received the same cake with the same size. During an interview with the DSS on 7/6/21 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 make a good faith effort to permanently repair the broken call light system previously identified as an immediate jeopardy deficiency; using the Quality Assurance and Performance Improvement ([QAPI] the coordinated application of two mutually-reinforcing aspects of a quality management system, taking a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality, while involving residents and families, and all nursing home caregivers in practical, and creative problem solving) by reviewing services, outcomes, and systems throughout the facility for assuring that call lights within the facility worked, in relation to those standards, to decrease the risks associated with residents' not being able to summon help. This deficient practice had the potential for 14 of 94 (5,10, 14, 21, 23, 26, 53, 55, 80, 81, 83, 88, 89,98,) residents' needs being unmet, residents' feeling isolated and neglected due not being able to call for help. Findings: During…

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

Based on interview and record review, the facility failed to implement its policy and procedures (P/P) and ensure there was a consistent process for screening and determining eligibility for residents to receive influenza ([flu], a respiratory virus that infects the nose, throat, and lungs; spread when people with flu cough, sneeze or talk, sending droplets with the virus into the air and potentially into the mouths or noses of people who are nearby) and pneumonia (a bacterial, viral, or fungal infection of the lungs that causes the air sacs, or alveoli, of the lungs to fill up with fluid or pus) vaccines, ensure the provision of education related to influenza and pneumococcal vaccines, and ensure administration of pneumococcal and/or influenza vaccines for 4 of 5 residents (Residents 61, 70, 67, 37). This deficient practice had the potential to place Residents 37, 61, 67, 70 and other residents, staff members, visitors, and the community at risk of acquiring, transmitting, and or experiencing complications from an outbreak of influenza and pneumonia. Findings: During a concurrent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews and record review, the facility failed to implement its policy and procedures (P/P) when discharging one of three sampled residents (Resident 57) by not ensuring the discharge of Resident 57 was completed and documented to indicate the discharge summary. This deficient practice resulted in Resident 57's health information not given to the receiving facility and not receiving all his belongings. Findings: During a review of Resident 57's admission Record (Face Sheet), the face sheet indicated Resident 57 was admitted to the facility on [DATE] for hospice care (care for people in the last phases of a disease so that they may live as fully and comfortably as possible) and was discharged on 6/18/2021. Resident 57's diagnoses included chronic kidney disease ([CKD] condition in which the pressure in the blood is too high caused by the organ in the body that filters excess waste fluid from the blood), presence of urogenital implants (injections of materials into the opening of the tube through in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to inform and provide a seven-day bed hold notification for one of one resident (Resident 37) prior to a general acute care hospital (GACH) transfer. This deficient practice had the potential to cause psychosocial harm for Resident 37 and the resident's representative due to not knowing Resident 37 could return to the facility upon discharge from the GACH and violated resident's right to be readmitted into the facility. Findings: During a review of Resident 37's admission record, the record indicated Resident 37 was readmitted to the facility on [DATE]. Resident 37's diagnoses included hypertension (high blood pressure), dependence on respirator (mechanical life support because of inability to breathe effectively) and chronic obstructive pulmonary disease (a lung disease that causes obstructed airflow, and difficulty breathing). During a review of Resident 37's Minimum Data Set (MDS) a standardized assessment and care planning tool), dated 5/24/2021, 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 reviews, the facility failed to ensure one of three sampled residents (Resident 66) with hand mitten (a glove covering the whole left hand) were assessed, use of less restrictive measures, and obtained a physician order before applying hand mitten as a physical restraint (any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body) to stop the resident from pulling out the gastrostomy tube (G-tube, a tube inserted through the abdomen that delivers nutrition directly to the stomach). These deficient practices resulted in an unnecessarily restricting Resident 66 and prevent him from using his right hand. Findings: During an observation on 7/7/2021 at 9:30 a.m., Resident 66 was observed with a hand mitten on the right hand. During a review of Resident 66 admission Record (Face Sheet), 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 interviews and record review, the facility failed to document a discharge summary, including an understanding of discharged medications and a post-discharge plan of care in one of three residents (Resident 57) medical record. This deficient practice had the potential to result in Resident 57 and his Responsible Party to not understand the specifications of the medications after being discharge from the facility and for Resident 57 to not receive the medications as prescribed. Findings: During a review of Resident 57's admission Record (Face sheet), the face sheet indicated Resident 57 was admitted to the facility on [DATE] for hospice care (care for people in the last phases of a disease so that they may live as fully and comfortably as possible) and was discharged on 6/18/2021. The resident's diagnosis included hypertensive chronic kidney disease (a condition in which the pressure in the blood is too high caused by the organ in the body that filters excess waste fluid from the blood), presence of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify one of one resident (Resident 61) physician about laboratory test results promptly, as per facility policy. Resident 61 had a laboratory test for valproic acid level (form of valproate, a medication used to treat residents with seizure disorders) done on 6/4/2021 and the results indicated a level of 26 (normal range 50-100). This deficient practice resulted in Resident 61's physician not being notify of the abnormal laboratory results until five (5) days later on 6/9/2021, and had the potential to delay care and treatment, which could have caused Resident 61 to have a seizure. Findings: During a review of Resident 61's admission Record (Face Sheet), the3 face sheet indicated Resident 61 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 61's diagnoses included: epilepsy (a neurological disorder causing seizures or periods of unusual behavior and sensations), bipolar disorder (a brain disorder that causes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of one resident (Resident 61) received assistance with communication and hearing abilities to maintain Resident 61's functional interaction with direct care staff and visitors. Resident 61's hearing aids were lost in 1/2021, however, the facility did not follow-up on the order for replacement hearing aid until 7/7/2021 (7 months after). This deficient practice resulted in Resident 61 unable to communicate her needs with care staff and had the potential to decline in communication, cause emotional distress, and to affect the activities of daily living (ADLs). Findings: During a review of Resident 61's admission Record (Face Sheet), the face sheet indicated Resident 61 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 61's diagnoses included epilepsy (a neurological disorder causing seizures or periods of unusual behavior and sensations), bipolar disorder (a brain disorder that causes unusual shifts in 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 reposition and redistribute pressure away from bony areas for one of eight sampled residents (Resident 53). Resident 53, who was at risk for developing pressure ulcers (damage to skin or underlying tissue that usually occurs over a bony area as a result of long term pressure) due to risk factors which included Impaired/decreased mobility, decreased functional ability, and history of a previously healed Stage 4 Pressure Ulcer (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage or bone. Slough [dead tissue] may be visible). This deficient practice had the potential to cause Resident 53 to develop adverse skin conditions and pressure ulcers. Findings: During a review of Resident 53's admission record, the admission record indicated Resident 53 was admitted to the facility on [DATE]. Resident 53's diagnoses included quadriplegic cerebral palsy (disease that affects all for limbs, the trunk, and face. 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 b. During a review of Resident 88's admission record, the admission record indicated Resident 88 was admitted to the facility on [DATE]. Resident 88's diagnoses included Parkinson's disease (progressive disease of nervous system marked by tremors, muscle stiffness and slow imprecise movement), respiratory failure (condition in which blood does not have enough oxygen or too much carbon dioxide) muscle weakness, and hypertension (high blood pressure). During a review of Resident 88's Minimum Data Set (MDS), a resident assessment and care-planning tool, dated 5/7/2021, the MDS indicated Resident 88 had severe cognitive (thought) impairment and is rarely/never understood. The MDS also indicated Resident 88 had trouble breathing when lying flat. During a review of Resident 88's care plan dated 7/2/2021 and titled, Alteration in Respiratory Function, the care plan indicated Resident 88 was at risk for tracheal (airway between the voice box and the lungs) tube obstruction and disconnection. The care plan also 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.

Based on observations, interviews and records review, the facility failed to ensure one out of 13 residents (Resident 23) received salad texture prepared according to the mechanical soft diet (food textures modified for people who have difficulty chewing and swallowing) spreadsheet. This failure had the potential to result in decreased intake related to difficulty chewing and increased choking risk for Resident 23. Findings: During a dining observation on 7/6/2021 at 12 p.m., observed Resident 23 had a plate of Caesar salad with croutons on the tray. The meal ticket on Resident 23 plate indicated Resident 23 diet was a mechanical soft diet. During a review of Resident 23 care plan titled, Nutrition, dated 2/21/2020, the care plan indicated Resident 23 was on a mechanical soft diet and Resident 23 was edentulous (without teeth). During a review of facility's lunch spreadsheet, dated 7/6/2021, the spreadsheet indicated for mechanical soft diet to provide ½ inch chop Caesar salad with no croutons. During an interview on 7/6/2021 at 12:01 p.m., Licensed Vocational Nurse 2 (LVN 2) stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure fortified cereal was provided as ordered by the physician to one of 13 sampled residents (Resident 14). This failure had the potential to result in decreased caloric intakes and lead to undesirable weight loss. Findings: During a review of resident 14's admission Record (Face Sheet), the face sheet indicated Resident 14 was admitted to the facility on [DATE]. Resident 14 diagnoses included anorexia (lack or loss of appetite for food) and generalized muscle weakness. During a review of Resident 14's Minimum Data Set (MDS), a resident assessment and care-planning tool, dated 5/28/2021, the MDS indicted Resident 14 was moderately impaired of cognition (thought process) for daily decision making. During an interview on 7/8/2021 at 7:40 a.m., Resident 14 stated she only had milk this morning. Resident 14 stated she did not eat foods because they were not good and stated she did not eat hot cereal because they did not have it. During an…

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

Based on observation, interview and record review, the facility failed to ensure trash stored in the dumpster area was maintained in a sanitary manner when one out of four garbage dumpsters were overfilled. This failure had the potential to attract disease causing pests to harbor in the dumpster area. Findings: During a concurrent observation and interview on 7/6/2021 at 9:41 a.m., the Dietary Service Supervisor (DSS) acknowledge one garbage dumpster in the parking lot were overfilled with cardboard boxes and both lids were unable to close. The DSS stated trash bin should not be overfilled. During an interview on 7/7/2021 at 8:51 a.m., the Director of Maintenance (DOM) stated the garbage dumpsters were maintained by the housekeeping staff. DOM stated he would do rounds to ensure cleanliness of the area and ensure garbage dumpster lids were closed. However, the DOM stated they may need more dumpsters as trash sometimes cannot all fit before trash collection time. The Facility did not have a policy specific to garbage dumpster maintenance and monitoring. According to the 2017 U.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.