Long Beach Care Center, INC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to investigate one of four sampled residents' (Resident 3) allegation of sexual abuse when Resident 3 yelled and screamed at Resident 2 that he (Resident 2) raped her. This deficient practice resulted in the facility's inability to determine if the allegation had actually occurred and had the potential for other uninvestigated allegations of abuse to be uninvestigated. 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 of metabolic encephalopathy (brain dysfunction) and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 3's Minimum Data Set ([MDS] a resident assessment tool) dated 9/21/2025, the MDS indicated Resident 3's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired and Resident 3…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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) 1 administered Heparin (a medication used to prevent the formation of blood clots [masses of blood that form when blood cells stick together]) as ordered by the physician for deep vein thrombosis ([DVT] a blood clot in a vein, usually in the leg) prophylaxis (treatment to prevent disease or infection from occurring or spreading) for one of four sampled residents (Resident 1). This deficient practice contributed to Resident 1 experiencing swelling and heaviness in her left lower extremity (leg), her subsequent transfer to a General Acute Care Hospital (GACH), where she was assessed and diagnosed with an extensive acute deep vein DVT of the left lower extremity.Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of a displaced intertrochanteric fracture (a type of broken bone in the upper part of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility staff failed ensure a Medication Administration Record ([MAR] a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for one of four sampled residents (Resident 1) was not falsified, when Licensed Vocational Nurse (LVN) 1 documented he administered a dose of Heparin (a medication to prevent the formation of clots [masses of blood that form when blood cells stick together]) to Resident 1 on 11/10/2025 at 2 p.m., when he had not given it to her and then on 11/17/2025 documented another incorrect entry also indicating he had administered the Heparin dose to Resident 1. This deficient practice resulted in the inaccurate depiction of Resident 1's medication management and had the potential for non-continuity of care based on the inaccurate documentation. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 update the facility assessment tool for 137 out of 137 residents when:1. The facility failed to include the Infection Prevention Nurse (IPN) as part of the required staff for daily facility operations; and2. The facility failed to assess the cultural and ethnic makeup of the facility's resident population.These deficient practices had the potential to result in delays of care and services and deter the facility to offer more culturally competent resident-centered care. Findings: During a concurrent interview and record review on 9/04/2025 at 8:43 a.m. with the Administrator, the Facility Assessment Tool, 7/10/2025, was reviewed. The Administrator confirmed missing that the Facility assessment Tool did not indicate that the IPN was part of the staff needed to function for the resident population every day and during emergencies. The Administrator stated the IPN needed to be included in the Facility Assessment Tool. The Administrator stated the tool was missing specific assessment on the different culture and ethnic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reviews, the facility failed to ensure three of six sampled residents' (Resident 7, 9 and 114) were free from unnecessary psychotropic medications (drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, or feelings, or behavior) by:a. Failing to ensure nonpharmacological interventions (therapies and measures that do not involve taking medication like distraction, music therapy, and activities) were attempted prior to administering Ativan (medication for anxiety [mental health condition characterized by excessive fear and worry]) as needed for inability to relax for Resident 7.b. Failing to ensure Resident 9 was monitored for adverse effects for Mirtazapine (medication for depression [a mood disorder that causes a persistent feeling of sadness and loss of interest]) use.c. Failing to indicate resident specific behaviors for Risperidone (medication used to treat various mental health conditions) use for Resident 114. These deficient…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement an individualized care plan with measurable objectives, timeframes, and interventions for 3 of 3 residents (Residents 16, 156, and 124) by failing to: Develop and implement a care plan to improve, maintain, or prevent a decline in range of motion (ROM, full movement potential of a joint) for Resident 16 who was identified as having ROM limitations in both arms and both legs.Develop and implement a comprehensive person-centered care plan for Resident 124's use of Lorazepam (Ativan, medication used to treat anxiety [a common mental health condition characterized by excessive worry, fear, and nervousness]).Develop and implement a comprehensive person centered care plan for Resident 156's diagnosis of post traumatic stress disorder ([PTSD], a mental health condition that's caused by an extremely stressful or terrifying event, either being part of it or witnessing it) with specific triggers, goals, and interventions.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 services to improve or maintain range of motion (ROM, full movement potential of a joint) for two of seven sampled residents (Residents 5 and 16) with ROM concerns by failing to: Objectively measure Resident 5's ROM in both hands during the Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) Evaluation, dated 6/27/2025.Provide ROM services to Resident 16 who was identified as having ROM limitations in both arms and both legs.These deficient practices had the potential for Residents 5 and 16 to experience a further decline in ROM resulting in contracture (loss of motion of a joint associated with stiffness and joint deformity) development and have a decline in physical functioning, mobility (ability to move), and activities of daily living (ADL, basic activities such as eating, dressing, toileting).Findings:1. During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to Identify and to intervene in two of three sampled residents (Resident 114 and Resident 156)'s history of trauma (a strong emotional reaction to something upsetting or harmful that happened). and triggers (a sound, smell, place, or even a memory-that suddenly reminds someone of a scary or upsetting experience from the past. It can make them feel afraid, sad, or upset, even if they are safe now) which may cause re-traumatization as evidenced by:A. Failing to assess and identify the triggers of Resident 114's trauma related to a war he was in. B. Failed to do an assessment and identify the triggers of Resident 156's trauma related to family health status. This failure had the potential to result in Resident 114 and Resident 156 experience re-traumatization (a person encounters a new event or stimulus that triggers them to re-experience the intense stress, emotional distress, and even flashbacks of a previous traumatic event as if it were happening…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 employee files were maintained and kept up to date when performance evaluations (a process used by organizations to assess how well employees are performing in their roles) were not completed for three out of six sampled employees.This failure had the potential to adversely impact the quality of care of residents when staff performance is not current.Findings:During a concurrent interview and record review on 9/5/2025 at 10:54 a.m. with the Director of Staff Development (DSD), the employee files for the Director of Nursing (DON), Registered Nurse Supervisor (RNS)1, Licensed Vocational Nurse (LVN) 2, Certified Nurse Assistant (CNA) 4, CNA 5, and the DSD were reviewed. There were no annual performance evaluations for RNS 1, LVN 2, and CNA 4. The DSD stated the importance of doing performance evaluation yearly was to ensure staff are meeting the standard of care to perform the duties as licensed staff in the facility. The DSD stated performance evaluation should be done on a yearly basis. The DSD stated if 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 observations, interviews and record review, the facility failed to ensure:1.18 residents on pureed diet (foods that do not require chewing and are easily swallowed. All food should be smooth and pureed to the consistency of pudding) received pureed sweet potato texture in form that meet their needs and in accordance with the international Dysphagia Diet Initiative-level 4 (IDDSI-a framework made up of levels and describes food textures and drink thickness) level Four (pureed foods and extremely thick drinks) when the texture of the pureed sweet potatoes was lumpy, not smooth and had large pieces of potato present requiring chewing before swallowing. This failure had the potential to result in meal dissatisfaction and increased choking risk for residents on pureed diet.During an observation of the tray line (tray line-a system of food preparation, in which trays move along an assembly line) service for lunch on 9/2/2025 at 11:56AM, it was observed that the pureed sweet potatoes looked lumpy and not smooth. It was observed during the serving of the pureed sweet potatoes that…

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

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when:1.Three boxes of juice were in use and connected to a juice dispensing machine with no date and label; one box with 24 ice cream cups stored in the reach in freezer (a vertical storage unit commonly found in commercial kitchens) with date 2/2025 expired; raw shelled eggs and raw liquid eggs stored on same shelf and next to milk and a box of raw bacon stored next to a medium container of cooked macaroni.2. One cart stored next to the food preparation area was dirty, stained with sticky residue, covered with crumbs and food particles, the coffee machine glass gauge pipe was stained with dark brown color residue and in the dry storage area there were cans of grape jelly that was covered with clear wet droplets and was sticky to touch.These deficiencies had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness 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 three of four sampled residents (Residents 5, 66, and 124) had complete and accurate medical records by failing to:Ensure Resident 5's Restorative Nursing Aide (RNA, nursing aide program that help residents maintain any progress made after therapy intervention to maintain their function) splinting (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) orders for both hands and both knees were accurately written to indicate the recommended splint wear time and schedule (length of time and frequency a person can tolerate wearing the splint for safety, comfort, and maximal benefits).Ensure documented evidence of a conservatorship (court-ordered arrangement where a judge appoints someone [a conservator] to make decisions for an adult who can't manage their own financial or personal affairs, often due to mental or physical incapacitation) was included in the medical records for one of two residents…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the Binding Arbitration agreements (a binding agreement by the parties to submit to a private process where disputing parties agree that one or several other individuals can decide about the dispute after receiving evidence and hearing arguments) provided a selection of a venue that is convenient to both parties for three of three sampled residents (Resident 29, 104, and 156).This deficient practice violated the rights of Resident 29, Resident 104 and Resident 156.Findings:During a review of Resident 29's admission Record, the admission Record indicated Resident 29 was originally admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities).During a review of Resident 29's Minimum Data set (MDS), A resident assessment tool, 6/28/2025, the MDS indicated Resident 29's cognitive skills (functions your brain uses to think, pay attention, process information, and remember things) for daily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one of three sampled resident's (Resident 7) informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for psychotropics (drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) was obtained prior to administration of medications. This deficient practice violated Resident 7 and the responsible party's rights to receive all information, in advance, of risks and benefits of proposed care, treatment, treatment alterative, and choose the alterative of choice which includes information for administration of psychotropic drugs.Findings: During a review of Resident 7's admission Record, the admission Record indicated Resident 7 was readmitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities) with psychotic disturbance (a…

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

Based on observation, interview, and record review, the facility failed to ensure the call light was within reach for one of eight sampled residents (Resident 124).This deficient practice had the potential for Resident 124's needs not being met.Findings:During an observation on 9/2/2025 at 2:50 p.m., Resident 124 was lying in his bed, and his call light was on the floor to the left side of his bed. Resident 124 had a gold star (indicating high-fall-risk) next to his name plaque at the entry of his door.During a review of Resident 124's admission record, the admission record indicated Resident 124 was admitted to the facility 5/1/2025 with diagnoses including dementia (a group of conditions that cause a decline in cognitive abilities, such as memory, language, attention, and problem-solving, severe enough to interfere with daily life), history of falling, and age-related osteoporosis (a condition that weakens bones, making them more prone to fractures [broken bones]).During a review of Resident 124's Minimum Data Set (MDS, a resident assessment tool) dated 8/8/2025, the MDS indicated…

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

Based on interview and record review the facility failed to honor the choices of one of eight sampled residents (Resident 160) regarding care and cleaning of his wheelchair.This deficient practice resulted in Resident 160's wheelchair being removed from his room against his wishes, was not readily available when he wanted to use it and did not honor his resident's rights.Findings:During a review of Resident 160's admission Record (face sheet), the admission Record indicated Resident 160 was admitted to the facility 7/24/2018 with diagnoses of peripheral vascular disease (a condition in which narrowed blood vessels reduce blood flow to the limbs) and cellulitis (a common bacterial infection of the skin and underlying tissues) of left toe.During a review of Resident 160's Minimum Data Set ([MDS], a resident assessment tool) dated 7/17/2025, the MDS indicated Resident 160 was cognitively intact (describes a person whose brain functions are normal and unimpaired, enabling them to think, learn, remember, solve problems, and make decisions effectively).During a concurrent observation and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an Advance Directive ([AD], a legal document that outlines a person's healthcare preferences and appoints a healthcare agent to make medical decisions on their behalf if they become unable to do so) was accurate and completed as per the facility's policy and procedure (P/P) for one of two sampled residents (Residents 156).This deficient practice violated the resident's rights to be fully informed of the option to formulate an AD and had the potential to cause conflict with the residents' wishes regarding health care in the event resident became incapacitated (unable to participate in a meaningful way in medical decisions) or unable to make medical decisions that would not be identified and/or carried out by the facility staff.Findings:During a record review of Resident 156's admission Record, the admission Record indicated Resident 156 was admitted to the facility on [DATE] with diagnoses including bipolar disorder (sometimes called…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents (Resident 13) written notice of transfer was provided to the State Long-term Care Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities). This deficient practice resulted in violation of resident rights because the ombudsman could not advocate for the residents and investigate potential violations. Findings:During a review of Resident 13's admission Record, the admission Record indicated Resident 13 was originally admitted to the facility on [DATE] with diagnoses including post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event), homicidal (thought pattern characterized by the desire to kill another person or persons) and suicidal ideations (thinking about or planning to kill ones' self), and paranoid schizophrenia (a mental illness that is characterized by disturbances 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 reviews, the facility failed to update one of the two sampled residents' (Resident 9) care plans.This deficient practice had the potential to result in delays of care and services. Findings: During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was readmitted to the facility on [DATE] with diagnosis including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), metabolic encephalopathy (change in how your brain works due to an underlying condition), type 2 diabetes a disorder characterized by difficulty in blood sugar control), Alzheimer's disease(a disease characterized by a progressive decline in mental abilities), chronic kidney disease (condition where the kidneys gradually lose their ability to filter waste products from the blood) and hypertension (high blood pressure).During a review of Resident 9's Minimum Data set ([MDS] a resident assessment tool), dated 8/23/2025, the MDS…

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

Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for the assessment and application of splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) for one of seven sampled residents (Resident 4) by failing to:Ensure the Director of Rehab (DOR) who was a Physical Therapist (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) performed an assessment to determine the appropriateness and fit of Resident 4's right wrist/hand splint and right elbow splint.Ensure the DOR monitored and established Resident 4's right wrist/hand and right elbow splint wear time tolerance (length of time and frequency a person can tolerate wearing the splint for safety, comfort, and maximal benefits).These deficient practices had the potential to cause Resident 4 to have skin break down (tissue damage caused by friction, shear, moisture, or pressure), pain, discomfort, joint (where two bones meet) dislocation (an injury…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 45) was sitting upright when eating lunch.This deficient practice placed Resident 45 at risk for choking and aspiration (inhaling small particles of food or drops of liquid into the lungs). Findings: During a review of Resident 45's admission Record, the admission Record indicated the facility initially admitted Resident 45 on 8/25/2023 and re-admitted Resident 45 on 11/7/2024 with diagnoses including asthma (condition in which your airways narrow and swell making breathing difficult) and chronic obstructive pulmonary disease (lung disease that causes obstruction of airflow and can limit normal breathing).During a review of Resident 45's Minimum Data Set (MDS, a resident assessment tool), dated 6/2/2025, the MDS indicated Resident 45 had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 45 required supervision 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 for two of two residents (Resident 114 and Resident 7):1. Ensure Resident 114's buspirone (a medication used to treat anxiety [a medical condition described by feeling of fear or uneasiness]) was available in stock to be administered within 60 minutes of scheduled time of administration in accordance with physician orders and as per facility's policy and procedure (P&P) titled, Medication Administration, undated, affecting one of six sampled residents during medication administration. 2. Ensure facility's licensed nurse signed the controlled drug record (CDR- a log signed by the nurse with the date and time each time a controlled medication [medications that the use and possession of are controlled by the federal government] is received from the pharmacy or given to a resident) to indicate Resident 7's morphine sulfate concentrate (a controlled medication used to manage severe pain) was received from pharmacy, as per the facility's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medications requiring refrigeration were stored in accordance with manufacturer specifications and per facility's policy and procedure (P&P) titled, Medications Storage, undated, at a temperature range of 36 Fahrenheit [( F) is a unit of temperature] to 46 F or 2 Celsius [( C) is a unit of temperature] to 8 C, affecting one of two facility's medication room refrigerators (Station B Medication Room Refrigerator).This deficient practice had the potential to result in facility residents receiving medications that had become expired, ineffective, or toxic due to improper storage and labeling possibly leading to adverse health consequences such as hyperglycemia (high blood glucose), neuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet), inadequate comfort care and hospitalization.Findings:During a concurrent inspection and interview on [DATE] at 1:39 p.m. with Licensed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 with status of unfitting dentures (a removable plate or frame holding one or more artificial teeth) for one of three sampled residents (Resident 63).This Failure had the potential to result in Resident 63 having discomfort while eating or chewing foods that could lead to unintended weight loss and low self-esteem.Findings:During a review of Resident 63's admission Record, the admission Record indicated, Resident 63 was initially admitted to the facility on [DATE] and last re-admission was on 9/24/2022 with diagnoses including moderate protein-calorie malnutrition (an imbalance between the nutrients your body needs to function and the nutrients it gets) and dementia (a progressive state of decline in mental abilities). During a review of Resident 63's History and Physical (H&P), dated 8/13/2025, the H&P indicated, Resident 63 was oriented to person, place, and time.During a review of Resident 63'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.

Based on observation, interview and record review, the facility failed to ensure the lunch menu and spreadsheet (food portions and serving guide) was followed on 9/2/2025 for one of one residents (Resident 30) on a renal diet (a diet intended for residents with decreased kidney function. This diet regulates the dietary intake of sodium, potassium and protein to lighten the work of the diseased kidney) received the baked sweet potato instead of the mashed potato and received brown gravy instead of no gravy per the menu and renal diet guidelines.This deficient practice had the potential to result in meal dissatisfaction, and inadequate nutritional status when the menu is not followed to reflect the needs of the residents.During a review of Resident 30's physician diet order, dated 5/22/2025, Resident 30's physician diet order indicated Resident 30 diet was Renal CCHO small portions diet (a diet aimed to reduce the amount of sodium, potassium and carbohydrates in the food for people who have kidney disease and high blood sugar levels). (CCHO-Controlled Carbohydrate Diet-diet for blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one of three sampled resident's (Resident 7) informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for Valproic Acid ([psychotropics]drug that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) was renewed after 6 months. This deficient practice violated Resident 7 and the responsible party's rights to receive all information, in advance, of risks and benefits of proposed care, treatment, treatment alterative, and choose the alterative of choice which includes information for administration of psychotropic drugs.Findings: During a review of Resident 7's admission Record, the admission Record indicated Resident 7 was readmitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities) with psychotic disturbance (a mental health condition…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Restorative Nursing Aide 1 (RNA 1) wore an isolation gown (protective apparel used to protect the wearer from the transfer of microorganisms and body fluids) while providing Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain any progress made after therapy intervention to maintain their function) exercises to one of seven sampled residents (Resident 5) who was on Enhanced Barrier Precautions (EBP, infection control intervention using gown and gloves during high contact resident care activities designed to reduce the transmission of multi-drug resistant organisms). This deficient practice had the potential to transmit infectious microorganisms and increase the risk of infection among the residents and staff members.Findings:During a review of Resident 5's admission Record, the admission Record indicated the facility initially admitted Resident 5 on 8/31/2018 and re-admitted Resident 5 on 6/26/2025 with diagnoses including chronic obstructive pulmonary disease (lung disease…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to protect one of three sampled residents' (Resident 1) right to be free from physical abuse. This failure resulted in Resident 2 punching Resident 1 on the left side of Resident 1's eye on 8/10/2025. Resident 1 had swelling on the left side of his forehead near the left eye.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought) and anxiety disorder (a mental health condition characterized by excessive and persistent worry, fear, and nervousness that can significantly interfere with daily life).During a review of Resident 1's Minimum Data Set ([MDS] - a resident assessment tool), dated 05/22/2025, the MDS assessment indicated Resident 1's cognitive (ability to think, understand, learn, and remember) skills for daily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of six sampled resident (Resident 2) who resided at the facility and was transferred to General Acute care hospital (GACH) on 8/10/2025 was readmitted to the facility.This deficient practice resulted in Resident 2 being denied readmission by the facility. Resident 1 did not return to the facility.Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] with diagnoses including schizoaffective disorder ( a mental illness that can affect thoughts, mood, and behavior) and unspecified psychosis ( a severe mental condition in which thought, and emotions are so affected that contact is lost with reality).During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 1's cognitive skills for daily decision making was intact. The MDS indicated Resident 2 was supervision or touching assistance with oral hygiene, toileting and dressing. The MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan with goals and interventions for one of six sampled residents (Resident 1) when Resident 1 was punched by Resident 2 on the left side of Resident 1's left eye on 8/10/2025.This deficient practice placed Resident 1 at risk for insufficient provision of care and services and had the potential for continued abuse.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought) and anxiety disorder (a mental health condition characterized by excessive and persistent worry, fear, and nervousness that can significantly interfere with daily life).During a review of Resident 1's Minimum Data Set ([MDS] - a resident assessment tool), dated 05/22/2025, the MDS assessment 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 interview and record review, the facility failed to schedule and follow up on the ordered neurology (specialty care related to the diagnosis and treatment of the nervous system) consultation for one of three sampled residents (Resident 1). This failure resulted in a delay for the delivery of care and services for Resident 1. Findings: During a review of Resident 1's admission record, the admission record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including polyneuropathy (condition where nerves are damaged causing numbness, tingling, pain, or weakness) and anxiety disorder (excessive worry that interferes with daily activities). During a review of Resident 1 ' s Minimum Data Set (MDS – a resident assessment tool), dated 3/20/2025, the MDS indicated Resident 1 had moderate cognitive (ability to learn, reason, remember, understand, and make decisions) impairment, required set-up assistance with eating, and required maximal assistance with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one of four sampled residents (Resident 1) was treated with respect and dignity by failing to honor resident ' s refusal to come back to bed for provision of personal care. This failure had the potential to violate resident ' s rights and led to Resident 1 having increased agitation and restlessness. 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 Alzheimer ' s disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities), depression (a constant feeling of sadness and loss of interest which stops a person doing normal activities), and unspecified psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a review of Resident 1 ' s History and Physical (H&P) dated 12/1/2024, the H&P…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the Certified Nursing Assistance (CNA)1 closed the privacy curtain while performing Activities of Daily Living(ADL ' s – daily task in life) for 2 out of 3 sample Residents (Resident 4) and (Resident 5). This deficient practice placed Resident 4 and Resident 5 visually exposed to other staff and residents . Findings: During a record review of Resident 4 ' s admission Records ), the admission record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses anxiety (conditions that cause excessive and persistent feelings of fear or worry that can interfere with daily life), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest.Spondylolysis (is a stress fracture in the pars interarticularis, a thin bone that connects two vertebrae in the spine). During a record review of Resident 4 ' s Minimum Data Set (MDS a resident assessment tool), dated 10/01/2024, the MDS…

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

Based on observation, interview and record review, the facility failed to: 1.Label and date food stored and thawing in the refrigerator and freezer according to facility policy. This deficient practice placed the facility residents at risk for foodborne illness. 2.Ensure the chemical in the dishwasher used for sanitizing, was at the proper level of 50 ppm (parts per million). When the kitchen staff tested the sanitizer in the dishwasher, the test strip indicated the chemical level was 0 ppm. This deficient practice of insufficient chemical sanitizer in the dishwasher had the potential to lead to use of contaminated dishes and utensils for 140 of 142 residents in the facility residents and can cause foodborne illness -an infection or irritation of the gastrointestinal (GI) tract caused by food or beverages that contain harmful bacteria, parasites, viruses, or chemicals). Findings 1. During an observation on 7/16/2024 at 8:56 a.m. the following was observed: In Freezer #3, three oven roasted turkey breast were not labeled with date received and expiration date. In Freezer #2, two bags…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 keep Refrigerator #1 in working condition when Refrigerator #1 was observed to have a pool of water sitting at the bottom of the refrigerator. This deficient practice had the potential to result in rapid growth of bacteria that can cause foodborne illness (food poisoning). Findings During an observation on 7/16/2024 at 8:58 a.m. of Refrigerator #1, it was observed that ham, chicken, and bacon were being defrosted. Observed a standing water at the bottom under the container of defrosting chicken. During an interview on 7/16/2024 at 8:58 a.m. with [NAME] 1, [NAME] 1 stated water will drip from the top of the refrigerator and collect at the bottom of the refrigerator. [NAME] 1 stated that it has been going on for the last two weeks. [NAME] 1 stated that maintenance was notified and checked Refrigerator #1. [NAME] 1 stated it was not normal for the refrigerator to operate in that way and it could grow germs or bacteria. During an interview on 7/17/2024 at 3:29 p.m. with the Regional Dietary Manager (RDM), the RDM stated she sent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure three out of 16 sampled residents (Resident 10, Resident 33, and Resident 61) were treated with dignity and respect by failing to: 1.Acknowledge the call lights for Resident 10 and Resident 33 when they needed assistance. This deficient practice had the potential to cause a safety risk of residents getting out of bed and falling due to their call lights not being answered and had a potential of not meeting the needs of Resident 10 and Resident 33 resulting in feelings of not being important and low self-esteem. 2. Ensure Certified Nurse Assistant (CNA) 3 fed Resident 61 lunch while sitting at eye level. This deficient practice had the potential for Resident 61 to feel as though they were not treated with dignity and respect. Findings: During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was admitted to the facility on [DATE] with diagnoses of major depressive disorder (a mental health…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 investigation was conducted following a resident-to-resident altercation between Residents 18 and 61. This deficient practice resulted in the facility not identifying other potential residents who may have had resident-to-resident altercations not being identified and had a potential for further resident-to-resident altercations to occur between Resident 18 and 61. Findings: a. During a review of Resident 18's admission Record, the admission Record indicated Resident 18 was admitted to the facility on [DATE]with diagnoses including osteoarthritis (when the cartilage that cushions the ends of bones in the joints gradually deteriorates), acute kidney failure (the rapid loss of the kidney's ability to remove waste and help balance fluids in the body), and gastro-esophageal reflux disease ([GERD] stomach acid repeatedly flows back up into the tube connecting the mouth and stomach). During a review of Resident 18's History and Physical (H&P) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow through with the Preadmission Screening and Resident Review ([PASRR] a tool to ensure possible individuals with mental illnesses or intellectual disabilities are appropriately placed in nursing homes for long term care) recommendation to obtain a PASRR Level II (helps determine placement and specialized services) evaluation for three of three sampled residents (Resident 4, 60 and 61). This failure had the potential to result in inappropriate placement and unidentified specialized services for Resident 4, 60 and 61. Findings: a. During a review of Resident 4's Face Sheet, the Face Sheet indicated Resident 4 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including basal cell carcinoma (cancer- body's cells grow uncontrollably and spread to other parts of the body) of the skin of the nose, malignant neoplasm (abnormal growth of tissue or cells) of right lacrimal (tear duct) gland and major depressive episode…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement an individualized person-centered plan of care with interventions to meet the residents' needs for one of two sampled residents (Resident 152). The facility failed to: Ensure Resident 152's, care plan interventions to include call light within reach and implemented by CNA 5 prior to leaving the residents' room. CNA 5 was not aware Resident 159 was visually impaired. This deficient practice had the potential to put Resident 152 at risk for injury, delays the provision of care and is a violation of residents' rights. Findings: During a review of Resident 152's admission Record (Face Sheet) the Face Sheet indicated Resident 152 was admitted to the facility on [DATE] with diagnoses including vision loss, schizoaffective disorder (condition where person will experience delusions and hallucinations), and muscle weakness. During a review of Resident 152's MDS, dated [DATE], the MDS indicated Resident 152 had the ability to…

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

Based on observation, interview, and record review, the facility failed to ensure staffing information was posted and readily available to residents and visitors. This deficient practice resulted in residents and visitors not being able to access accurate daily numbers of clinical staff taking care of residents. Findings: During an observation on 7/16/2024 at 10:57 a.m., at the facility entrance, there was no daily staffing information posted. During a concurrent observation and interview on 7/16/2024 at 11:02 a.m., with Registered Nurse (RNS) 1, at the nurse's station and front entry doors, there was no daily staffing information posted. RNS 1 stated there was no daily staffing information posted at the nurse's station nor the front entry. RNS 1 stated the daily staffing information should be posted at the front entry way double doors. During a concurrent observation and interview on 7/16/2024 at 11:13 a.m., with the Director of Staff Development (DSD), the DSD stated she is responsible for posting the daily staffing information at the facility's entryway but did not post the daily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to track and record the administration of controlled substances (a medication/ drug or other substance that is tightly controlled by the government because it may be abused or cause addiction) in real time for four out of 54 (Resident 34, Resident 82, Resident 115, and Resident 149) sampled Residents. This deficient practice had the potential to cause medication errors (any preventable event that may cause or lead to inappropriate medication use or patient harm) and the potential for drug diversion (illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber). Findings: During a review of Resident 34's admission Record, the admission Record indicated Resident 34 was admitted to the facility on [DATE] with diagnoses of anxiety disorder (persistent and excessive worry that interferes with daily activities) and schizophrenia (a disorder that affects a person's ability to think, feel, and behave…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dietary staff (Cook 1 and [NAME] 2) were competent in safe and effective food preparation. This deficient practice resulted in [NAME] 1 and 2 not having the knowledge and competency to prepare a fortified meal (add vitamins and minerals that are not naturally present in food). Findings During an observation on 7/17/2024 at 11:39 a.m. with [NAME] 2 during tray line (meal preparation when trays are moved along an assembly line), [NAME] 2 was observed adding extra tomato sauce for a fortified meal. During an interview on 7/17/2024 at 11:40 a.m. and a subsequent interview at 3:24 p.m. with [NAME] 2, [NAME] 2 stated when a meal needs to be fortified, extra sauce or gravy was added. [NAME] 2 stated the purpose of fortified meal was to make the food easier to swallow for the residents. During an interview on 7/17/2024 at 11:42 a.m. with [NAME] 1, [NAME] 1 stated when a meal needs to be fortified, she would sprinkle cheese on top of it. During a review of a sign posted in the kitchen titled Fortified Diet,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 appropriately assess one of one sampled resident (Resident 152) who was visually impaired. This deficient practice resulted to inaccurate assessment of Resident 152's vision leading to a potential delay in care and needed vision services. Findings: During a review of Resident 152's admission Record (Face Sheet) the Face Sheet indicated Resident 152 was admitted to the facility on [DATE] with diagnoses including vision loss, schizoaffective disorder ( condition where person will experience delusions and hallucinations), and muscle weakness. During a review of Resident 152's Resident admission assessment document, dated 7/1/2024, the assessment indicated Resident 152 is legally blind. During a review of Resident 152's care plan, dated 7/3/2024, the care plan indicated the following concerns Resident 152 is at risk for injury related to unspecified vision loss. The care plan indicated the following goals, resident is at risk for injury related to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to revise the comprehensive resident centered care plan for one of three sampled residents (Resident 88). The facility failed to ensure Resident 88's care plan interventions were specific to include the need for direct line of sight (unobstructive view) monitoring for Resident 88. This deficient practice placed Resident 88 at high risk for harm due to falls or accidents. Findings: During a review of Resident 88's admission Record, the admission Record indicated Resident 88 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including schizophrenia (mental disorder affecting the ability to think, reason, make decisions), muscle weakness and polyarthritis (pain and swelling in joints). During a review of Resident 88's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 4/9/2024, the MDS indicated Resident 88 had severe cognitive impairment (ability to think, learn, remember, use…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of three sample residents (Resident 129) who was receiving enteral (nutrition delivering into the body with the aid of a feeding tube) feedings received appropriate care and services to prevent complications of enteral feedings. The facility failed to ensure the licensed nursing staff appropriately assessed Resident 129 to be positioned with the head of bed (HOB- head of resident's bed elevated) at 35-45 degrees. This deficient practice resulted in potential harm resulting from aspiration (when fluid accidentally enters windpipe into the lungs) for Resident 129. Findings: During a review of Resident 129's admission Record (Face Sheet) the Face Sheet indicated Resident 129 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia (loss of the ability to think, remember and reason), dysphagia (difficulty swallowing) and encephalopathy (damage or disease affecting brain). During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure: a. physician gave informed consent (the process in which a health care provider educated a patient about the risks, benefits, and alternatives of a given procedure or intervention) before the administration of any psychotropic (capable of affecting the mind, emotions, and behavior) medication for one of eight sampled residents (Resident 14). b. Resident 4's Responsible Party (RP)and the Licensed Nurse who received the medication order and verified that medical doctor obtained informed consent (decision made freely by the resident or RP, after he/she had knowledge and understanding of the risks and benefits, available options about the various treatment alternatives) for the administration of Lorazepam (psychotherapeutic drug). c. informed consent was signed and dated for Resident 152 's administration of Invega Sustenna (psychotherapeutic drug) and Ativan (psychotherapeutic drug). These failures resulted in violation of resident's rights and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement the antibiotic stewardship program policy for one of one sampled resident (Resident 129) when an antibiotic (a substance used to kill bacteria and to treat infections) did not meet McGreer Criteria (criteria used to determine appropriate use of antibiotics). This deficient practice had the potential to increase antibiotic resistance and the resident to be provided antibiotics without justification. Findings: During a review of Resident 129's admission Record, the admission Record indicated Resident 129 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses including urinary tract infection (bacterial infection of the bladder). During a review of Resident 27's Minimum Data Set (MDS), standardized resident assessment and care screening tool dated 10/1/2023 indicated Resident 129's cognition (the ability to think and make decisions) was severely impaired. Resident 129 was not oriented to date or time and 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 mitigate the spread of legionella bacteria (a bacteria found in aquatic environment that can spread in droplets small enough for people to breathe in that cause lung infection with symptoms that include cough, shortness of breath, fever, muscle aches, headaches, diarrhea, nausea and confusion)in the facility when one of eight sampled residents was transferred to a General Acute Care Hospital (GACH) and tested positive for legionella bacteria on approximately 3/5/2024. a. the facility failed to ensure the facility's water supply used for drinking water, ice making (ice cubes), beverages and hygienic purposes (resident showers and personal hygiene) have been tested for the presence of legionella bacteria. b. the facility failed to ensure residents were not consuming the untested water for drinking and ice cubes. These deficient practices had the potential to result in the spread of legionella bacteria in the facility affecting the residents,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was safely assisted by a Certified Nursing Assistant (CNA 2) when Resident 1 was turned and repositioned during incontinence care (cleaning the skin with mild soapy water, rinsing well, and patting the skin dry after an episode of uncontrolled urine and bowel movement). This deficient practice resulted in Resident 1 falling from her bed, hitting her head and knee on the floor and had the potential for Resident 1 to sustain injuries. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus ([DM] a serious condition where the blood glucose [sugar] is too high) and atrial fibrillation (an irregular, often rapid heart rate) During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 1/15/2024, the MDS indicated Resident 1 was able…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to observe infection control measures by: 1. Failing to handle and dispose trash bags in an appropriate receptacle by leaving them on the floor of Resident 1 ' s room. 2. Failing to ensure an unvaccinated employee ' s N95 mask ( high filtering face piece respirator that protects the wearer from inhaling airborne particles) fit test was up to date during a Covid-19( contagious and infectious respiratory disease) outbreak This failure had the potential to result in spread of infection and risk of cross contamination( physical movement or transfer of harmful bacteria from one person, object or place to another). Findings: 1.During a review of Resident 1 ' s Face Sheet, the Face Sheet indicated the resident was initially admitted on [DATE] and was readmitted on [DATE] with diagnoses that included Parkinsonism( occurs when nerve cells of the brain don ' t make enough of a body chemical which can affect your mood and movement),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 preparation and storage practices were followed in the kitchen when: The foods were not identified, not labeled with opened dates, there was no received dates, foods were stored for use past its printed best by dates, the shelves and floors of the refrigerator and dry storage areas contained food debris and dust, and the chemicals were kept next to foods. The residents' personal refrigerators (4, 9, 89, 100) contained foods that were expired, not labeled and dated, the residents who refused to discard the foods when expired were not educated on the risks of foodborne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins and food poisoning symptoms may include cramping, nausea, vomiting, or diarrhea), the personal refrigerator temperatures were not consistently documented. These failures to ensure the resident's personal refrigerators were maintained in a clean manner…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide two of 12 residents (19, 100), and or their responsible parties with written information on how to formulate an Advanced Directive (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor). This deficient practice had the potential for violating Resident 19 and 100 choices about their medical care. Findings: a. During a review of Resident 100's medical records the following information was missing: Resident 100 (admitted on [DATE], readmitted on [DATE]) did not have an advanced directive or a signature declining information on how to obtain an advanced directive that was accessible in the current clinical records. During an interview and concurrent record review on 5/12/2021 at 11:17 a.m., the Licensed Vocational Nurse (LVN 1) stated once the resident was admitted to the facility the Advance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement comprehensive care plans that included measurable objectives and timeframe to meet four of 27 resident (22, 25, 80, 209) medical, nursing, and mental, and psychosocial needs as identified in the comprehensive assessment by: Resident 22, who was performing self cauterization (the insertion and removal of a catheter several times per day to empty urine in bladder) did not have a plan of care to reduce the risks for infections. Resident 25, was assessed for an inflatable carrot orthosis (a carrot shaped orthotic device to reduce the risks for contractures) due to contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) to the right hand but there was no plan of care formulated that addressed the use of the orthosis. Resident 80, did not have a plan of care that addressed aspiration (inhalation of oropharyngeal or gastric contents into…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 four of 4 residents (9, 53, 95, 100) by notifying and inviting the residents, their family members or responsible parties to an Interdisciplinary Team ([IDT] a team of healthcare professionals from different professional disciplines who work together to manage the physical, psychological and spiritual needs of the patient, whenever possible the patient and the patient's family should be part of the team) meetings to participate in the development, review or revisions of the plan of care. This failure had the potential to cause inappropriate care and services by not receiving any pertinent or necessary information from Resident 9, 53, 95, and 100, their responsible parties and/or family members to assist with developing and revising comprehensive person centered plan of care. Findings: a. During a review of Resident 9's admission Face sheet indicated the resident was admitted to the facility on [DATE]. The admission Face sheet indicated Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide quality of care and treatments based on the comprehensive assessment and plan of care for four of 5 residents (14, 44, 80, 90), which put them at risk for further decline by: Resident 14, complained of itchiness and rash (temporary outbreak of red, bumpy, scaly, or itchy patches of skin, possibly with blisters or welts) to the staff but the change of condition was not reported to the charge nurse. Resident 44, who had a fracture (broken bone), pain during ambulation (walking), and used a controlled ankle motion (cam) boot was not rescheduled for a cancelled orthopedic (the branch of medicine that deals with the musculoskeletal system) appointment. Resident 80, who had swallowing problems was not provided with 1:1 supervision, and aspiration precaution (are practices that help prevent foods or fluids get into the airway causing infections) by lying flat in bed while attempting to eat. Resident 90, who needed oxygen therapy but the…

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

Based on observation, interview, and record review, the facility failed to ensure staff followed food production recipes and the fortified diet (diet enhanced to increase caloric intake) spreadsheet when preparing lunch using pre-made frozen meatballs. The facility failed to serve fortified diets for the first three meal carts during the 5/11/21 lunch service as ordered. This deficient practice of not following recipes during food production had the potential to affect overall nutrient intakes for residents who consumed pre-made meatballs and not providing fortified diets as instructed had the potential to result in undesirable weight loss for residents who required a fortified diet. Findings: During a meal trayline observation on 5/11/21 at 12:03 p.m., [NAME] 3 was observed serving six meatballs with gravy during plating. The Diet Aide (DA) was observed from 12:03 p.m. to 12:15 p.m. calling out the resident's diet orders while the cooks plated each dish. The DA did not call out the fortified diets although the residents had fortified diets written on the tray card for the first…

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

Based on observation, interview, and record review, the staff failed to have a systematic timeline and documenting the inspection for checking the laundry room dryer lint screens in for increased buildup of lint in order to reduce the risks of fire hazard. This deficient practice had the potential of exposing all the residents, staff, and visitors to an unsafe and hazardous environment. Findings: On 5/13/21 at 10:30 a.m., during a general observation in the presence of Laundry Room Supervisor (LRS) he was not able to provide evidence, such as a log to show the dryers had been systematically checked for buildup of lint to prevent a fire hazard. During observation both of the dryer lint screens had increased buildup of lint and both dryers were in process of drying the resident's linens. A review of a log record on 5/13/21 at 10:35 a.m. titled Covid-19 Cleaning and Disinfection Log of high Touch Surfaces, that was kept in the laundry room, provided by LRS did not indicate the dryer lint screens were checked systematically for increased build of lint. On 5/13/21 at 10:45 a.m. during an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a functioning call light (a communication system that calls directly to a staff member or to a centralized location where staff are working, such as a nurses' station) for two of 2 resident (52, 104). Resident 52, who needed the assistance of staff for activities of daily living ([ADLs] self-care activities performed daily such as bathing, eating, and getting in and out of a bed or chair) had was not equipped with a call light. Resident 104, who needed the assistance of staff for ADLs was not equipped with a functioning call light. Resident 104's call cord was broken. This deficient practice had the potential to result in a delay in meeting Residents 52, and 104's during emergencies, and when needing assistance with ADLs. Findings: a. During a review of Resident 52's admission Record indicated the resident was admitted to the facility on [DATE], and last readmitted on [DATE]. The admission Record indicated Resident 52's diagnoses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complete personal privacy for one of 3 residents (102) who had a behavior of undressing self. Resident 102, who needed assistance with activities of daily living ([ADL] a term used to collectively describe fundamental skills that are required to independently care for oneself), needed incontinent briefs (diaper) due to incontinence (no control) of bowel and bladder functions, and who had a behavior of undressing self was exposed to the general population walking in the hallway. This deficient practice resulted in the violation of Resident 102's personal privacy. Findings: A review of the admission Records indicated Resident 102 was re-admitted to the facility on [DATE] with diagnoses that included chronic diastolic heart failure (when your heart is not able to relax fast enough), type 2 diabetes mellitus (abnormal blood blood sugar), unspecified atrial fibrillation (a quivering or irregular heartbeat that can lead to blood clots,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 5 residents (66) was made aware of a facility's bed-hold policy by documenting the acknowledgment of the rights before and upon transfer to a hospital or when taking a therapeutic leave of absence from the facility. This deficient practice had the potential for Resident 66 to be at risk for not understanding their rights for bed hold policy during all transfers. Findings: A review of Resident's 66 admission Face sheet dated 12/23/19 indicated the resident was readmitted [DATE] with diagnoses including metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), hypothyroidism (underactive thyroid), and schizoaffective (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania). A review of Resident's 66 Minimum Data Set (MDS), a standardized assessment and care screening tool dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of 3 residents (53) received assessment and assistive devices if needed, to improve hearing. Resident 53, who was assessed as having minimal difficulties with hearing, and cerumen ( (ear wax) but the physician orders/treatment for a follow-up with for re-evaluation of the hearing abilities was not followed up. This deficient practice prevented Resident 53 from gaining access to an appointments and possible treatment to be reassessed for hearing and to be fitted with hearing aids if needed. Findings: A review of Resident 53's admission Face Sheet indicated the resident was admitted to the facility on [DATE]. The Face sheet indicated Resident 53's admitting diagnosis was epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electric activity in the brain). A review of Resident 53'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.

Based on observation, interview, and record review the facility failed to ensure one of 27 residents (109) received the services for range of motion ([ROM] the full movement potential of a joint) and when refused the physician and responsible party were both notified. Resident 109, who refused rehabilitation department to assess the mobility status when there was no weight bearing (NWB) of the left lower extremity, the risks were identified and the physician and responsible party were both notified. The deficient practice could potentially cause the ROM to decline further leading to increased pain for Resident 109. Findings: On 5/11/21 at 11:50 a.m., Resident 109 who was identified as having limited ROM was observed sitting in a wheelchair. The resident was able to use the upper and lower extremities to move around the facility by using the left extremities to crossover the right extremities. A review of Resident 109's admission record indicated the resident's diagnoses included schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves) 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 1 resident (19) was provided with a safe and secure bed that was equipped with functioning wheel locks to avoid accidents when leaning or standing along the bedside. This deficient practice had the potential for the bed to move and cause Resident 19 to stumble and fall resulting in bodily harm or injury. Findings: A review of admission Records indicated Resident 19 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included stroke (occurs if the flow of oxygen-rich blood to a portion of the brain is blocked and without oxygen, brain cells start to die after a few minutes), hemiplegia (total or partial paralysis of one side of the body), type 2 diabetes mellitus ([DM] abnormal blood sugar levels), cataracts (a medical condition in which the lens of the eye becomes progressively opaque, resulting in blurred vision), anxiety (apprehension, tension, or uneasiness that stems from the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement and reevaluate the plan of care that was ordered by the physician for one of three sampled residents (Resident 22). Resident 22, who preferred to self-catheterize by using an in and out catheter method; Resident 22 not provided with services and treatments to prevent urinary tract infections and to restore incontinence to the extent possible. This deficient practice of delaying treatment from an Infectious Disease consult [ID](A physician that specialized in infections) prevent the reevaluation of recurring urinary tract infections. Resident 22 has had multiple recurrent Urinary Tract Infections (An infection in any part of the urinary system [kidney, bladder or urethra) and an E. Coli infection (A type bacteria that lives in the intestines) was identified on 5/3/2021, 4/03/2021 and 2/2/2021. An ID consult was ordered on 4/29/2021. The facility failed to assess and document the techniques for catheter care and reevaluate with treatment…

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