Long Beach Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an allegation of abuse was reported for one of three sampled residents (Resident 1), when Resident 1 reported that a resident (Resident 2) pulled his right arm and touched his right leg multiple times. This deficient practice resulted in the inability of the California Department of Public Health (CDPH) to investigate the allegation of abuse in a timely manner and had the potential for information and recollection of the event(s) to be possibly lost. Findings: During a review of Resident 2's admission Record (Face Sheet) Face Sheet indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including picks disease (a gradual deterioration of nerve cells leading to changes in behavior and social appropriateness), and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 2's Minimum Data Set ([MDS] a resident assessment tool) dated 6/30/2025,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure for four of four sampled residents, who had orders for an electrocardiogram ([EKG/ ECG] a test that measures the electrical activity of the heart), and/or who had a change of condition (COC), that the EKG results and the COC were reported to the physician(s) in a timely manner. The facility failed to: 1. Notify the physician when Resident 2 reported lightheadedness, weakness and feeling dizzy when ambulating to the bathroom on 6/20/2025. 2. Notify the physician(s) of the results of EKGs conducted for Resident 1, Resident 3 and Resident 4. These deficient practices resulted in: 1. Resident 2 being assessed with an altered level of consciousness ([ALOC] a change in a person's awareness and responsiveness to their environment, compared to their normal state), bradycardia (a slow HR , reference range 60-100 bpm), hypotension (low blood pressure, below 90/60 mmHg), bradypnea (slow breathing, below 12 breaths per minute) and a critically high…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 5) was not verbally abused by Certified Nursing Assistant (CNA) 1, when CNA 1 and Resident 5 got into an argument and CNA 1 used profanity. This deficient practice resulted in Resident 5 being frustrated and upset when during an argument between him and CNA 1, CNA 1 said fuck you.During a review of Resident 5's admission Record (Face Sheet), the Face Sheet indicated Resident 5 was admitted to the facility on [DATE] with diagnoses including post laminectomy syndrome (a condition where persistent or recurrent pain develops after a laminectomy or other spinal surgery) and depression (a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest in previously enjoyable activities). During a review of Resident 5's Minimum Data Set ([MDS] a resident assessment tool) dated 7/17/2025, the MDS indicated Resident 5's cognition (the mental action or process 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 assess one of four sampled residents (Resident 1) after Resident 1 complained of chest pain and a electrocardiogram ([EKG/ECG] a test that measures the electrical activity of the heart) was ordered due to chest discomfort. This deficient practice resulted no documentation or knowledge of Resident 1's medical stats and had the potential for a delay in care and treatment.During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with the diagnoses including CKD and DM. During a review of Resident 1's MDS dated [DATE], the MDS indicated Resident 1's cognition was intact. During a review of Resident 1's Physician Progress Note dated 6/10/2025, the Physician Progress Note indicated Resident 1 reported that she was experiencing chest pain on her left side which started a few weeks prior, but she could not remember the exact date that it began. The Physician Progress Note 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 implement its abuse prevention policy by failing to report the alleged physical abuse between Resident 1 and Resident 2 to the State Survey Agency (California Department of Public Health-CDPH) within two hours of the occurrence for two of three sample residents (Resident 1 and Resident 2).This failure had potential to result in a delay of an onsite inspection by the CDPH to ensure alleged physical abuse was investigated and lead to a delay in prevention of potential ongoing physical abuse.Findings:A. During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was initially admitted to the facility on [DATE] and last readmission was on 6/14/2025 with diagnoses including anxiety disorder (a group of mental health conditions characterized by excessive, persistent, and unrealistic worry and fear about everyday situations), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) 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 three of 12 sampled residents( Resident 22, Resident 90 and Resident 96) received necessary care and services by failing to: 1. Document a change in condition ( COC a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral or functional condition ) for Resident 22's missed laboratory blood draw. 2. Assess and perform full body skin assessment when Resident 90 verbalized allegation of physical and sexual abuse against a certified nursing assistant. 3. Identify Resident 96's episodes of hyperglycemia ( high blood sugar) and notify the physician when Resident 96's blood sugar readings was persistently abnormal and elevated from 5/19/2025 to 5/22/2025. These failures had the potential to place Resident 22, Resident 90 and Resident 96 at risk for delay of care and treatment. Findings: 1.During a review of Resident 22's admission Record, the admission Record indicated Resident 22 was admitted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Restorative Nursing Aide (nursing aide program that help residents maintain any progress made after therapy intervention to maintain their function) services provided were accurately documented for three of nine sampled residents (Residents 3, 116, and 121). 1.For Residents 3, the facility failed to ensure RNA daily documentation accurately reflected RNA services provided. 2.For Resident 116, the facility failed to ensure RNA daily documentation accurately reflected RNA services provided. 3.For Resident 121, the facility failed to ensure the RNA daily documentation prompts (questions or cues used to direct the write on the specific focus or task) pertained to the RNA task of services provided. These deficient practices had the potential to negatively impact the provision of necessary care and services due to the inaccurate reflection of services provided. Findings: 1. During a review of Resident 3's admission Record, the admission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain and observe infection control practices by: 1.Failing to ensure Resident 91's curtains were clean and free of stains. 2.Staff failed to perform hand hygiene when entering and exiting resident's room (Resident 38 and 40) when done with providing care. 3.Failing to ensure Occupational Therapist 1 (OT 1) used the appropriate cleaning agent to effectively clean and disinfect a cloth gait belt after providing occupational therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) services to Resident 24. 4. Failing to ensure Certified Nursing Assistant 9 (CNA 9) performed hand hygiene after touching high contact surfaces in Resident 82's room. These failures had the potential to result in cross contamination (physical, movement or transfer of harmful bacteria from one person, object, or place to another) and place residents at risk for spread of…

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

Based on observation, interview, and record review, the facility failed to maintain electrical therapy (services given to restore an individual back to their highest possible level of physical, mental, and psychosocial well-being) equipment for three (3) of 3 devices for resident use during therapy treatment in the therapy gym. These failures jeopardized resident and staff safety and had the potential to cause harm and injury to residents using the therapy equipment during electrical therapy treatment. Findings: During a concurrent observation and interview on 5/20/2025 at 1:45 p.m., in the therapy gym, the Director of Rehabilitation (DOR) stated the rehabilitation department (Rehab) had three types of electric equipment for resident use during therapy treatment: a motorized electrical bicycle for the arms and legs (TE1), a recumbent cross trainer (TE2, exercise machine used in a sitting position with foot pedals and handlebars), and recumbent stepper (TE3, exercise machine used in a sitting position with foot pedals). TE 1, TE 2, and TE 3 were observed in the back of the therapy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility did not ensure that staff assisted residents at eye level during feeding for two of the four sample residents (Resident 38 and Resident 40). These deficiencies had the potential to impact the residents' rights, particularly regarding dignity and respect, which could lead to feelings of inadequacy among the residents. Findings: a.During a review of Resident 38's admission Record, the admission Record indicated Resident 38 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including dementia (a progressive state of decline in mental abilities), anxiety (a feeling of fear, dread, and uneasiness), cirrhosis of liver (a type of liver damage where healthy cells are replaced by scar tissue), and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 38's History and Physical (H/P), dated 9/24/2024, the H/P indicated Resident 38 can make needs known but cannot…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the licensed nursing staff failed to ensure the resident and/or responsible party (RP) were informed in advance of the risks and benefits of psychoactive medications (a drug that changes brain function and results in alterations, mood, consciousness, or behavior) for one of four sampled residents (Resident 38). This failure violated the residents' right to make an informed decision regarding the use of psychoactive medications. Findings: During a review of Resident 38's admission Record, the admission Record indicated Resident 38 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), mood disorder (a mental health condition that primarily affects your emotional state), and anxiety (a common emotion characterized by feelings of worry, fear, and unease). During a review of Resident 38's Minimum Data Set (MDS- a resident assessment tool) dated 11/29/2024, the MDS indicated Resident 38's cognition (ability…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled resident (Resident 23) needs were accommodated when Resident 23's mattress was too small for Resident 23's bedframe. This failure resulted in Resident 23 needs not provided to make it a comfortable and homelike environment. Findings: During a review of Resident 23's admission Record, the admission Record indicated Resident 23 was admitted to the facility on [DATE] with diagnoses including paraplegia (loss of movement and/or sensation, to some degree, of the legs), obesity (having too much body fat), and depression (a persistent state of sadness or lack of interest in things that you used to enjoy). During a review of Resident 23's Minimum Data Set (MDS- a resident assessment tool) dated 3/26/2025, the MDS indicated Resident 23's cognition (ability to think, understand, learn, and remember) was intact and was dependent (helper does all the effort) with toileting, bathing, and dressing. During a concurrent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the interview and record review, the facility did not honor the choice and preferences of one of six sampled residents (Resident 90) to have a shower before a medical appointment. This failure had the potential to violate Resident 90's right to have a personal choice which could lead to frustration and anger. Findings: During a review of Resident 90's admission Record, the admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] to the facility with diagnoses that included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hemiplegia and hemiparesis (total paralysis of the arm, leg, and trunk on the same side of the body) following cerebral infarction (stroke)affecting left side and anxiety disorder( intense , excessive, and persistent worry and fear about everyday situations). During a review of Resident 90's Minimum Data Set (MDS-resident assessment tool) dated 4/3/2025, the MDS indicated Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to inform the physician when one of three sampled residents (Resident 22) laboratory (lab) tests were not successfully drawn by the laboratory for three days. This failure resulted in a delay in care and treatment for Resident 22. This failure resulted in Resident 22 to feel frustrated. Findings: During a review of Resident 22's admission Record, the admission Record indicated Resident 22 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) and hypertension (HTN- high blood pressure). During a review of Resident 22's Minimum Data Set (MDS- a resident assessment tool) dated 5/6/2025, the MDS indicated Resident 22's cognition (ability to think, understand, learn and remember) was intact and was dependent (helper does all the effort) with toileting, showering, and dressing. During a review of Resident 22's Order Summary Report, the Order…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 privacy curtains were provided for one of one sampled resident (Resident 135). This failure had the potential to result in Resident 135 feeling embarrass and loss of dignity. Findings: During a review of Resident 135's admission Record, the admission Record indicated Resident 135 was admitted to the facility on [DATE] with diagnoses including broken right leg, broken hip, and encephalopathy (damage or disease that affects the brain). During a review of Resident 135's History and Physical (H&P), dated 4/21/2025, the H&P indicated Resident 135 had fluctuating capacity to understand and make decisions. During a review of Resident 135's Minimum Data Sheet (MDS - a resident assessment tool), dated 4/25/2025, the MDS indicated Resident 135 needed partial to moderate assistance from nursing staff with toileting, showering, dressing and putting on and taking off footwear. The MDS indicated Resident 135 needed partial to moderate assistance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 96) was free of chemical restraints ( use of medication to control a patient's behavior or restrict the patient's movement and not required to treat the medical symptom) by failing to: 1. Ensure Resident 96 was provided with non-pharmacological interventions( intervention that does not primarily use medicine) before administering a prn (as needed) psychotropic medication. 2.Ensure prn (as needed) psychotropic medication ( any drugs that affects the brain activities associated with mental processes and behavior) use for Resident 96 did not exceed 14 days. These failures placed Resident 96 at risk for adverse consequences ( unintended , harmful events attributed to the use of medication ) due to unnecessary prolonged use of psychotropic medication. Findings: 1.During a review of Resident 96's admission Record, the admission Record indicated Resident 96 was originally admitted to the facility on [DATE] 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 an individualized care plan for two of four sampled residents (Resident 22 and Resident 90). This failure had the potential to result in a delay of the delivery of care and services. Findings: During a review of Resident 22's admission Record, the admission Record indicated Resident 22 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) and hypertension (HTN- high blood pressure). During a review of Resident 22's Minimum Data Set (MDS- a resident assessment tool) dated 5/6/2025, the MDS indicated Resident 22's cognition (ability to think, understand, learn and remember) was intact and was dependent (helper does all the effort) with toileting, showering, and dressing. During a review of Resident 22's Order Summary Report, the Order Summary Report indicated an order was placed 5/16/2025 for labs to be drawn every three…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not provide one of three sampled residents (Resident 96) with an alternative communication method in a language that the resident could understand. This failure had the potential to place Resident 96 at risk of experiencing frustration, isolation, and inability to communicate their needs to the staff, which could lead to a delay in receiving appropriate care and services. Findings: During a review of Resident 96's admission Record, the admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] to the facility with diagnoses that included vascular dementia (decline in thinking skills caused by conditions that block or reduce blood flow to various areas of the brain )without behavioral disturbances, anxiety disorder( mental health conditions characterized by excessive and persistent worry, fear, and nervousness that interfere with daily life) and depression (emotional state that is marked by feelings of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of four sampled residents (Resident 22 and Resident 78) fingernails were trimmed and free from accumulation of unknown substances underneath their fingernails. This failure had resulted in Resident 22 and 78 fingernails to be long with an accumulation of unknown substances underneath the fingernails. This failure had the potential to cause infection and impaired skin integrity. Findings: During a review of Resident 22's admission Record, the admission Record indicated Resident 22 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) and hypertension (HTN- high blood pressure). During a review of Resident 22's Minimum Data Set (MDS- a resident assessment tool) dated 5/6/2025, the MDS indicated Resident 22's cognition (ability to think, understand, learn and remember) was intact and was dependent (helper does all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure one of 2 sampled residents (Resident 53) ophthalmology (focused on the diagnosis, treatment, and surgery of eye diseases and disorders) referral was followed up. This failure had the potential to negatively affect Resident 53's quality of life. Findings: During a review of Resident 53's admission Record the admission Record indicated Resident 53 was admitted to the facility on [DATE] with diagnosis including glaucoma (a group of eye conditions that damage the optic nerve which connects the eye to the brain), muscle weakness, and anxiety (intense, excessive, and persistent worry and fear about everyday situations. During a review of Resident 53's History and Physical (H&P) dated 12/31/24, the H&P indicated Resident 53 had the capacity to understand and make decisions. During a review of Resident 53's Minimum Data Set (MDS - a resident assessment tool) dated 3/11/2025, the MDS indicated Resident 53 had severely impaired cognition…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 improve and/or prevent a decline in range of motion (ROM, full movement potential of a joint) for one of nine sample residents (Resident 112) by failing to provide Resident 112 with passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises to the left leg in accordance with Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) recommendations on 2/7/2025. This deficient practice had the potential to cause Resident 112 to have a decline in ROM leading to contracture (loss of motion of a joint) development and have a decline in physical functioning and mobility (ability to move). Findings: During a review of Resident 112's admission Record, the admission Record indicated Resident 112 was admitted to the facility on [DATE] with diagnoses including left-sided hemiplegia (weakness to one side of the body) and hemiparesis (inability…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 15 and 2) oxygen nasal cannula (a small plastic tube, which fits into the person's nostril for providing supplemental oxygen) tubing with the date and change every seven (7) days, or as needed while receiving oxygen therapy and oxygen humidifier (medical device used to humidify supplemental oxygen) were labeled and dated for Resident 2. This failure had the potential for resident harm, as the possibly over-extended use of unchanged nasal cannulas placed Resident 15 at high risk of developing a respiratory infection. Findings: 1.During a review of Resident 15's admission Record dated 5/22/2025, the admission Record indicated, the facility initially admitted Resident 15 on 9/3/2021, then readmitted on [DATE], with admitting diagnoses that included chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing). During a review of Resident 15's Minimum Data…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure pain medication was reordered to pharmacy in a timely manner for one of one sampled resident (Resident 77). This failure had the potential for Resident 77 to experience pain and delay in treatment. Findings: During a review of Resident 77's admission Record, the admission Record indicated, Resident 77 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including bilateral breast cancer (a disease where abnormal cells in the breast grow uncontrollably, forming tumors), bilateral leg neuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet) and hypertension (HTN-high blood pressure). During a review of Resident 77's Minimum Data Set (MDS - a resident assessment tool), dated 3/15/2025, the MDS indicated Resident 77 had the ability to express ideas and wants. The MDS indicated Resident 77 had the ability to understand others. The MDS indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the Restorative Nursing Aide program (RNA, nursing aide program that helps residents maintain any progress after therapy intervention to maintain their function) was modified by qualified and competent staff when Restorative Nursing Assistant 1 (RNA 1) modified Resident 112's RNA program independently. This deficient practice placed the residents in the facility at risk for harm and injury and had the potential to result in inaccurate and inappropriate provision of necessary care and services, assessments, and interventions. Findings: During a review of Resident 112's admission Record, the admission Record indicated Resident 112 was admitted to the facility on [DATE] with diagnoses including left-sided hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following an intracerebral hemorrhage (bleeding in the brain), abnormal posture, and muscle weakness. During a review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide social services for two of six sampled residents by failing to: 1.Follow up with Resident 23's request for a larger mattress. 2.Request conservatorship (when a judge appoints another person to act or make decisions for the person who needs help) for Resident 38 who was unable to make medical decisions on his own. This failure resulted in a delay in necessary care and services for Resident's 23, and 38. Findings: During a review of Resident 23's admission Record, the admission Record indicated Resident 23 was admitted to the facility on [DATE] with diagnoses including paraplegia (loss of movement and/or sensation, to some degree, of the legs), obesity (having too much body fat), and depression (a persistent state of sadness or lack of interest in things that you used to enjoy). During a review of Resident 23's Minimum Data Set (MDS- a resident assessment tool) dated 3/26/2025, the MDS indicated Resident 23's cognition (ability to think,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure blood pressure parameters for blood pressure medications prior to administration for one out of four sampled residents (Resident 342). This deficient practice has the potential to result in low blood pressure which can cause light-headedness, dizziness, and fatigue for Resident 342. Findings: During a review of Resident 342's admission Record, the admission Record indicated Resident 342 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including ([DM]-a disorder characterized by difficulty in blood sugar control and poor wound healing), heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), hypertension ([HTN], high blood pressure), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 342's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to inform the physician of consultant pharmacist's (a professional responsible for reviewing each resident's medication profile monthly to identify and report changes) recommendation for one of one sampled residents ( Resident 69) related to administration of sertraline ( medication used to treat depression [a serious mental disorder characterized by persistent sadness, loss of interest, and changes in thinking, sleeping, eating, and acting]). This deficient practice possibly resulting in medication side effects (a secondary, typically undesirable effect of a drug or medical treatment) and leading to a decrease in resident's physical, mental, or psychosocial well-being. Findings: During a review of Resident 69's admission Record, the admission Record indicated Resident 69 was admitted to the facility on [DATE], with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure two of two sampled residents (Resident 69 and Resident 129) had dental services. This failure had the potential to lead to weight loss for Resident 69 and Resident 129. Findings: During a review of Resident 69's admission Record, the admission Record indicated Resident 69 was re-admitted to facility on 2/6/2024, with diagnoses including severe protein- calorie malnutrition (a state of inadequate intake of both protein and calories), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), schizophrenia(a mental illness that is characterized by disturbances in thought), and chronic kidney disease (kidneys that are damaged and not working properly to filter blood). During a review of resident 69's Order Summary, dated 2/6/2024, the Order Summary indicated, Resident 69 may have a dental consult and treatment as indicated. During a review of Resident 69's History and Physical (H&P), dated 2/7/2024,…

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

Based on interview and record review the facility failed to effectively use its Quality Assessment and Performance Improvement (QAPI) program to identify and address resident care concerns, such as weight loss. a. The facility did not monitor or identify the resident's weight loss. b. The facility did not follow the Restorative Nursing Assistant Program exercises as recommended by Physical Therapy. c. The facility did not ensure accurate documentation by Restorative Nursing Assistant Services. d. The facility did not observe infection control practices. e. The facility failed to ensure staff is not standing over while feeding a resident. f. The facility did not follow up on a missed outpatient appointment. These failures had the potential to negatively impact residents ' care and could lead to a delay of care and treatment to the residents. Findings: During an interview on 5/23/2025, at 2:47 p.m. with Assistant Director of Nursing (ADON), ADON stated she did not know what the specific deficient practices from last standard health survey. ADON stated they did not identify any weight…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation interview and record review the facility failed to ensure one of one sampled resident (Resident 1's) room remained safe from fire hazards. This failure had the potential to result in significant harm during a facility fire. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated, Resident 1 was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses of but not limited to multiple sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension (HTN-high blood pressure). During a record review of Resident 1's History and Physical, dated 8/14/2024, indicated that Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS- resident assessment tool), the MDS indicated, Resident 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident (Resident 1) who had an open cast (also referred to as a half cast, a medical device used to immobilize an injured area while allowing room for swelling) and had a physician ' s order to see a surgeon, authorization was obtained promptly for one of four sampled residents (Resident 1). This deficient practice resulted in a delay in Resident 1 being seen by the surgeon and had the potential for Resident 1 to have muscle atrophy (muscle wasting), joint stiffness, decreased range of motion (the direction a joint can move to its full potential), skin irritation, and delayed healing. Findings: During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with the diagnoses including fracture (broken bone) of the right radius (wrist). During a review of Resident 1 ' s Minimum Data Set (MDS – a resident assessment tool) dated 2/19/2025, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide treatment and services to maintain or prevent further decrease in joint range of motion ([ROM]full movement potential of a joint) and/or mobility for one of four sampled residents (Resident 1) by failing to: 1. Provided services to maintain and prevent a decline in range of motion for Resident 1 ' s bilateral upper extremities. 2. Provide services to maintain and prevent a decline in Resident 1 ' s mobility. 3. Ensure Rehabilitation (therapy given to restore an individual back to their highest possible level of physical, mental, and psychosocial well-being) Screenings were performed upon Resident 1 ' s readmission from a General Acute Care Hospital (GACH). These deficient practices placed Resident 1 at risk for decline in ROM, mobility, physical functioning, and contractures (loss of motion of a joint). Findings: During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide rehabilitation (therapy given to restore an individual back to their highest possible level of physical, mental, and psychosocial well-being) services for one of four residents (Resident 1) services when Resident 1 had a physician order dated 10/11/2024 for a physical therapy evaluation. This deficient practice resulted in a delay of providing rehabilitation services to Resident 1 and placed Resident 1 at risk for a decline in range of motion ([ROM] full movement potential of a joint), mobility, physical functioning and contractures (loss of motion of a joint). Findings: During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including fracture (broken bone) of right radius (wrist). During a review of Resident 1 ' s Minimum Data Set (MDS – a resident assessment tool) dated 2/19/2025, the MDS indicated Resident 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that one out of two sampled residents (Resident 2) were free from a significant medication error when Resident 2 ' s escitalopram (depression medication) was not started on 5/1/2024 as ordered by Resident 1 ' s physician. This failure had the potential for Resident 2 ' s clinical depression to worsen. Findings: During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), type 2 diabetes mellitus ( DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and heart failure (heart muscle is unable to pump enough blood to meet the body ' s needs for blood and oxygen). During a review of Resident 2 ' s History & Physical (H&P), dated 5/2/24, the H&P indicated, Resident 2 had the capacity to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one of three sampled residents (Resident 1's) was treated with respect and in a dignified manner, when the Social Services Director (SSD) tugged at and eventually took Resident 1's sweater and a bottle of medication ([Norco] medication used to treat moderate to severe pain) from her without her permission and after Resident 1 refused to give the SSD the bottle of medication. This deficient practice resulted in Resident 1's complaint of pain to her left and right shoulders, Resident 1 being afraid of the SSD and not wanting to interact with her anymore. This deficient practice had the potential for long term injury and pain and for care and services to be unprovided to Resident 1 due to fear of interacting with the SSD. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including bipolar disorder (a serious mental illness that affects…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an alleged physical altercation between the Social Services Director (SSD) and one of three sampled residents (Resident 1) to the California Department of Public Health (CDPH) within two hours of them being made aware of the allegation. On 10/18/2024 at approximately 8:30 a.m., Licensed Vocational Nurse (LVN) 1 witnessed the SSD tug Resident 1's sweater, eventually taking it from her (Resident 1) without Resident 1's permission. On 10/18/2024 Resident 1's Responsible Party (RP) 1, reported that LVN 1 had taken Resident 1's sweater from her by tugging on it, causing Resident 1 pain to both of her shoulders and Resident 1 being afraid of the SSD. On 10/25/2024, Resident 1 complained of left and right shoulder on alleging the pain resulted from the SSD pulling/tugging and taking the sweater from her (Resident 1). This deficient practice resulted in the CDPH being unaware of the allegation of abuse and potential injury to Resident 1, causing a delay…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 conduct a timely and thorough investigation for one of three sampled residents ( Resident 1) when the Social Services Director (SSD) removed Resident 1's sweater from Resident 1's grasp against Resident 1's consent on 10/18/2024. Resident 1 complained of left and right shoulder on 10/25/2024 alleging the pain resulted from the SSD removing the sweater from her grasp. This deficient practice had the potential to result in unidentified abuse affecting Resident 1. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including bipolar disorder (a serious mental illness that affects how a person thinks, feels, and behaves), Atrioventricular Block ([AV block] a heart rhythm disorder that causes the heart to beat slower than it should) and diabetes type 2 ([DM] a disease that occurs when blood glucose, also called blood sugar [b/s], is too high).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), was seen by the psychiatrist after she continued to express feelings of sadness on 8/12/2024, 8/22/2024, and on 9/23/2024. This failure resulted in Resident 1 not being seen by the psychiatrist after referrals were made on 8/12/2024 and 9/23/2024, and had the potential to place Resident 1 at risk to suffer further mental anguish and decreased quality of life. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to 7/17/2024 and readmitted [DATE] with diagnoses including anemia (not having enough healthy red blood cells), dementia (a progressive state of decline in mental abilities), and polyneuropathy (condition which causes many nerves in the body to malfunction at the same time). During a review of Resident 1 ' s History and Physical (H&P) dated 8/9/2024, the H&P indicated Resident 1 had fluctuating capacity to understand and make…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement a care plan addressing specific interventions for one of three sampled residents (Resident 3) who frequently removes her nasal cannula (small plastic tube, which fits into the person ' s nostrils for providing supplemental oxygen). These deficient practices resulted in Resident 3 not receiving oxygen as ordered and staff not being aware of specific interventions to provide to Resident 3. Findings: During a review of Resident 3's admission Record (Face Sheet) the Face Sheet indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including sepsis (a life-threatening blood infection), heart failure (serious condition that occurs when the heart can't pump enough blood to meet the body's needs) and dementia (a progressive state of decline in mental abilities). During a review of Resident 3's Minimum Data Set (MDS – a federally mandated resident assessment tool) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure incontinence care was provided for one out of three sampled residents (Resident 2). This deficient practice had the potential to result in Resident 2 having complications from skin break down. Findings: During a review of Resident 2 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM) type 2 [a chronic disease characterized by elevated levels of blood glucose (or blood sugar) in a bloodstream], and a stage 4 (a depth to the muscle, bone, tendon, or joint) pressure ulcer (a skin injury caused by sustained pressure on an area of the body) of the sacral region (lower back) and right buttock. During a review of Resident 2 ' s Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 8/10/2024, the MDS indicated Resident 2 was moderately cognitively impaired…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 2) physician's orders to change Resident 2's nasal cannula and to clean Resident 2's right ischium (lower and back region of the hip bone) pressure injury (an area of skin is under pressure for a long time, causing the skin and underlying tissue to break down) and Stage IV (deep wound that may impact muscle, tendons, ligaments, and bone) sacral coccyx (tail bone) pressure injury with normal saline ([n/s] a mixture of sodium chloride [salt] and water, often used to clean wounds) was followed. These deficient practices resulted in the physician's orders to change Resident 2's nasal cannula and Resident 2's wound treatment not being followed, placing Resident 2 at risk of acquiring an infection from exposure to bacteria and germs, and delay healing for Resident 2's right ischium and sacral coccyx wounds. Findings: During a review of Resident 2's admission Record (Face Sheet), the Face Sheet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to create a care plan for one of three sampled residents (Resident 1) when Resident 1 refused care and treatment to his left buttock stage 2 (outer layer of skin (epidermis) or the deeper layer of skin (dermis) is damaged) pressure injury (injury to the skin and soft tissue that occur when an area of skin is under prolonged pressure), right hip stage 2 pressure injury and bilateral foot diabetic ulcers (open wound caused by poor circulation, nerve damage or infection). This deficient practice had the potential for Resident 1's left buttock stage 2 pressure injury, right hip stage 2 pressure injury and bilateral foot diabetic ulcers to increase in size and delay healing. 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 type two diabetes ([DM] high blood sugar) with skin ulcers (open wound) and unstageable pressure ulcers of the sacral region (portion of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure six of six sampled residents (Residents 3, 4, 5, 6, 7 and 10) who were kept awake during the night and/or who were yelled at, called names, and verbally attacked by a resident (Resident 1) who was known by the facility staff to have disruptive behaviors, were provided a safe, peaceful, homelike environment. This deficient practice resulted in Resident 1's known disruptive behavior causing a toxic living environment for Residents 3, 4, 5, 6, 7 and 10 which resulted in residents' tiredness from not sleeping and the inability of the residents to enjoy the place where they resided. These deficient practices had the potential for Residents 3, 4, 5, 6, 7, and 10 to experience emotional and mental anguish due to the facility's lack of attention to Resident 1's know behaviors. 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 anxiety…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to re-admit one of two sampled residents (Resident 1) when Resident 1 was transferred to a General Acute Care Hospital (GACH) for evaluation of uncontrolled behaviors and was placed on a 5150 hold (an involuntary 72-hour detainment of a person who experiences a mental health crisis and is evaluated to be a danger to others, to himself/herself, or is gravely disabled). When the GACH cleared Resident 1 to return to the facility on 7/31/2024, the facility refused to readmit Resident 1. This deficient practice resulted in Resident 1 not being provided with a bed hold notice when she was transferred from the facility on 7/28/2024, being discharged from the GACH on 7/31/2024 to the care of a family member (FM) and denied readmittance to a facility where she had resided for over eight months. 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 monitor one of three sampled residents (Resident 1), who eloped (left the facility undetected by staff without their knowledge or approval) from the facility on 7/17/2024 at 9:07 p.m., and who earlier that same day at approximately 9:45 a.m., was brought back to the facility, after being found approximately half a mile away at the Los Angeles river and refused to come back to the facility. A Care Plan developed after Resident 1 left the facility indicated to monitor Resident 1's location every hour, however, documentation from multiple facility staff indicated Resident 1 was in the facility after 9 p.m., when facility video surveillance indicated Resident 1 eloped from facility at 9:07 p.m., and staff did not recognize Resident 1 was missing from the facility until 2:16 a.m., more than three hours after the start of the 11 p.m., to 7 a.m., shift. This deficient practice resulted in Resident 1 missing from the facility for two days, from 7/19/2024 at 9:07 p.m., thru 7/19/2024 at 6 p.m., when Registered Nurse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurately document the whereabouts for one of three sampled resident (Resident 1), who eloped (left the facility undetected by staff without their knowledge or approval) from the facility on 7/17/2024 at 9:07 p.m., but multiple facility staff documented they saw Resident 1 in the facility after his elopement at 9:07 p.m This deficient practice resulted in the whereabouts of Resident 1 not being monitored, per Resident 1's Care Plan, from (9:30 p.m., on 7/17/2024 thru 2 a.m., on 7/18/2024 when Resident 1 was discovered missing from the facility). This deficient practice had the potential for other residents who were assessed with wandering/elopement behaviors to go missing due to staff not monitoring residents' and their inaccurate and false documentation of residents' whereabouts. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to facility on 2/1/2024, with diagnoses of hemiplegia, hemiparesis following a cerebral infarction affecting…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of one resident ' s (Resident 1) Emergency Contact/Family Member (FM) 1, was informed immediately after receiving a physician ' s order to transfer to a General Acute Care Hospital (GACH) and upon transferring Resident 1 to the GACH. This deficient practice resulted in the FM 1 being unaware of Resident 1 ' s whereabouts and concern regarding the health status of Resident 1. This deficient practice had to the potential to affect other residents who were transferred to a GACH. Findings: During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnosis including pneumonia (an infection which affects one or both lungs), lack of coordination (not able to move different parts of the body together well), and type 2 diabetes mellitus (a chronic disease characterized by elevated levels of blood glucose or blood sugar in 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 kitchen staff were routinely trained and evaluated for competency skills as followed: a. Staff failed to verbalize and demonstrate how to check dishwasher temperatures. This failure had a potential to result in cross-contamination (a transfer of bacteria from one object to another), due to un-sanitized dishware, and result in bacterial growth that could lead to food borne illness (an illness caused by contaminated food and beverages) in 122 of 131 medically compromised residents of the facility who received food and ice from the kitchen. Findings: a.During an interview with the Food Service Director (FSD) on 5/21/2024 at 9:04 AM, the FSD stated they used a low temperature dishwasher and chlorine to wash and sanitize the dishes. During concurrent observation of the dishwashing on 5/21/2024 at 3:57 PM and interview with Dietary Aide 1 (DA 1), DA 1 stated they used a high temperature dishwasher, checked one water temperature and the chemical concentration. DA 1 stated the chemical concentration must be…

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

Based on observation, interview, and record review the facility failed to follow the portion sizes and did not meet nutritional needs of 2 of 2 residents who requested zucchini without carrots on their tray and 1 of 1 resident on a soft mechanical diet (diet consisted of foods that were soft and chopped for residents who had difficulty chewing and swallowing) small portion. This deficient practice had the potential to cause a decreased food intake resulting in unintended weight loss or increased food intake resulting in unintended weight gain. Findings: a. A review of the facilities' daily spreadsheet titled Spring Cycle Menus, dated, week four (4), Wednesday 5/22/2024, indicated residents would receive the following: 2 ounces ([oz] a unit of measurement of weight) oven barbecue beef roast for regular diet (diet with no food restriction) for small portions. 3 oz of meat for regular portions for regular diet 4 oz for large portions for regular diet ½ cup ([c] a household measurement) of fresh zucchini and carrots. During an observation of the lunch tray-line (an area where resident'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.

Based on observation, interview, and record review, the facility failed to prepare food that was palatable when the oven roast barbecue (BBQ) beef roast that was served was chewy. This deficient practice had a potential to cause unplanned weight loss, a consequence of poor food intake to 71 of 131 facility residents on regular diet texture (a diet texture with no restriction) getting food from the kitchen. Findings: a. During a test tray (process of taste testing food) of regular diet with the Food Service Director (FSD) on 5/22/2024 at 12:40 PM, the FSD stated the oven BBQ beef roast's texture was a bit tough and chewy after tasting it. The FSD questioned [NAME] 1 why the beef was chewy today as it was always soft in texture every time, they served it in the past. The FSD stated residents might not eat if food was chewy and potential outcome would be weight loss. A review of the facility's policies and procedures (P&P) titled Menu Planning dated 2023, indicated (4) The menus are planned to meet nutritional needs of the residents in accordance with established national guidelines,…

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

Cross Reference F802 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. Equipment, utensils, and kitchen cleanliness a. Low temperature dishmachine was not dispensing chlorine. b. [NAME] refrigerator bottom shelves had dirt and a torn gasket. c. Reach-in freezer five (5) had dried up sticky residue. d. Reach-in-refrigerator vent had dust buildup. e. Two wall fans by the clean dishwashing area had dust buildup. f. Mixer had white food residue.g. Juice dispensing area had sticky dried up buildup. h. Washed trays had tape residue and debris. i. Trays was stacked wet and not air dried. j. Dish machine temperature log for lunch time on 5/21/2024 was blank. k. Seven of 72 resident's tray were chipped and cracked. l. Ice machine had hard water buildup. 2. Proper food handling and storage a. Staff did not monitor time and temperature when thawing ground turkey. 3. Hygiene a. Staff were wearing jewelry during food handling and preparation. 4. Temperature log for dry storage…

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

Based on observation, interview, and record review, the facility failed to dispose garbage and refuse properly by not completely covering two (2) of 2 gray dumpsters (a large trash container designed to be emptied into a truck) for an unknown amount of time. This deficient practice had a potential to attract flies, insects, cats, and other animals to the dumpster area placing 122 of 131 facility residents getting food from the kitchen at risk for cross-contamination (a transfer of harmful bacteria from one place to another). Findings: During a concurrent observation of the garbage area located outside the facility near the kitchen and interview with Food Service Director (FSD) at 5/21/2024 10:25 PM, 2 of 2 gray trash bin were not completely closed and covered. There were two soiled and used gloves on the floor near the trash area. The FSD stated the trash bin lids were not completely closed and it could contaminate the air, attract flies and other animals. During an interview with the Maintenance Supervisor (MS) on 5/22/2024 at 3:50 PM, the MS stated he noticed the trash was not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY (Cross-referenced with F755) Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5 % (percent) during medication pass for three of four sampled residents (Residents 61, 66, and 68), observed during medication administration by failing to: 1. Ensure Resident 66's physician order for Aspirin (a medication used to prevent heart attack [flow of blood and oxygen is blocked] and stroke [blood supply to brain blocked]) was administered as a chewable according to manufacturer formulation specifications instead of being swallowed, on [DATE]. 2. Ensure Resident 68's physician order for Diclofenac Gel (a medication in form of gel used to treat pain and arthritis, a condition with inflammation of joints) was applied to the neck area as prescribed instead of applying to hands, on [DATE]. 3a. Ensure Resident 61 was administered the physician order of Multivitamin (an external source of supplement to treat or prevent deficiency of vitamins) only instead of 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 observation, interview, and record review, the facility failed to ensure storage and/or removal of undated and/or expired insulin (a medication used to treat high blood sugar), Latanoprost ophthalmic solution (a medication in form of eye drops used to treat high pressure in the eyes), Advair Diskus inhalation device ([Generic Name: Fluticasone-Salmeterol] a medication delivered in the form of inhalation powder through a device used to treat breathing problems), Calcitonin nasal spray (a medication administered into the nostrils to treat osteoporosis [a bone disease with low bone mineral density]), and Aranesp injection vial (a medication used to treat anemia [a condition with low red blood cells or hemoglobin]), per manufacturer's requirements affecting four residents (Residents 7, 24, 56, 98) in three of four inspected medication carts (South Medication Cart, Middle Medication Cart, North Medication Cart), and in one of three inspected medication rooms (North Station Medication Room). This 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 interview and record review, the facility failed to document: a. Resident 94's Informed Consent for the Pneumococcal Vaccine (a shot that helps protect from infections like pneumonia (a lung infection that makes it hard to breathe) accurately and completely. b. Resident 110 had complete advanced directive acknowledgement form. c. Resident 116 had a complete advanced directive acknowledgement form documented. These deficient practices had the potential to result in inaccurate care and services rendered to residents that may have an advanced directive in place to accept or refuse certain medical treatments for two of five sampled Residents (Resident 110 and 116). The failure for incomplete pneumococcal vaccine consent had the potential to result in confusion in administering the Pneumococcal vaccine to Resident 94 placing the resident at risk of not receiving appropriate care due to inaccurate and incomplete resident medical care information for one of 5 sampled Residents( Resident 94). Findings: 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 observation, interview, and record review, the facility failed to observe infection control measures for three out of 137 sample residents (Residents 23, 86 and125) by failing to: 1.Ensure Resident 23's indwelling catheter (or known as Foley catheter a tube that allows urine to drain from the bladder into a bag that is usually attached to the thigh) drainage bag is not touching the floor and the urinal ( a bottle for urination while still in bed) was not placed on the floor. 2.Ensure facility staff cleaned the utility room door after touching it with soiled gloves . 3. Ensure facility staff did not enter other rooms with a soiled linen bag and place it in the room . These deficient practices had the potential to transmit infectious microorganisms and increase the risk of infection for the residents in the facility. Findings : During a record review of the admission record, the admission record indicated Resident 125 was initially admitted to the facility on [DATE] with diagnoses including but not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure one of two sampled residents (Resident 1) was treated with respect and dignity by failing to Ensure Resident 1's indwelling urinary catheter (medical device that helps drain urine from your bladder) drainage bag (holds the urine) had a dignity bag (a bag used to the cover, drainage bag so it was not visible). This deficient practice had the potential to cause Resident 1 to feel embarrassed and have low self-esteem (when someone lacks confidence about who they are and what they can do). Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including type 2 diabetes mellitus (chronic condition that affects how the body processes sugar), and hypertension (high blood pressure). During a review of Resident 1's History & Physical ([H&P] the most formal and complete assessment of the patient and the problem), dated 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 record review and interview, the facility failed to implement its abuse policy and procedure by failing to investigate a resident-to-resident altercation between two of four sampled residents (Resident 1 and Resident 109). This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect residents from abuse. Findings: During a review of Resident 1's admission record, the admission Record indicated Resident 1 was readmitted to the facility on [DATE] with diagnoses including multiple sclerosis (MS: autoimmune disease (immune system accidentally attacking your body) that causes the covers of the nerve cells in the brain and spinal cord are damaged), abnormal posture, lack of coordination, osteoarthritis (degenerative joint disease that causes the tissues in the joint to break down), on the left shoulder, low back pain, chronic obstructive pulmonary disease (COPD: a chronic inflammatory lung disease that obstructs the airflow from the lungs.), type II diabetes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to initiate and implement an individualized person-centered plan of care with measurable objectives, timeframe, and interventions to meet the residents' needs for one of three sampled residents (Resident 75) who had a urinary tract infection (UTI- infection involving any part of the urinary system, including urethra, bladders, ureters, and kidney). This deficient practice had the potential to negatively affect the delivery of necessary care and services for Resident 75. Findings: During a review of Resident 75's admission record, the admission record indicated Resident 75 was admitted to the facility on [DATE] with diagnoses that included neuromuscular dysfunction of bladder (lacks bladder control due to brain, spinal cord, or nerve problems). During a review of the Minimum Date Set (MDS- a comprehensive assessment and care screening tool) dated May 6, 2024, the MDS indicated Resident 75 had impairment of both upper and lower extremities and requires…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 that residents received treatment and care in accordance with professional standards of practice by failing to: 1. Ensure Resident 37 made it to a scheduled Cardiology (a branch of medicine that specializes in diagnosing and treating diseases of the heart, blood vessels, and circulatory system) follow-up appointment. 2. Ensure Resident 3 who allegedly went out to receive chemotherapy (a drug treatment that uses powerful chemicals to kill fast-growing cancer cells in the body) on 5/20/2024 and did not follow up with transportation company and chemotherapy clinic when Resident 3 did not return back to the facility on 5/20/2024. These deficient practices had the potential to result in delays to receive life sustaining treatment (any treatment that serves to prolong life without reversing the underlying medical condition) for Resident 37 and Resident 3. Findings: 1. During a review of Resident 37's admission Record, the admission Record indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure four of four sampled residents (Resident 71, 114, 110 and 116) with limited range of motion (ROM - the extent of movement of a joint) and/or limited mobility, received restorative nursing (a program available in nursing homes that helps residents maintain any progress they've made during therapy treatments, enabling them to function at a high capacity) care as ordered by physician and follow through the progress of the residents who received restorative nursing care by: a. Failing to assess, evaluate, and document the progress of Restorative Nursing Assistant (RNA) service and to document frequency and reasons of refusal for Resident 71 before discontinuing the service. b. Failing to assess and evaluate the progress of RNA service for Resident 114 and provide RNA service as ordered due to short staffing. c. Failing to consistently document the dates and time of RNA service and the reasons for refusal of service for Resident 110 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 (Cross-Referenced with F761) Based on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 7, was trained and had knowledge on how to store and label refrigerated medications with an opened date and/or expiration date after removal from the refrigerator and ensure removal of expired medications from medication cart in one of four inspected medication carts (Middle Medication Cart). This deficient practice of failing to store medications per the manufacturer's requirements increased the risk that residents could have received medications that had become ineffective or toxic due to improper storage or labeling possibly leading to health complications or hospitalization. Findings: During a concurrent observation and inspection on 5/22/2024 at 1:18 p.m. of the Middle Medication Cart with LVN 7, the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow up on three of 131 sampled residents by: A.Failing to follow up with a missed outpatient appointment for Resident 73. B. The facility failed to initiate the process to obtain a public guardian (provides a vital service to persons unable to properly care for themselves or who are unable to manage their finances)/conservatorship (a judge appoints another person to act or make decisions for the person who needs help) to protect Resident 71 who had fluctuated mental capacity. These deficient practices had the potential to postpone the delivery of care and services provided to the residents. A During a review of Resident 73's Face Sheet, the Face Sheet indicated Resident 73 was admitted to the facility on [DATE] with diagnoses including type II diabetes mellitus (uncontrolled blood sugar), ileostomy (surgical opening created in the abdominal wall where digested food passes) status, absence of other parts of the digestive tract, and volvulus (loop 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 (Cross-referenced with F759) Based on observation, interview, and record review, the facility failed to: 1. Ensure medications were administered and/or available in stock according to physician orders and/or manufacturer formulation guidelines for three of four sampled residents (Residents 66, 68 and 61). 2. Maintain emergency kit ([e-kit] a small quantity of medications that can be dispensed when pharmacy services are not available) usage and accountability documentation. These deficient practices failed to provide pharmacy services, accountability, and oversight of e-kits, and had the potential to result in misuse, drug loss and/or diversion of controlled and non-controlled prescription drugs. Findings: 1a. During a review of Resident 66's admission Record, (a document containing demographics and diagnostic information), dated 5/21/2024, the admission record indicated that the resident was admitted on [DATE] with diagnoses including coronary artery disease (damage to major blood vessels in heart) 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 define clinical behaviors related to the use of antidepressant medication and attempt a gradual dose reduction (GDR -tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the medication can be discontinued altogether) for one of one resident (Resident 27) who was on bupropion (medication used to treat depression). This deficient practice had the potential for Resident 27 to experience adverse (unwanted or dangerous medication side effects) effects of Bupropion and continue receiving medication which was not targeting clinical behaviors. Findings: During an observation on 5/21/2024 at 9:17 a.m. in Resident 27's room, the resident was lying on bed with eyes closed. During a record review of Resident 27's admission Record (face sheet), the admission Record indicated Resident 27 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses including type 2 diabetes mellitus…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 employ a qualified social worker (health professional that helps individuals, groups, and families cope with problems in everyday lives) on a full-time basis that met the qualifications specified in the regulation. This failure had the potential to result in 130 out of 130 residents not being assisted and receiving medically related necessary care to attain highest practicable well-being. Findings: During a concurrent observation and interview on 5/17/2024 at 9:37 a.m. with Social Service Director (SSD), SSD was noted with a badge indicating SSD. SSD stated, she has been working as SSD for approximately two years, and she did not have a bachelor's degree. SSD stated, she had an associate degree for family counselling. SSD stated, she was the only social service person in charge of all the residents in the facility. SSD pointed out her badge and stated she was the SSD as her badge indicated. During an interview on 5/17/2024 at 10:45 a.m., with SSD, SSD stated, she could not provide a copy of her associate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure two of three sampled residents (Residents 2 and 3) call light devices were within reach. This deficient practice resulted in Resident 2 and 3 being unable to call for assistance and resulted in a delay of care and services. Findings: During a review of Resident 2's the admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including cirrhosis (scarring and damage) of the liver (organ cleans blood and aids in digestion), encephalopathy (group of condition that cause brain dysfunction) and glaucoma (diseases that can cause vision loss). During a review of Resident 2's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 2/10/2024, the MDS indicated Resident 2 had highly impaired vision. The MDS indicated Resident 2 could understand express ideas and wants and can understand others. The MDS indicated, Resident 2 required partial /moderate assistance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 three of 11 sampled residents (Residents 2, 8, and 9) were treated in a dignified and respectful manner by Certified Nursing Assistant 7 (CNA 7). This deficient practice resulted in Residents 2, 8 and 9 feeling intimidated, fearful of and hesitant to ask for assistance from CNA 7 and had the potential to negatively affect the residents care and future interaction with the facility staff. a. During a review of Resident 2's admission Records (Face sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis of anxiety disorder (a disorder that involves persistent and excessive worry that interferes with daily activities). During a review of Resident 2's Minimum Data Set ([MDS]) a standardized assessment and care screening tool), dated 2/24/2024, the MDS indicated Resident 2 was able to make independent decisions that were reasonable and consistent. During a review of facility's Grievance Record 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 administer three medications: Doptelet (used to prevent excessive bleeding in adults with low platelets [small cell fragments whose function is to prevent and stop bleeding]) oral tablet twenty (20) milligrams (mg- unit of measurement), Opsumit (medication used to treat high blood pressure [force of blood] in the lungs) oral tablet 10 mg, and Rifaximin (use to treat liver encephalopathy [a brain disorder that develops in some individuals as a result of severe liver disease) oral tablet 550 mg to one out of three sampled residents, Resident 1 from 3/18/2024 to 3/21/2024. As a result, Resident 1 did not receive necessary medications which could have resulted in complications like in severe high blood pressure and possible bleeding. Findings: During a review of Resident 1's admission Record (Face Sheet), dated 3/28/2024, the FS indicated, Resident 1 was admitted on [DATE] with a diagnosis including thrombocytopenia (low platelets), primary pulmonary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 nine sampled residents (Resident 3) was not humiliated and embarrassed by a Certified Nursing Assistant (CNA 2), when CNA 2 in front of other staff and visitors spoke to Resident 3 using a curse word in a loud, angry, and aggressive tone. This deficient practice resulted in Resident 3 with tears in his eyes and a lowered head, expressing how he felt humiliated by CNA 2 and had the potential to affect his care needs and how he interacted with staff in the future. 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 depression (a consistent feeling of sadness and loss of interest, which stops the person form doing normal life activities). During a review of Resident 3 ' s Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 12/6/2023, the MDS indicated Resident 3 was able to make…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to implement their policy preventing accidents and ensuring safety when the facility failed to A. Ensure one of one front door entrance of the facility was left unmonitored, unlocked, and accessible to the public at 3:00 a.m. on 12/5/2023. B. Implement their policy to identify the possible causes of a fall for two of three sampled residents (Resident 3 and 4) after Resident 3 and 4 suffered unwitnessed falls. These deficient practices placed the residents at risk for harm from possible trespassers entering the facility and placed Resident 3 and Resident 4 at increased risk for sustaining another fall leading to injury. Findings: A. During an observation on 12/5/2023, at 3:00 a.m., at the front entrance of the facility, the front door was observed to be ajar. During an observation on 12/5/2023, at 3:10 a.m., at the front entrance of the facility, the front desk was facing the front door was observed to be unattended while the front door…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure one of three sampled residents (Resident 1)'s call light was answered timely when Certified Nurse Aide (CNA) 2 stated he ignored the call light because he was busy. This deficient practice violated resulted in Resident 1's anger, humiliation, and distrust to the facility staff. Findings: During a review of Resident 1's the admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including multiple sclerosis (disease affecting the brain and spinal cord), contracture (tightening or stiffing, prevention normal movement) of right hand and neuromuscular dysfunction of bladder (bladder does not fill or empty correctly). During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 10/20/2023, the MDS indicated Resident 1 always can express ideas and wants and always can understand others. According to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure one of three sampled residents (Resident 1) were provided with reasonable accommodations. The facility failed to provide Resident 1, whom has a history of muscular weakness due to spinal bifida, with a touch pad call switch (a device that allows people with limited mobility to summon help) instead of a regular call light. This deficient practice resulted in Resident 1 being unable to call for assistance and resulted in a delay of care and services. Findings: During a review of Resident 1's the admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including multiple sclerosis (disease affecting the brain and spinal cord), contracture (tightening or stiffing, prevention normal movement) of right hand and neuromuscular dysfunction of bladder (bladder does not fill or empty correctly). During a review of Resident 1's Minimum Data Set (MDS), a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement Coronavirus disease (COVID-19 a potentially severe respiratory illness caused by a corona virus and characterized by fever, coughing, and shortness of breath) outbreak response measures (acts and procedures to minimize the spread of a disease) as evidenced by the facility's failure to: a. Ensure housekeeper (HS 1) and Certified Nursing Assistant 1 (CNA1)) doffed (took off) their personal protective equipment (PPE- equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses), N95 mask (a respiratory protective device designed to achieve a very close facial fit for effective filtration of airborne particles), isolation gown, gloves, and eye protection, they wore inside the isolation (rooms in a designated area, to keep residents, who have infections, separate from other people while they receive treatment for the infections) rooms of Covid-19 positive residents (Resident 9) prior to exiting…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 review the facility failed to develop resident centered care plans for three of three residents (Resident 1,6, and 8) positive for coronavirus disease (COVID-19 a potentially severe, highly contagious illness caused by a corona virus and characterized by fever, coughing, and shortness of breath). This deficient practice had the potential to result in inadequate care and services for Resident 1, Resident 6, and Resident 8. Findings: During a review of Resident 1's admission Record, the admission record indicated Resident 2 was originally admitted to the facility on [DATE] with diagnoses that included anemia (a condition in which the blood doesn't have enough healthy red blood cells) hypertension (a condition in which the force of the blood against the artery walls is too high), schizophrenia (a serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior and reality). During a review of the Resident 1's minimum data set (MDS a standardized…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the isolation (used to reduce transmission of infection) orders for three of three Coronavirus disease (Covid-19 a very contagious infectious disease) positive residents (Resident 4, 5, and 6) were for specifically for Covid-19 transmission-based precautions (preventive measures based on the way the infection is transmitted). These deficient practices had the potential for the continued spread of Covid-19 to other residents and staff in the facility. Findings: During a review of Resident 6 's admission record, the admission record indicated Resident 6 was originally admitted to the facility on [DATE] with diagnoses including sepsis (blood infection), abnormalities of gait and mobility, and chronic obstructive pulmonary disease (COPD group of diseases that cause airflow blockage and breathing related problems). During a review of Resident 6's MDS dated [DATE], the MDS indicated Resident 6 was rarely / never understood. During a review of Resident…

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

Based on interview and record review, the facility failed to include the Infection Prevention and Control Program ([IPC]practical, evidence-based approach preventing residents and health workers from being harmed by avoidable infections) in the Facility Assessment for 140 of 140 residents. These deficient practices had a potential to result in the provision of inadequate care and services to the facility ' s resident population. Findings: During a review of the facility ' s Facility Assessment 2023, updated 12/22/2022, the assessment did not include the role of the IPC program. During an interview on 11/24/2023 at 1:40 p.m. with the Administrator (ADMIN), the ADMIN stated the Facility Assessment did not indicate the role and function of the IPC Program. Admin stated facility assessment is to assess the type of resident being taken care in the facility. Facility assessment is to make sure that the facility is ready for any outbreak or diseases that the resident might have iin the facility. Admin stated that Covid-19 has been part of the outbreaks since 2019 so the facility should…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to assess residents for eligibility for the pneumonia (an infection of the lungs) vaccination (medication to prevent a particular disease) and offer the vaccination based on eligibility to one of one sampled residents (Resident 8). This deficient practice placed Resident 8 at a higher risk of acquiring and transmitting pneumonia to other vulnerable and immunocompromised residents in the facility. Findings: During a review of Resident 8's admission record, the admission record indicated Resident 8 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nervous system) cardiomegaly (an abnormal enlargement of the heart), anemia. During a review of Resident 8's MDS dated [DATE], the MDS indicated Resident 8 sometimes makes self-understood and is sometimes able to understand others, required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to offer the coronavirus disease (Covid-19 a potentially severe respiratory illness caused by a corona virus and characterized by fever, coughing, and shortness of breath) vaccine for two of two sampled residents (Resident 1 and 5). This deficient practice placed Resident 1 and Resident 5 at higher risk for acquiring Covid-19. Findings: a.During a review of Resident 1's admission Record, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses that included anemia (a condition in which the blood doesn't have enough healthy red blood cells) hypertension (a condition in which the force of the blood against the artery walls is too high), schizophrenia (a serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior and reality). During a review of the Resident 1's minimum data set (MDS a standardized assessment and care planning tool), dated 11/9/23, 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 interview and record review the facility failed to ensure the Coronavirus disease (Covid-19 a very contagious infectious disease) tests details indicating the type of test, who completed the test, test results, and the date and time the test was completed were documented for 126 out of 140 residents. These deficient practices had the potential to result in an inaccurate depiction of care rendered and received by the residents. Findings: During a review of the facility's Covid-19 list of residents, submitted on 11/24/2023, the list did not indicate the residents whose test results were negative. During an interview with the Infection Preventionist (IP) on 11/24/2023 at 12:00 p.m., the IP stated he only documented the Covid test results of the residents who were positive for Covid-19. The IP stated he did not document any of the tests that resulted negative in the medical records. The IP stated he tested 126 residents that resulted negative. The IP stated the facility did not have a way to document rapid tests (an over-the-counter covid test that produces results in 15-20…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect one of three sampled residents (Resident 1) from Resident 2 by not assessing and treating Resident 2 when Resident 2 was already very agitated and yelling at another resident and staff earlier that day (9/1/2023). This deficient practice resulted in the Resident 2 slapping Resident 1 on the left side of his face and left Resident 1 feeling disturbed. Findings: During a review of Resident 1's admission Record (Face sheet), the face sheet indicated Resident 1 was admitted at the facility on 12/23/2021 with a diagnosis that included cellulitis of the left lower limb (superficial infection of the skin of the left leg), peripheral venous insufficiency (a disease that occurs when the veins in the legs are damaged making it difficult for blood to return to the heart) and obesity (a disorder involving excessive body fat that increases the risk of health problems). During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment 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 one of three sampled residents (Resident 2) was assessed and treated with nonpharmacological (any type of health interventions like exercise, distraction, not based on medication) approaches and/or Lorazepam (medication to treat anxiety [mental health disorder characterized by feelings of worry or fear strong enough to interfere with one's daily activities]) after Resident 2 was very agitated and yelling at another resident and staff on 9/1/2023 at 1:00 p.m. This deficient practice resulted in the escalation of Resident 2's agitation and on 9/1/2023 at 2:30 p.m. Resident 2 slapped Resident 1 on his face, unprovoked and has caused Resident 1 to feel perturbed (disturbed). Findings: During a review of Resident 1's admission Record (Face sheet), the face sheet indicated Resident 1 was admitted at the facility on 12/23/2021 with a diagnosis that included cellulitis of the left lower limb (superficial infection of the skin of the left leg),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 in the kitchen when: 1. Three gnats (small flying insect) were observed on the wall next to the handwashing sink in the dishwashing area. One gnat was observed flying near the bread rack by the walk-in refrigerator. 2. Shelves inside the reach-in freezer, reach-in refrigerator and walk-in refrigerator were dirty. Juice machine spouts were dirty with juice concentrate residue build up around the dispenser. The floor was dirty in the dry storeroom and walk- in refrigerator under the shelf. The fan cover on the walk-in refrigerator condenser was dusty. The wall under the dishwashing sink was dirty. The fan cover on the fan inside the dishwashing area was dusty. 3. Three bins of dry cereals out of their original containers were not labeled to indicate its content. One tray of Jell-O and pudding prepared for lunch service did not have a label to identify the food content. One bag…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of 21 sampled residents (Residents 62 and 86) privacy rights were not violated, and were treated with respect and dignity by: 1. Staff taking pictures of Resident 62's pressure ulcers (injuries to skin and underlying tissue resulting from prolonged pressure on the skin over bony prominences [PU]) with a personal cell phone and without authorization from the resident's representative. 2. Failing to provide podiatry services for Resident 86, whose toenails were long and dark yellowish in color and were hurting every time the staff would put socks and shoes on. These deficient practices resulted in Residents 62 and 86 privacy being violated and had the potential to cause psychosocial harm. a. During a review of Resident 62's admission Record, the admission Record indicated Resident 62 was last readmitted to the facility on [DATE]. Resident 62's diagnoses included diabetes mellitus (the body's inability to process and use glucose…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, facility failed to ensure recipes and portion sizes were followed when: 1. The lasagna serving size was not followed during lunch service on April 6, 2021. The lasagna recipe and spreadsheet (meal serving size guide) indicated serving should be 8 ounce ([oz] unit of measurement), but the served portion was 7oz when weighed. 2. Diet aide 1 (DA 1) did not follow fortified milk instruction when preparing fortified milk. The instruction required 2 cups of nonfat dry milk powder per 1 gallon of milk, but only 1 cup of nonfat dried milk powder was used. These failures had the potential to result in lower protein and calorie content of the meals provided and may contribute to decline in nutritional status and undesirable weight loss for medically compromised residents who received lasagna and fortified milk from the kitchen. Findings: a. During a trayline observation on April 6, 2021 at 11:48 AM, there was one pan of lasagna observed on the steam table cut into 9 x 6 servings. When the Director of Dietary Services (DDS) weighed one…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 foods served from the kitchen was within safe and appetizing temperature when: 1. Two cartons of milk from the trayline were 43-degree Fahrenheit (F) on April 6, 2021 during temperature check during lunch service. Resident 15 complained that the milk tasted warm during lunch on April 6, 2021 and on another occurrence about 3 weeks prior. On April 7, 2021, one carton of milk was 42.8 degrees Fahrenheit (F) on the test tray prior to leaving the kitchen during lunch service. When the test tray was received at 12:08 PM, the milk temperature was 51.6 degrees F. 2. One bowl of fortified soup was 120 degrees F during a trayline temperature check on April 6, 2021. This failure had the potential to lead to foodborne illness for medically compromised residents who received milk and fortified soups from the kitchen. Findings: a. During a trayline observation on April 6, 2021 at 11:45 AM, the Director of Dietary Services (DDS) checked the temperature on one carton of milk, which was 43 degrees F. The DDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by preventing and managing the potential spread of COVID-19 (a highly contagious respiratory infection caused by a virus that can easily spread from person to person) by: a. The facility failed to screen seven of the 27 incoming morning shift staff (7:00 AM - 3:30 PM) before the start of their shift, and did not have a process in place to ensure all staff were fully screened for any risks related to COVID-19 infection that included fever, cough, difficulty breathing, chills, fatigue, body aches, headache, new loss of taste or smell, sore throat, congestion, or runny nose, nausea or vomiting, diarrhea, or any contact with a person under investigation for COVID-19 or confirmed positive with COVID-19 within the last 14 days 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 one of 18 sampled residents (Residents 57) received restorative nursing aide (RNA) services and adaptive equipment to maintain mobility and range of motion ([ROM] full movement potential of a joint). This deficient practice resulted in Resident 57, who was admitted with contractures (permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff), not being evaluated for eight (8) months or receiving RNA services. Findings: During a review of Resident 57's Face sheet (admission Record), the face sheet indicated Resident 57 was admitted to the facility on [DATE]. Resident 57's diagnoses included cerebral palsy (congenital disorder of movement, muscle tone, or posture) and asthma (respiratory condition marked by spasms in the lungs that causes difficulty breathing). During a review of Resident 57's History and Physical (H/P) dated May 23, 2019, the H/P indicated Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Licensed Vocational Nurse 1 (LVN 1) was competent and did not practice outside of her scope by administering zinc oxide (insoluble [incapable of being dissolved] white solid used as a pigment and in medicinal ointments) without a physician's order and leaving the zinc oxide at the bedside for one of three sampled residents (Resident 88). These deficient practices resulted in LVN 1 applying a wound treatment to Resident 88 without physician orders and multiple unidentified certified nurse assistants (CNA) applying the zinc oxide during care. Findings: During a review of Resident 88's Face Sheet (admission Record), the Face sheet indicated Resident 88 was admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 88's diagnoses included spastic quadriplegic cerebral palsy (loss of use of the whole body), muscle weakness, contractures (permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints 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.