Marlora Post Acute Rehab Hosp

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 6) Preadmission Screening and Resident Review (PASARR - a federal assessment requirement to help ensure that individuals who have a mental disorder are placed in facilities that can provide the appropriate care) was filled out to indicate an existing psychiatric condition. This deficient practice had the potential to result in improper placement and unidentified specialized services for Resident 6. Findings:During a review of Resident 6's admission Record (Face Sheet), the admission Record indicated the facility originally admitted Resident 6 on 5/06/2022 and was re-admitted on [DATE] with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 6's Minimum Data Set (MDS - a resident assessment tool), dated 1/26/2026, the MDS indicated Resident 6's cognition (ability to think and make decisions) was moderately impaired. The MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement a care plan for one of five residents (Resident 89) by failing to inform Resident 89 of the risks and consequences of refusing to take Keppra ([generic name - levetiracetam] a medication used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]) as indicated in Resident 89's care plan.This deficient practice failed to explain to Resident 89 about the risk of seizures due to refusal of Keppra and had the potential of causing seizures, falls and hospitalization.Findings:During a review of Resident 89's admission Record, dated 3/11/2026, the admission record indicated the facility originally admitted Resident 89 on 6/16/2013 and readmitted on [DATE] with diagnoses that included epilepsy, intractable, unspecified without status epilepticus (a condition of recurrent seizures [a sudden, uncontrolled electrical disturbance 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one of five sampled residents (Residents 6) by failing to follow up with an orthopedic (specialty area in medicine referring to the management of the muscles, bones, and their connective structures) consultation appointment for Resident 6's left humerus (upper arm bone) fracture (broken bone) per consulting physician's recommendations.This deficient practice resulted in a delay of Resident 6's care and had the potential for worsening of the fracture, delayed healing, and a decline in mobility (ability to move), range of motion (ROM, full movement potential of a joint), activities of daily living (ADL, basic activities such as eating, dressing, toileting), physical comfort and psychosocial well-being. CROSS-REFERENCE TO F842 Findings: During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was initially admitted 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 interview and record review the facility failed to ensure one out of one sampled resident (Resident 11) with a nephrostomy tube (thin, flexible catheter inserted through the back into the kidney to drain urine directly into an external bag) had documented evidence of assessing and monitoring of the urine for signs and symptoms of infection.The deficient practice had the potential to result in urinary tract infections ([UTI] an infection in the bladder/urinary tract).Findings:During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was admitted to the facility on [DATE] with diagnoses including artificial openings of urinary tract status (covers the presence of surgically created, permanent, or temporary, urinary diversion), obstructive and reflux uropathy (dangerous blockage of urine flow).During a review of Resident 11's Minimum Data Set (MDS - a resident assessment tool), dated 2/19/2026, the MDS indicated Resident 11's cognition (ability to think) was intact. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure a physician assessed one of three sampled residents (Resident 1) within 72 hours after admission.This failure resulted in a delayed physician assessment which placed Resident 1's health status and safety at risk for timely medical interventions.Findings:During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis including Intervertebral disc degeneration (the natural wear and tear of the cushiony pads between your backbones), acute pulmonary edema (a dangerous, sudden buildup of fluid inside the lungs that makes it feel like you are drowning) and Type 2 diabetes mellitus ( a long-term condition where the body cannot use sugar for energy properly, causing it to build up in the blood). During a review of Resident 1's History and Physical (H&P), dated 2/4/2026, the H&P indicated Resident 1 had the ability to understand and make decisions.During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one of one resident (Resident 6) was followed up by a psychologist (medical doctor who can diagnose and treat mental health conditions) as ordered by the resident's primary physician. This failure resulted in Resident 6 not receiving a psychology follow-up while in the facility to attain mental and psychosocial well-beingFindings:During a review of Resident 6's admission Record (Face Sheet), the admission Record indicated the facility originally admitted Resident 6 on 5/06/2022 and was re-admitted on [DATE] with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 6's Minimum Data Set (MDS - a resident assessment tool), dated 1/26/2026, the MDS indicated Resident 6's cognition (ability to think and make decisions) was moderately impaired. The MDS indicated Resident 6 was dependent (helper does all the effort) on staff with all activities of daily living (ADLs-…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to:1. Ensure one of five residents' (Resident 36's) instructions for holding parameters on medication bubble pack (sealed card containing individual, daily, or weekly doses of medication in clear, push-through plastic bubbles) for amlodipine (a medication used to treat hypertension [HTN - high blood pressure] and heart conditions) matched with physician's order, before medication administration during medication pass observation. 2. Ensure one of five residents (Resident 62's) polyethylene glycol powder (a medication in powder form used to treat constipation after being dissolved in a specific amount of water) was dissolved in the correct volume of water, in accordance with physician's order and manufacturer's specifications while preparing for administration during medication pass observation.These deficient practices increased the risk of medication errors for Residents 36 and 62 and had the potential to result in abnormal heart rate,…

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

Based on observation, interview, and record review, the facility failed to:1. Ensure one of five residents (Resident 36's) five (5) medications that included amlodipine (a medication used to treat hypertension [HTN - high blood pressure]), gabapentin (a medication used to treat nerve pain), carvedilol (a medication used to treat HTN), lidocaine patch (a medication applied on skin to treat localized pain) and docusate sodium (a medication used to treat constipation) were secured and not left unattended on bedside cart with the resident during medication pass observation.2. Ensure that the discarded medications in two of two inspected medication carts (Station 1 Morning Medication Cart 1 also known as split cart and Station 2 Medication Cart 4) were stored in a closed-lid container and/or disposed of in an irretrievable, safe and secure manner.These deficient practices failed to destroy the unidentifiable discarded medications and secure Resident 36's prepared medications, resulting in an unsafe and unsecure environment for medication storage in medication carts and Resident 36'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 and interview, the facility failed to ensure Dietary Staff 1 (DS 1) changed gloves to prevent growth of microorganisms that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, and viruses) in between tasks for 91 out of the 99 residents in the facility. This deficient practice had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea and fever and can lead to other serious medical complications and hospitalization. During an observation and interview on 2/9/2026 at 8:31 a.m., with DS 1, DS 1 was observed going to the sanitation area and back to the clean dishwashing area with the same gloves on and received clean dishes without changing his gloves. DS 1 stated one must change gloves to prevent contamination. DS 1 stated he (DS 1) did not have to change his gloves from the sanitation area prior to going back to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Discharge Summary/Post Discharge Plan of Care was provided to the receiving Skilled Nursing Facility (SNF) for one of three sampled residents (Resident 1) when Resident 1 was transferred and/or discharged on 12/11/2025.This deficient practice resulted in the receiving facility obtaining incomplete medical records for Resident 1 and had the potential for Resident 1's discharge care instructions to be overlooked, which could delay the continuity of care at the receiving facility.Findings:During a review of Resident 1's admission Record (Face sheet), the Face sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including end stage renal disease ([ESRD] irreversible kidney failure), 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), depression…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 California Department of Public Health (CDPH) was notified within 24-hours when the facility had a Covid (a highly contagious disease caused by the coronavirus SARS-Cov-2 spread by droplets from coughing, sneezing or talking) outbreak on 10/16/2025 for two of two sampled residents (Residents 3 and 10) and one facility staff. This deficient practice resulted in an increase of Covid positive residents and staff without CDPH knowledge and oversight and had the potential for the Covid to continue spreading amongst residents, staff and visitors due to possible ineffective infection control practice. Findings: a. During a record review of Resident 3's admission Record (Face sheet), the Face sheet indicated Resident 3 was admitted to the facility on [DATE] with diagnosis including Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow imprecise movements) and failure to thrive (a decline…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure three of four sampled residents (Residents 10, 30, and 40), who smoked cigarettes, and required safety precautions when smoking which included wearing smoking aprons (a fireproof covering worn over the chest and lap to protect a person and their clothing from burn holes caused by dropped cigarettes, cigars, or ashes), wore the smoking aprons while smoking. This deficient practice has the potential to place Residents 10, 20, 30, and 40 at risk for burns and/or injuries related to smoking.Findings:a. During a review of Resident 10's admission Record (Face Sheet), the Face Sheet indicated Resident 10 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease ([COPD] a chronic lung disease causing difficulty in breathing). During a review of Resident 10's Minimum Data Set ([MDS] a resident assessment tool) dated 7/14/2025, the MDS indicated Resident 10's cognition (the mental action or process…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 two of four sample residents (Resident 30 and 40) related to Resident 30 and 40 being smokers.This deficient practice places Resident 30 and 40 at risk for injuries or accidents related to smoking.Findings:a. During a review of Resident 30's admission Record (Face Sheet), the Face Sheet indicated Resident 30 was admitted to the facility on [DATE] with diagnoses including sepsis (a life-threatening blood infection). During a review of Resident 30's Minimum Data Set ([MDS] a resident assessment tool) dated 8/17/2025, the MDS indicated Resident 30's cognition was intact and required substantial/maximal assistance (helper does less than half the effort) from staff to complete his activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 30's Smoking assessment dated [DATE], the Smoking Assessment indicated Resident 30 required smoking measures such as 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 interviews and record reviews, the facility did not ensure that a resident received medication as prescribed by the physician for two out of four sampled residents (Residents 1 and 3). This deficient practice had the potential to place Resident 1 and 3 at risk of receiving unnecessary medication. Findings: a. During a review of Resident 1's admission record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (brain disorder that disrupts the body's process of converting food into energy), unspecified mood [affective] disorder (mental health condition characterized as persistent changed in mood and behaviors, and abnormal posture. During a review of Resident 1's Minimum Data Set [MDS] a resident assessment tool), dated 3/14/2025, the MDS indicated Resident 1's cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) were mildly impaired. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not implement and develop a resident-centered fall care plan for one of the five sampled residents (Resident 3). This deficient practice could adversely impact the resident's physical wellbeing and increase the risk of further falls and injuries. 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 diagnoses including encephalopathy (any damage or disease that affects the brain), sciatica (type of pain compressed nerve), and dementia (group of thinking and social symptoms that interferes with daily functioning). During a review of Resident 3's History and Physical (H&P), dated 4/20/2025, the H&P indicated Resident 3 has the capacity to understand and make decisions. During a review of Resident 3's Minimum Data Set ([MDS] a resident assessment tool), dated 4/18/2025, the MDS indicated Resident 3's cognitive skills (the mental action or process of acquiring…

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

Based on interview and record review, the facility's Quality Assessment and Assurance committee ([QAA] a group of facility staff who identifies, evaluates, and implements measures to improve the quality care and life for the residents in the facility) and Quality Assurance Performance Improvement ([QAPI] a group who takes a systemic, interdisciplinary, comprehensive, and data driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families, and all nursing home caregivers in practical and creative problem solving) committee failed to identify concerns related to significant medication errors (a preventable event that jeopardizes a patient's health and safety) in the facility. This deficient practice had the potential for continued significant medication errors, (a failure in drug therapy that may result in harmful effects to patents) and placed all residents residing in the facility at risk for adverse effects (unwanted undesirable effects) because of the medication errors and mismanagement of their medication regimen. (Cross…

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

Based on interview and record review the facility failed to ensure two out of two sampled staff, Licensed Vocational Nurse (LVN) 2 and 3, received mandatory training of effective communications upon hire. This failure had the potential to result in staff with poor communication skills and may negatively affect the residents' quality of care. Findings: During an interview and record review on 12/6/2024 at 11:50 a.m. with the Director of Staff Development (DSD), LVN 2 and 3's personnel records were reviewed, and the orientation training indicated no documented evidence effective communication was taught to LVN 2 and 3. The DSD stated effective communication was not part of the orientation in services upon hire of staff. During an interview on 12/7/2024 at 12:30 p.m., with the Director of Nursing (DON) the DON stated mandatory training need to be implemented in the facility. During a review of the facility's policy and procedure (P&P) titled, Competency of Nursing Staff, 5/2019, the P&P indicated all nursing staff must meet the specific competency requirements of their respective…

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

Based on interview and record review the facility failed to ensure two out of two sampled staff, Licensed Vocational Nurse (LVN) 2 and 3, received mandatory training of Quality Assurance and Performance Improvement (QAPI- systematic and interdisciplinary approach to maintaining and improving safety and quality in nursing homes while involving residents and families in practical problem solving) upon hire. This failure had the potential to negatively affect the residents' quality of care. Findings: During an interview and record review on 12/6/2024 at 11:50 a.m. with the Director of Staff Development (DSD), LVN 2 and 3's personnel records were reviewed, and the orientation training indicated no documented evidence QAPI training was taught to LVN 2 and 3. The DSD stated QAPI training was not part of the orientation in services upon hire of staff. During an interview on 12/7/2024 at 12:30 p.m., with the Director of Nursing (DON) the DON stated mandatory training need to be implemented in the facility. During a review of the facility's policy and procedure (P&P) titled, Competency 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 residents medical records were up to date as per the facility's policy and procedure (P/P) titled, Advance Directives ([AD], a legal document of a resident's wishes regarding medical treatment) for two of six sampled residents (Residents 38 and Resident 86). This deficient practice violated the residents' rights to be fully informed of the option to formulate an AD and had the potential to cause conflict with the residents' wishes regarding health care in the event residents became incapacitated (unable to participate in a meaningful way in medical decisions) or unable to make medical decisions that would not be identified and/or carried out by the facility staff. a.During a review of Resident 38's admission Record, the admission Record indicated Resident 38 was admitted to the facility on [DATE] with diagnoses of bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression 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 notify two of eight sampled resident's (Residents 6 and 26) primary care physician immediately when: a. Resident 6, who had a diagnosis of Diabetes Mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) and received insulin (a hormone which lowers the level of glucose [a type of sugar in the blood] had a blood sugar reading of 508 milligrams (mg - metric unit of measurement, used for medication dosage and/or amount)/deciliter (dL- a metric unit of capacity) on 11/17/2024. This deficient practice resulted in Resident 6's physician being unaware of Resident 6's elevated blood sugar (BS) level and had the potential for a delay in treatment interventions to decrease Resident 6's BS level. This deficient practice had the potential for Resident 6 to have diabetic ketoacidosis (DKA- a serious and potentially life-threatening complication of diabetes that occurs when the body doesn't have enough insulin to use blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY AMENDED 1/2/2025 Based on interview and record review the facility did not protect three of three sampled resident (Resident's 62 and 69) from abuse and neglect: The facility failed to: 1a.Report alleged abuse of Resident 69 by Resident 1 b.Ensure Resident 69 was safe from Resident 1 after alleged abuse. c.Monitor Resident 1 and 69 for alleged abuse. 2a. Ensure Resident 146, who was aggressive and combative toward staff on 8/15/2024 was sent out to a general acute care hospital (GACH) on a 5150 (temporary, involuntary psychiatric commitment of residents who present a danger to themselves or others due to signs of mental illness) hold, was not placed in the in front of the nursing station around other residents. b. Ensure Resident 62 was not subjected to Resident 146's aggressive outburst when suddenly Resident 146 grabbed Resident 62's quad cane (adjustable walking cane with 4-pronged base for extra stability) and hit Resident 62. As a result, Resident 146 punched Resident 62 in the chest and arms subjecting…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 allegations of physical abuse involving two of four sampled residents (Resident 146 and 62), to the California Department of Public Health (CDPH) within the regulated time frame of two hours. This deficient practice resulted in CDPH's inability to investigate the allegation of abuse timely and had the potential for other allegations of abuse to go unreported. Findings: During a review of Resident 62s admission Record, the admission Record indicated Resident 40 was admitted to the facility on [DATE] with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), Post-Traumatic Stress Disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event), difficulty of walking, and abnormalities of gait and mobility. During a review of Resident 62's Minimum Data Set (MDS), a resident assessment tool, dated 10/24/2024, the MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report allegations of physical abuse and submit the investigation report involving two of four sampled residents (Resident 146 and 62), to the California Department of Public Health (CDPH), within 5 days of the incident. This deficient practice resulted in CDPH's inability to investigate the allegation of abuse timely and had the potential for other allegations of abuse to go unreported. Findings: During a review of Resident 62s admission Record, the admission Record indicated Resident 40 was admitted to the facility on [DATE] with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), Post-Traumatic Stress Disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event), difficulty of walking, and abnormalities of gait and mobility. During a review of Resident 62's Minimum Data Set (MDS), a resident assessment tool,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 residents (Resident 62 and 146), who was diagnosed with post-traumatic stress disorder (PTSD - mental health condition that can develop after someone experiences or witnesses a traumatic even), received trauma informed care (a model that aims to provide effective mental health services by considering a person's past experiences with trauma). This deficient practice had the potential to result in resident re-traumatization and can be detrimental for the resident's psychosocial status. Findings: During a review of Resident 62s admission Record, the admission Record indicated Resident 40 was admitted to the facility on [DATE] with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and PTSD. During a review of Resident 62's Minimum Data Set (MDS), a resident assessment tool, dated 10/24/2024, the MDS indicated Resident 62's cognitive skills (ability to think 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 the licensed nurses were competent during medication administration for four out of eight sampled residents (Resident 6, 26, 29, and Resident 30). These deficient practices resulted in Resident 6, 26, 29, and Resident 30 having significant medication errors and had the potential for all residents in the facility to experience medication errors. (Cross Reference to F760 and F865) Findings: a. During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was admitted to the facility 6/23/2011 and readmitted on [DATE] with diagnoses including type 2 Diabetes Mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), supraventricular tachycardia (SVT- a rapid heart rate), and heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 6's Minimum Data Set (MDS- a federally mandated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure an Interdisciplinary Team ([IDT] team members from different departments working together, to set goals, make decisions that ensure residents receive the best care) Care Conference meeting, involving one of three sampled residents (Resident 86) was initiated after Resident 86 had been to multiple eye doctor appointments and neither staff nor resident were aware of the outcome from the appointments. This deficient practice violated Resident 86's right to be an active participant in the IDT meeting to discuss his plan of care and services with the IDT members and possible delayed discussion of needed care and services. Findings: During a record review of Resident 86's admission Record, the admission Record indicated Resident 86 was admitted to the facility on [DATE] with diagnoses of end stage renal disease ([ESRD], also known as kidney failure, an illness that occurs when the kidneys can no longer function properly), diabetes type 2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement a care plan for poor/decline in vision for one of three sampled residents (Resident 86). This deficient practice had the potential to negatively affect the quality of life and wellbeing for Resident 86 and to prevent him from achieving his highest practicable well-being. Findings: During a review of Resident 86's admission Record, the admission Record indicated Resident 86 was admitted to the facility on [DATE] with diagnoses of end stage renal disease ([ESRD], also known as kidney failure, is a terminal illness that occurs when the kidneys can no longer function properly), diabetes type 2 ([DM]-a disorder characterized by difficulty in blood sugar control and poor wound healing), anemia (a condition where the body does not have enough healthy red blood cells), and hypertension ([HTN]-high blood pressure). During a review of Resident 86's Minimum Data Set ([MDS], a resident assessment tool), dated 10/2/2024, 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 interview and record review the facility failed to ensure one of one resident's (Resident 70) diclofenac sodium external gel (medication for pain) order indicated the dose. This deficient practice resulted to Resident 70's diclofenac was administered from 11/17/2024 to 12/3/2024 without a documented dose which had the potential for overdosing or underdosing. Findings: During a review of Resident 70's admission Record, the admission Record indicated Resident 70 was readmitted to the facility on [DATE] with diagnoses including ventricular fibrillation (life threatening irregular heart beat), paroxysmal atrial fibrillation (type of irregular heart beat that usually end on their own within a week), and hypertensive heart disease (group of heart conditions caused by long-term high blood pressure - force of the blood pushing against the artery walls is consistently too high)with heart failure (serious condition that occurs when the heart is unable to pump enough blood and oxygen to the body's organs). During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident was provided a foley catheter (a thin, flexible tube that drains urine from the bladder into a bag outside the body, also called urinary catheter or indwelling urethral catheter) care to prevent recurrent urinary tract infections ([UTI], a bacterial infection that affects the urinary tract, which includes the bladder, ureters, and kidneys) for one of two sampled resident (Resident 25). This deficient practice had the potential to result in Resident 25 acquiring recurrent UTIs when foley catheter care was not provided according to the doctor's order. Findings: During a record review of Resident 25's admission Records, the admission Records indicated Resident 25 was admitted to the facility on [DATE] with a readmission date on 5/120/24 with diagnoses of obstructive and reflux uropathy (a blockage in the urinary tract that prevents urine from draining which can cause urine to build up in the kidneys, which can lead to kidney…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 resident (Resident 45) was receiving the correct concentration of oxygen. This failure has the potential to result in too much oxygen which can cause serious health problems. Findings: During a review of Resident 45's admission Record, the admission Record indicated Resident 45 was readmitted to the facility on [DATE] with diagnoses including interstitial pulmonary disease (chronic condition that refers to a group of disorders that cause scarring in the lungs), pulmonary fibrosis (chronic lung disease that causes scarring and thickening of the lung tissue, making it difficult to breathe), acute respiratory failure (life-threatening condition that occurs when the lungs and blood are unable to exchange gases properly), and dependence on supplemental oxygen. During a review of Resident 45's Minimum Data set (MDS), A resident assessment tool, dated 11/22/2024, the MDS indicated Resident 45's cognitive skills (functions your…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 monitor one of two resident's (Resident 146) behaviors while prescribed psychotropic medications (medications can alter brain chemistry, impact body functions, and modify a person's thoughts, moods, feelings, awareness, and perceptions). This failure had the potential to result in unnecessary medications. Findings: During a review of Resident 146's admission Record, the admission Record indicated Resident 146 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), PTSD, and acquired absence of left foot, and acquired absence of right leg below the knee. During a review of Resident 146's MDS, dated [DATE], the MDS indicated Resident 146's cognitive skills for daily decision-making was moderately impaired. The MDS indicated Resident 146 required set up assistance when with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure one of three resident's (Resident 70) medication was not left on top of the medication cart unattended. This failure had the potential to result in visitors, residents, and staff unauthorized access to Resident 70's medication. Findings: During a review of Resident 70's admission Record, the admission Record indicated Resident 70 was readmitted to the facility on [DATE] with diagnoses including ventricular fibrillation (life threatening irregular heart beat), paroxysmal atrial fibrillation (type of irregular heart beat that usually end on their own within a week), and hypertensive heart disease (group of heart conditions caused by long-term high blood pressure - force of the blood pushing against the artery walls is consistently too high)with heart failure (serious condition that occurs when the heart is unable to pump enough blood and oxygen to the body's organs). During a review of Resident 70's Minimum Data set (MDS), A resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to observe infection control measures for 2 of 3 sampled residents (Residents 14 and 69) by failing to: Sanitize the Mechanical lift between caring for Resident 14 and Resident 69 This deficient practice had the potential to spread infections to other residents in the facility. Findings: During a review of Resident 69's admission Record, the admission Record indicated the facility initially admitted Resident 69 to the facility on 1/16/2023 and re-admitted on [DATE] with diagnoses including end stage renal disease (kidney failure-a condition in which the kidney's loose ability to remove waste and balance fluids in the body), generalized muscle weakness, and hypertension (high blood pressure). During a review of Resident 69's history and physical (H&P), dated 3/20/2024, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 69's Minimum Data Set ([MDS] a resident assessment tool),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide care and services to prevent a fall for one of three sampled residents (Resident 1) by failing to ensure: 1.Certified Nursing Assistant (CNA) 1 provided a two-person physical assist (help from two persons) when using a Mechanical Lift (a device used to transfer residents from a bed to a chair or other similar places) to transfer Resident 1 from the wheelchair to the bed. 2. Implement the facility policy titled Mechanical Lift indicated a Mechanical Lift is used appropriately to facilitate transfers of residents. At least two people are present while the resident is being transferred with the Mechanical Lift. As a result of this failure Resident 1 fell on the floor from the Mechanical Lift and sustained a right shoulder nondisplaced fracture (a broken bone where the pieces of the bone remained aligned and don't move far enough to be out of place. This fracture is usually treated with a cast, brace, or splint to immobilize the bone,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure two of three sampled residents (Resident 2 and Resident 3) resident rights were upheld and protected when the Administrator (ADM) failed to speak to Resident 2 and Resident 3 in a respectful manner that maintained the resident's dignity, privacy, and individuality. This deficient practice resulted in Resident 2 and Resident 3 feeling anxious, powerless, frustrated, humiliated, angry and distrustful toward the facility. Findings: a. During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including generalized anxiety disorder (excessive and persistent feelings of fear, worry and dread), major depressive disorder ([MDD] a serious condition that affects how a person feels, thinks, acts), and hemiplegia (a slight paralysis or weakness on one side of the body) and hemiparesis (paralysis of the arm, leg, and trunk on 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 facility staff called 911 immediately to activate Emergency Medical Services ([EMS] a system that responds to emergencies in need of highly skilled pre-hospital clinicians), delegate staff to retrieve the facility's crash cart (a mobile cabinet that contains equipment and medications used to treat patients in a medical emergency) and obtain a non-rebreather mask (a device that delivers a large amount of O2, between 10 to 15 liters per minute [LPM]) to deliver an effective amount of oxygen (O2), when one of three sample residents (Resident 1), was observed choking while eating and required emergency assistance. As a result of this deficient practice, there was a 14 minute delay in calling 911 after Resident 1 was found choking, when RN 1 and LVN 1 went to check Resident 1's code status (the type of emergent treatment a person would or would not receive if their heart or breathing were to stop) while at the same time calling the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to document the care provided to one of three sampled residents (Resident 1), who was observed choking while being fed at dinner time, and who required a licensed nurse (LVN 1) to perform the Heimlich maneuver (a first aid and lifesaving technique used to help someone who is choking) on him. This deficient practice resulted in Resident 1's medical record having no documentation to show Resident 1's condition following a choking episode and the care provided to him. This deficient practice had the potential for non-continuity of care to 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 dysphagia (difficulty swallowing), and encephalopathy (a disease affecting brain and its function). During a review of Resident 1's History and Physical (H&P), dated 3/22/2024, the H&P indicated Resident 1 did not have 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 resident ' s (Resident 1) grievance (complaints regarding treatment, care, management of funds, lost clothing, or violation of rights) regarding Resident 1 ' s missing cellphone was resolved to the satisfaction of the resident and representative. This deficient practice violated the resident ' s right to have his grievance resolved promptly with Resident ' s 1 satisfaction. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with the diagnoses including sepsis (infection affecting entire body), depression (persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities), and hemiparesis (condition causing partial weakness or paralysis [loss of the ability to move] on one side of the body). During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care-screening tool)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify a family member on a timely manner when there was a change of condition (COC) for one of one sampled resident (Resident 3). This deficient practice had the potential to affect the resident's care being provided when there is a change of condition. Findings: During a review of Resident 3's admission record, the admission record indicated Resident 89 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, obstructive (the inability for urine to pass through due to a blockage) and reflux (abnormal flow of the urine that flows back up to the kidneys) uropathy, and unspecified dementia (a group of symptoms that affects memory and thinking) without behavioral disturbance (aggression, anxiety). During a review of Resident 3's Minimum Data Set [(MDS) a standardized assessment and care screening tool], dated 7/9/2024, the MDS indicated Resident 3's cognitive skills (the mental action or process of acquiring knowledge 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 evaluate the resident for possible injuries obtain and record assessment and notify physician when resident was found on the floor the morning of 1/14/2024 for one of three sample residents (Resident 1) This failure had the potential to result in delayed provision of necessary care and services for 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 unspecified glaucoma (group of eye diseases that can cause vision loss and blindness), chronic obstructive pulmonary disease (COPD- group of lung disease that block the airflow which can cause difficulty of breathing) and chronic kidney disease (gradual loss of kidney function). During a review of Resident 1 ' s Minimum Data Set (MDS, standardized assessment and care screening tool) dated 1/10/2024, the MDS indicated Resident 1 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 interview and record review the facility failed to ensure two of 20 sampled residents (Resident 7 and Resident 33) was properly and adequately assessed for pain and provided with pain medication timely. This failure resulted in Resident 7 and Resident 33 experiencing unnecessary pain. Findings: a. During a review of Resident 7's admission record(Face Sheet), the Face Sheet indicated Resident 7 was admitted to the facility originally on 2/12/2023 with the diagnoses of but not limited to fistula (an abnormal connection between two parts of the body, such as the intestine and skin) of the intestine (the tubular part of the digestive tract from the stomach to the anus), gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), peripheral vascular disease ( a systemic ( something relating to or affecting the whole of a system or organization) disorder that causes pain, discomfort and limb ischemia (inadequate blood supply to a limb that may cause tissue…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (% per hundred). Three medication errors out of 25 total opportunities contributed to an overall medication error rate of 12 % affecting one of three residents observed for medication administration (Resident 7) The deficient practice of failing to administer medications correctly increases the risk for residents to have additional health complications and could have negatively impacted their health and well-being. During a review of Resident 7's admission record, the admission recorded indicated Resident 7 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD: long term progressive lung disease that causes breathlessness and cough), fistula of intestine (abnormal opening in the digestive tract), gastrostomy (G-Tube: tube that is inserted into the stomach through the abdomen 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 proper Infection control practices were followed by: a. wearing appropriate personal protective equipment (PPE) prior to entering contact isolation room of 1 of 3 residents (Resident 190). b. perform hand hygiene while administering medication to Resident 51. c. Resident 81'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. These deficient practices had the potential to spread diseases and infection to other residents. This deficient practice resulted in contamination of the resident's care equipment and placed the residents at risk for infection. Findings: A. During a record review of the admission record of Resident 190 was admitted to the facility on [DATE]. Resident 190's diagnoses included but was not limited to encounter for surgical aftercare following surgery of skin and subcutaneous…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 2) Preadmission Screening and Resident Review (PASRR: a tool that is used to identify evidence of serious mental illness) Level I assessment screening was accurately documented. This deficient practice placed the resident at risk of not receiving the appropriate care and services needed. Findings: During a review of Resident 2's Face Sheet (admission record), the Face Sheet indicated Resident 2 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnosis including atherosclerotic heart disease without angina pectoris (early stage of a heart disease that causes plaque to build up in the arteries), palliative care (care provided to improve the quality of life for residents who have a serious or life-threatening disease), Type II Diabetes Mellitus (DM II: a condition that affects how a hormone helps control blood sugar levels), paranoid schizophrenia (a type of mental disorder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of one sampled residents (Resident 188) received Oxygen at 4Liters (L - unit of measurement of volume)/minute (min) via Nasal Canula (a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help) continuously as ordered by the physician for a diagnosis of shortness of breath (SOB). This deficient practice had the potential for Resident 188 to experience complications due to lack of oxygen and shortness of breath. Findings: During a review of the admission record, the record indicated Resident 188 was admitted to the facility on [DATE]. Resident 188 diagnoses included chronic congestive heart failure (a condition in which the heart does not pump enough blood to meet the body's needs) , muscle weakness, dysphagia (difficulty swallowing), respiratory failure ([RF] impairment in the process of gas exchange between the lungs and the blood over a period of time), Chronic Obstructive 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 20 sampled residents (Resident 15) had an appointment and transportation for a dental recommendation intended for new dentures was arranged since 7/13/2023. This failure resulted in Resident 15 not being able to chew food adequately and had the potential to result in weight loss and low self-esteem. Findings: During a record review of Resident 15's admission Record Face Sheet, the Face Sheet indicates Resident 15 was admitted to the facility on [DATE], with diagnoses of but not limited to aphasia (a brain disorder that results from damage to portions of the brain that are responsible for language), hemiplegia (brain damage or spinal cord injury that leads to paralysis on one side of the body, hemiparesis (weakness of one entire side of the body) affecting the right dominant side, diabetes, and cerebrovascular disease (a variety of medical conditions that affect the blood vessels of the brain and the cerebral circulation).…

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

Based on interview and record review, the facility failed to implement the grievance (complaint) policy for one of one resident (Resident 1) when Resident 1 filed a grievance on 9/6/2023 regarding waiting 2 hours for his call light to be answered and there was no investigation or resolution done. This deficient practice violated the residents' right to have his grievance addressed. Findings During a review of Resident 1's admission Record, the record indicated an admission date of 11/22/2022 with the diagnoses including depression (persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities) and end stage renal disease (last stage of long-term [chronic] kidney disease, when the kidneys [organ that filters waste from the body] can no longer support the body's needs). During a review of Resident 1's Minimum Data Set ([MDS- a standardized assessment and care-screening tool) dated 8/25/2023, the MDS indicated Resident 4's cognition (thinking) was intact, and Resident 4 required extensive assistance from one facility staff member to complete…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 Licensed Vocational Nurse 1 (LVN 1) provided toileting assistance and change the incontinence brief of one of one resident (Resident 3) after the resident had diarrhea (liquid stool). This deficient practice resulted in Resident 3 waiting for 45 minutes with diarrhea in their incontinence brief and delayed Resident 3 from leaving to go to the resident's dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) appointment. Findings During a review of Resident 3's admission Record, the admission record indicated Resident 3 was admitted to the facility on [DATE] with the diagnoses including end stage renal disease (when the kidneys [organ that filter waste from the body] can no longer support the body's needs). During a review of Resident 3's Minimum Data Set ([MDS]- a standardized assessment and care screening tool) dated 9/12/2023, the MDS indicated Resident 3's 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 interview and record review, the facility failed to monitor the aggressive behavior of one of two residents (Resident 1) after Resident 1 was found grabbing Resident 2's hands. This deficient practice had the potential to negatively affect the resident's psychological wellbeing and placed other residents at risk for abuse from Resident 1. Findings During a review of Resident 1's admission record, the admission record indicated Resident 1 was admitted to the facility on [DATE] with the diagnoses of dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a review of Resident 1's Minimum Data Set ([MDS]- a standardized assessment and care screening tool), dated 8/11/2023, the MDS indicated Resident 1's cognition(thinking) was severely impaired, and Resident 1 required limited assistance from one facility staff member to complete activities of daily living ([ADLs] activities related to personal care). During a review of Resident 2's admission…

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

Based on observation, interview and record review, the facility failed to follow Resident 4's food preferences when Resident 4 received a pulled pork sandwich and baked beans, when Resident 4's diet card stated Resident 4 preferred two peanut butter and jelly sandwiches for lunch. This deficient practice had the potential to result in decreased meal intake by Resident 4 and can lead to weight loss and malnutrition (not enough nutrients). Findings During a review of Resident 4's admission Record, the record indicated an admission date of 11/22/2022 with the diagnoses including depression (persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities) and end stage renal disease (last stage of long-term (chronic) kidney disease, when the kidneys [organ that filters waste from the body] can no longer support the body's needs). During a review of Resident 4's Minimum Data Set ([MDS- a standardized assessment and care-screening tool) dated 8/25/2023, the MDS indicated Resident 4's cognition (thinking) was intact, and Resident 4 required extensive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility staff failed to implement care plan interventions for one of two sampled residents (Residents 1 ) who were at risk for falls. This deficient practice had the potential to result in injury. Findings: A review of the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and re-admitted on 9/12/ 2023, with diagnosis that included a history of muscle weakness generalized ( decrease in muscle strength), Unspecified dementia ( an impaired ability to remember, think, or make decisions that interferes with doing everyday activities ) and personal history of healed traumatic fracture ( occurs when significant or extreme force is applied to a bone). A review of the Resident 1 ' s Minimum Data Set (MDS- a comprehensive assessment tool) dated August 4,2023, indicated Resident 1 indicates cognitive intactness skills for daily decision making. Resident 1 required limited assistance ( staff provide guided maneuvering ) with…

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