North Long Beach Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY A. Based on interview and record review, the facility failed to ensure one out of five sampled residents (Resident 38) had the mental capacity (the ability to make an informed decision based on understanding a situation, the options available, and the consequences of the decision) to sign an informed consent (permission granted in the knowledge of the possible consequences, typically that which is given by a patient to a doctor for treatment with full knowledge of the possible risks and benefits) for his psychotropic (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) medications. This deficient practice had the potential for Resident 38 to sign consent for a psychotropic medication without being aware of the risks and benefits. B. Based on interview and record review, the facility failed to ensure Resident 69's clonazepam (a controlled medication [medications that the use and possession of are controlled by the federal government]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately document the Minimum Data Set (MDS - a resident assessment tool) for three of 12 sampled residents by failing to: a. Ensure Resident 87's hemodialysis status was reflected on the MDS. b. Ensure Resident 111's accurate discharge destination was documented. c. Ensure the accuracy of information in the MDS assessment for one of three sampled residents (Resident 32) who was on oxygen therapy. This failure had the potential to negatively affect resident's plan of care and delivery of necessary care and services. Findings: During a review of Resident 87's admission record , the admission record indicated Resident 87 was initially admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis including end stage renal disease (ESRD-irreversible kidney failure) with dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). 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 develop and implement care plans for two of six sampled residents (Resident 60, Resident 67) when: a. The facility failed to ensure a care plan for Divalproex (medication to treat outbursts of aggression related to dementia and other behavioral disturbances) was developed and implemented for one of four sampled residents (Resident 60). This deficient practice placed Resident 60 at risk for physical harm and injury and had the potential to delay necessary monitoring and safety interventions. b. Resident 67 did not have a care plan in place for his use of Quetiapine Fumarate (Seroquel, medication used to treat psychosis [a mental state characterized by a loss of contact with reality]). These deficient practices had the potential for Resident 60, Resident 67 to not receive personalized care. Findings: a.During a review of Resident 60's admission Record, the admission Record indicated the facility admitted Resident 60 on 12/27/2022 and was re-admitted on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Ensure hydrocodone-acetaminophen (a controlled medication [medications that the use and possession of are controlled by the federal government] in combination with acetaminophen [a medication used to treat pain] used to relieve pain) was administered to Resident 12 only for the prescribed severe pain level and as per physician orders, affecting one of three sampled residents during medication administration (Resident 12). 2. Maintain accurate documentation of lorazepam (a controlled medication used to treat anxiety [a medical condition described by feeling of fear or uneasiness]) oral solution on accountability record or controlled medication count sheet/controlled drug record ([CDR] - a document indicating perpetual inventory and administration of controlled substances, as per facility's policy and procedure (P&P) titled, Controlled Medications, dated 4/2008, affecting one resident (Resident 32) in one of three inspected medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain an informed consent from a resident's responsible party for one of five sampled residents (Resident 79). This failure had the potential to result in violating the resident's right to be informed and refuse treatment. Findings: During a review of Resident 79's admission record, the admission record indicated Resident 79 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including metabolic encephalopathy (damage or disease that affects brain function) and dementia (a progressive state of decline in mental abilities). During a review of Resident 79's History and Physical (H&P), dated 1/20/2025, the H&P indicated Resident 79 did not have the capacity to understand and make own medical decisions. During a review of Resident 79's Minimum Data Set (MDS - a resident assessment tool), dated 5/7/2025, the MDS indicated had severe cognitive (ability to learn, reason, remember, understand, and make decisions)…

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

Based on observation, interview, and record review, the facility failed to ensure that the call light device was within reach for one of six sampled residents (Resident 41). This deficient practice had the potential to prevent Resident 41 from receiving necessary care and services. Findings: During a review of Resident 41's admission Record, the admission Record indicated the facility admitted Resident 41 on 5/10/2025 with diagnoses including Parkinson's disease (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), diaphragmatic hernia (birth defect where there is an abnormal opening in the diaphragm [muscle separating the chest and abdomen]), and lack of coordination (ability to use different parts of the body together smoothly and efficiently). During a review of Resident 41's Minimum Data Set (MDS, a resident assessment tool), dated 5/16/2025, the MDS indicated Resident 41 had moderately impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 41 required supervision or touching…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 medical doctor (MD) was notified when one out of two residents (Resident 71) had multiple blood sugar levels that were over 400 milligram ([mg]unit of measure weight])/deciLiter (dl unit of measure of volume) (reference range 70 and 100 mg/dL). This deficient practice had the potential to cause a delay in treating the elevated blood sugar levels for Resident 7, and risk transfer to the general acute care hospital (GACH) for treatment of high blood sugar. Findings: During a review of Resident 71's admission Record, the admission Record indicated Resident 71 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease (a condition where the kidneys are damaged and cannot filter blood effectively, leading to a buildup of waste and excess fluid in the body), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), depression (mental illness that causes persistent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 a written 7-day bed hold notice for one of two sampled residents (Resident 87). This failure had the potential to result in violating Resident 87's right to be informed upon transfer of the bed-hold period permitting the resident to return to the facility. Findings: During a review of Resident 87's admission record, the admission record indicated Resident 87 was initially admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis including end stage renal disease (ESRD-irreversible kidney failure) with dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). During a review of Resident 87's History and Physical (H&P), dated 5/20/2024, the H&P indicated Resident 87 had the capacity to understand and make decisions. During a review of Resident 87's Minimum Data Set (MDS - a resident assessment tool), dated 5/27/2025, 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 observation, interview, and record review, the facility failed to ensure that Licensed Vocational Nurse (LVN) 1 did not crush delayed release ([DR] medication released over an extended time) divalproex (a medication used to treat seizure [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]) and did not administer crushed divalproex delayed release and crushed lorazepam (a controlled medication [medications that the use and possession of are controlled by the federal government] used to treat anxiety [a medical condition described by feeling of fear or uneasiness]) together for one of three sampled residents (Resident 2) during medication administration observation. This deficient practice had the potential to place Resident 2 at risk for drug interactions (occur when two or more drugs taken simultaneously affect each other's actions in the body) or intolerability to one or more medications without possibly knowing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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. One of six sampled residents (Resident 41) was sitting upright when eating lunch. This deficient practice placed Resident 41 at risk for aspiration (inhaling small particles of food or drops of liquid into the lungs) and choking. B. Two of three residents (Resident 45) were transferred by two persons in a mechanical lift ( a mechanical device used to safely transfer individuals who have limited mobility from one place to another ). This deficient practice had the potential to result in Resident 45 falling from the mechanical lift and causing injury. Findings: A. During a review of Resident 41's admission Record, the admission Record indicated the facility admitted Resident 41 on 5/10/2025 with diagnoses including Parkinson's disease (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), diaphragmatic hernia (birth defect where there is an abnormal opening in the diaphragm…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 perform a trauma informed care assessment for one of two sampled residents (Resident 64) who was diagnosed with post-traumatic stress disorder (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). This deficient practice had the potential for Resident 64 to experience triggers (memories tied to the traumatic event) in the facility and had the potential for re-traumatization (the experience where past traumatic memories are triggered, leading to further physical and psychological harm, often due to inadequate care or inappropriate situations). Findings: During a review of Resident 64's admission Record (face sheet), the admission Record indicated Resident 64 was admitted to the facility 12/6/2023 with diagnosis including PTSD and dementia (a condition characterized by progressive or persistent loss of intellectual functioning). During a review of Resident 64's Minimum Data Set (MDS, a minimum data set) dated 5/22/2025, the MDS indicated Resident 64 had severe…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 and consultant pharmacist (a professional responsible for reviewing each resident's medication profile monthly to identify and report changes) failed to identify that Resident 69's clonazepam (a controlled medication [medications that the use and possession of are controlled by the federal government] used to treat anxiety [a medical condition described by feeling of fear or uneasiness]) did not indicate a specific duration of treatment and did not indicate a stop date, affecting one of four sampled residents for unnecessary medications (Resident 69). The deficient practice of failing to identify and report irregularities resulted in Resident 69 receiving clonazepam unnecessarily without a specific duration of treatment 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 medication administration and adequate monitoring of side effects for one of two sample residents (Resident 53) who was receiving an anticoagulant (a medication used to prevent and treat blood clots that can cause severe health issues in the blood vessels and the heart) medication and were at high risk for bleeding. This deficient practice had the potential to cause a delay in necessary care and services resulting in injury or death. Findings: During a review of Resident 53's admission Record, the admission Record indicated Resident 53 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation ([a-fib], a type of heartbeat where the heart beats fast and irregularly), diabetes mellitus ([DM]-a disorder characterized by difficulty in blood sugar control and poor wound healing), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anemia (a condition…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 two of three sampled residents (Residents 2 and 12) by failing to: 1. Ensure Resident 2's divalproex (a medication used to treat seizure [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]) delayed release ([DR] medication released over an extended time) was not crushed. 2. Ensure Resident 2's crushed divalproex delayed release tablet and crushed lorazepam (a controlled medication [medications that the use and possession of are controlled by the federal government] used to treat anxiety [a medical condition described by feeling of fear or uneasiness]) tablet were administered separately. 3. Ensure Resident 12's hydrocodone-acetaminophen (a controlled medication [medications that the use and possession of are controlled by the federal government] in combination 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.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 12) was free from significant medication error during medication administration, by failing to ensure hydrocodone-acetaminophen (a controlled medication [medications that the use and possession of are controlled by the federal government] in combination with acetaminophen [a medication used to treat pain] used to relieve pain) was administered to Resident 12 only for the prescribed severe pain, on the pain level scale (a tool used to measure the intensity of pain 1-4 mild pain, 5-7 moderate pain, 6-10 severe pain) and as per physician orders. This deficient practice failed to provide hydrocodone-acetaminophen in accordance with physician orders or professional standards of practice and had the potential to result in drug overdose, drug misuse and hospitalization. Findings: During a review of Resident 12's admission Record (a document containing demographic and diagnostic information), dated 6/24/2025, the admission record indicated, Resident 12 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: 1. Ensure discontinued lorazepam (a controlled substance [a medication with a high potential for abuse] used to treat anxiety [a medical condition described by feeling of fear or uneasiness]) 2 milligrams (mg - a unit of measurement for mass) per milliliters (mL - a unit of measurement for volume) oral solutions for Residents 44 and 63 were removed from Station 1 Medication Room Refrigerator and disposed of in accordance with the facility's policy and procedures (P&P) titled, Disposal of Medications and Medication-Related Supplies - Controlled Medication Disposal, dated 1/2025, Medication Destruction, dated 1/2025 and Discontinued Medications, dated 1/2025, affecting one of one inspected medication room (Station 1 Medication Room). 2. Ensure Resident 44's ondansetron (a medication used to treat nausea and vomiting) orally disintegrating tablets ([ODT] fast dissolving in mouth), hyoscyamine (a medication used to provide symptomatic relief…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 specialized rehabilitative (rehab) services (services that require specialized training and experience of a licensed therapist or therapy assistant) to two of six sampled residents (Residents 16 and 41) by failing to: 1.Ensure Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function), Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities), and Speech Therapy (ST, profession aimed in the prevention, assessment, and treatment of speech, language, communicative, and swallowing disorders) evaluations were provided in accordance with physician's orders for Resident 16. 2.Ensure a ST evaluation was provided in accordance with physician's orders for Resident 41. These deficient practices prevented Residents 16 and 41 from receiving skilled rehab services to potentially maintain or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure; a. The medical record for one of six sampled residents (Resident 71) was accurate by failing to ensure the physician's orders for Resident 71's right leg weight bearing restrictions were accurately documented. This deficient practice had the potential to negatively impact the provision of necessary care and services, cause miscommunication among staff, and cause a decline in range of motion (ROM, full movement potential of a joint), mobility, and overall function. b. Restorative Nursing Aide ([RNA], nursing aide program that help residents maintain any progress made after therapy intervention to maintain their function) services provided were accurately documented for one of three sampled residents (Resident 48). These deficient practices had the potential to negatively impact the provision of necessary care and services and portray an inaccurate reflection of services provided. Findings: a.During a review of Resident 71'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 interview and record review, the facility's Quality Assessment and Assurance (QAA) Committee failed to identify and implement corrective action on repeated systemic problems that were identified from the last survey process, affecting 102 of 102 residents: a. Ensure staff were notifying the medical doctor of any change in condition in residents. b. Ensure the accuracy of Minimum Data Set (MDS, a resident assessment tool) for residents. The deficient practices placed the residents at risk of not receiving the quality treatment necessary to adequately meet their highest practicable well-being. Findings: During an interview on 6/26/2025 at 4:20 p.m., with the Administrator (ADM), the ADM stated the following systemic issues identified were not identified by the QAA committee during this survey process: a. Ensure staff were notifying the medical doctor of any change in conditions in residents. b. Ensure the accuracy of Minimum Data Set (MDS, a resident assessment tool) for residents. During a record review of the facility's policy and procedure (P/P) titled, Quality Assurance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 offer and educate coronavirus ([Covid-19] n infectious disease caused by the SARS-CoV-2 virus) vaccinations to staff per facility's policy for six of seven sampled employees. This failure had the potential to place all residents at risk for infection of Covid-19. Findings: During a concurrent interview and record review on 6/25/2025 at 9:49 a.m. with the Infection Preventionist Nurse (IPN), the Employee Vaccine Tracker Log was reviewed. The IPN stated Covid-19 vaccine booster and vaccines are encouraged to all employees. The IPN stated the facility accepts verbal declinations for vaccinations. The IPN stated the facility does not use vaccine declination forms and does not have documentation indicating staff were offered and educated about the Covid-19 vaccination for the 2024-2025 season. During an interview on 6/26/2025 at 4:34 p.m. with the Director of Nursing (DON), the DON stated it is important to educate and document staff coronavirus vaccinations to protect residents and staff from a Covid-19 outbreak. The DON…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the physician for two of three sampled residents on: a) 5/22/2025 when Resident 3 was transferred to a general acute care hospital (GACH) for difficulty breathing, b) 5/23/2025 when Resident 4 had a new skin redness to the nose area, and c) 5/26/2025 when Resident 4 was refusing care, had agitation, and increased confusion. This failure had the potential to result in a delay of care for Resident 3 and Resident 4. Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD - -a chronic lung disease causing difficulty in breathing) and anxiety disorder (persistent and excessive worry that interferes with daily activities). During a review of Resident 3 ' s Minimum Data Set (MDS – a resident assessment tool), dated 5/21/2025, the MDS indicated Resident 3 had severe…

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

Based on interview and record review the facility failed to ensure one of three sampled residents (Resident 1) was free from physical restraints (any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body) by failing to: 1.Assess Resident 1 for possible causes of behaviors and implement interventions before the application of physical restraints. 2.Notify the physician of Resident 1 ' s continued agitation and obtain a Physician Order for the use of Physical restraints before applying the restraints. 3.Develop a care plan to address the need for the implementation of physical restraints. 4.Attempt to use less restrictive interventions before application of physical restraints on Resident 1. 5. Ensure Registered Nurses (RN), Certified Nurse Assistants (CNA), and staff were competent in using physical restraints and managing fall risks and challenging behaviors. These deficient practices resulted in violation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: a. Obtain informed consent for Ativan for one of three sampled residents (Resident 3) prior to administration b. Monitor and document manifested behaviors for the administration of Ativan and Seroquel for one of three sampled residents (Resident 1). These deficiencies have the potential to result in the use of unnecessary medication, or non-therapeutic use of psychotropic medication. Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD - -a chronic lung disease causing difficulty in breathing) and anxiety disorder (persistent and excessive worry that interferes with aily activities). During a review of Resident 3 ' s Minimum Data Set (MDS – a resident assessment tool), dated 5/21/2025, the MDS indicated had severe cognitive (ability to learn, reason, remember,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 a fall risk care plan for one of two sampled residents (Resident 1) when Resident 1 was identified as a fall risk. This failure resulted in Resident 1 experiencing a fall on 5/23/2025 and sustaining a skin tear to the right elbow. 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 hyponatremia [low levels of sodium (salt) in the blood that cause headache, confusion, or seizures] and nontraumatic intracerebral hemorrhage (bleeding in the brain not caused by an injury During a review of Resident 1's History and Physical (H&P), dated 5/27/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/24/2025, the MDS indicated Resident 1 had severe cognitive (ability to learn, reason, remember, understand, 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 1), who was transferred to a General Acute Care Hospital (GACH) due to blood in her urine, was readmitted to the facility, when it was determined by the GACH that Resident 1 was appropriate for transfer back to the facility (2/24/2025). This deficient practice resulted in Resident 1 remaining in the GACH for 20 days after attempts to transfer her back to the facility were made by the GACH. This deficient practice had the potential to cause Resident 1 anxiety and non-continuity of care. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including alcohol cirrhosis (a severe and irreversible liver disease caused by long-term excessive alcohol consumption) of the liver with ascites (a condition where excessive fluid accumulates in the abdomen) and portal hypertension (a condition in which there is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 five sampled residents (Resident 4) was not hit by Resident 5. This deficient practice resulted in Resident 4 being punched in the stomach by Resident 5 and had the potential for Resident 4 to suffer physical or psychosocial harm as a result. This deficient practice had the potential for other residents in the facility to be subjected to suffer physical abuse. Findings: 1. During a review of Resident 4 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), dementia (a progressive state of decline in mental abilities), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and schizophrenia (a mental illness that is characterized by disturbances in…

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

Based on interview, and record review, the facility failed to treat resident with dignity, when Certified Nurse Assistant (CNA) 1 spoke disrespectfully to one of three residents (Resident 2). This deficient practice had the potential to compromise the resident ' s emotional well-being and violate their right to respectful and dignified care. Findings: During a review of Resident 2 ' s admission Record, the admission Record indicated the facility admitted Resident 2 on 5/16/2024, with diagnoses including bipolar disorder (a mental illness that causes extreme mood swings), major depressive disorder (a common mental health condition that involves a persistent low mood or loss of interest in activities), generalized anxiety disorder (a mental health condition that causes excessive and persistent feelings of fear, dread, and uneasiness that can interfere with daily life), and mental and behavioral disorders (conditions that affect your thinking, feeling, mood, and behavior). During a review of Resident 2 ' s Minimum Data Set (MDS-a resident assessment tool), dated 9/20/2024, the MDS…

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

Based on interview and record review, the facility failed to document a resident had refused a physician ' s visit for one of three residents (Resident 1) when Resident 1 refused psychiatric care and treatment. This failure has the potential to result in Resident 1 ' wishes and rights not being respected or miscommunicated among staff. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on 4/26/2024, readmitted him on 10/17/2024 with diagnoses including depression (a mental health condition that involves persistent feelings of sadness, loss of interest, and difficulty functioning in daily life), and anxiety disorder (a condition that causes excessive and persistent feelings of fear, dread, and uneasiness that can interfere with daily life.) During a review of Resident 1 ' s physician ' s Subjective, Objective, Assessment, and Plan-(SOAP - a standardized method of documentation sed by healthcare providers to record patient care) note, dated 12/22/2024, the Physician ' s SOAP indicated, Resident 1 had the mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled resident ' s (Resident 4), who did not have capacity to understand and make decisions, Responsible Parties (RPs 1 and 2), were invited and attended an Interdisciplinary Team (IDT- the resident and or RP along with various healthcare professionals who meet to coordinate the resident's care plan) care conference on /11/22/2024. This deficient practice violated Resident 1 and RPs 1 and 2 right to be informed and active participants to discuss Resident 1 ' s plan of care and services with the IDT and had the potential for a delayed discussion of needed care and services. Findings: During a review of Resident 4's admission Record (Face Sheet), the Face Sheet indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify one of three sampled resident ' s (Resident 4) primary care doctor (MD 1) and Responsible Parties (RPs 1 and 2) when Resident 4 ' s coronavirus disease 2019 (COVID-19 an infectious disease caused by the SARS-CoV-2 virus which affects the respiratory [breathing] system) test was not completed as ordered. This failure resulted in Resident 4 ' s COVID-19 status being unknown and could have resulted in Resident 4 being positive for COVID-19. This deficient practice had the potential to cause a delay in treatment to Resident 4, and result in the spread of COVID-19 to all staff, residents, and visitors in the facility. Findings: During a review of Resident 4's admission Record (Face Sheet), the Face Sheet indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 four sampled residents (Resident 1) personal belonging list (inventory list) was updated when Resident 1 received and kept a debit card in his possession and assist Resident 1 in safeguarding the key to Resident 1 ' s bedside drawer. These failures had the potential for Resident 1 ' s belongings to be unaccounted for and his personal items to be unsafe. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with a diagnoses including cerebral infarction (damage to the brain from interruption of its blood supply) with left side hemiplegia (paralysis to the left side of the body), hypertension (high blood pressure) with heart failure (a condition that occurs when the heart cannot pump enough blood for the body ' s needs) and depression (a constant feeling of sadness and loss of interest). During a review of Resident 1 ' s Minimum Data Set…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement comprehensive plan of care for the use of Plavix (blood thinner medication) on one of four sampled residents (Resident 1). This failure had the potential to result in inadequate monitoring and assessment of Resident 1 ' s bruises on both arms after an allegation of abuse. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] to the facility with diagnoses that included atherosclerotic heart disease of native coronary artery( buildup of fats, cholesterol and other substances on the blood vessels supplying the heart) , hypertensive heart disease( group of heart problems that develop over many years due to chronic high blood pressure) and hyperlipidemia (condition where there are high levels of fats in the blood). During a review of Resident 1 ' s Minimum Data Set ([MDS] standardized screening tool) dated 6/28/2024, the MDS indicated 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 call light was within reach for two of seven sampled residents (Resident 20 and 57). This deficient practice had the potential for Resident 20 and 57 not able to find the call light to call for assistance when needed, and experienced loss of self-esteem. Findings: During a review of Resident 20's admission Order, the admission Record indicated Resident 20 was admitted to the facility on [DATE], with diagnoses including acute respiratory failure (a serious condition that makes it difficult to breathe on your own), vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), dysphagia (difficulty of swallowing). During a review of Resident 20's Minimum Data Sheet (MDS- a standardized assessment and care screening tool) dated 04/02/2024 indicated Resident 20 had no cognitive impairment (ability to learn, understand, and make decisions) and requires assistance for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to notify nursing and the primary physician of the change in condition (COC- major decline or improvement in a resident's status that will not resolve itself without intervention) for two of eight sampled residents (Resident 102 and 61) with limited range of motion ([ROM], full movement potential of a joint {where two bones meet}) and mobility (ability to move) concerns by failing to: a. Report Resident 61's increased pain and ROM impairments in the left leg indicated on the Rehab Screening (brief assessment of a resident's abilities), dated 11/5/2021. b. Report Resident 102's significant decline in mobility and activities of daily living (ADLs, tasks related to personal care including bathing, dressing, hygiene, eating, and mobility) indicated on the Rehab Screening, dated 4/5/2024. These deficient practices prevented Resident 102 and Resident 61 from receiving intervention to decrease pain and improve their ability to perform 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.

Based on interview and record review, the facility failed to ensure thoroughly investigate the background of Registered Nurse Supervisor (RNS 1) who had history of disciplinary actions on her nursing license during hiring process. This failure had the potential to place residents at risk for abuse and gross negligence (repeated failure to provide required nursing care or exercise precaution in a situation which the nurse knew or should have known could result in patient harm). Findings: During a record review of RNS 1 's 2023 Facility's' Application for Employment, the Application for Employment indicated RNS1 had disclosed in her application form that she was asked to resign or was involuntarily discharged . During a review of RNS 1's California Board of Registered Nursing ( BRN, state governmental agency established by law to protect the public by regulating the practice of registered nurses) Licensing details, indicated four administrative disciplinary actions( legal document formally charging a licensee with violation of the practice act and notifying the public that a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Ensure a Preadmission Screening and Resident Review (PASARR: required screening for individuals with serious mental illness to ensure needs are met and are placed in an appropriate environment) assessment was resubmitted for a resident who was newly diagnosed with a mental illness for one of one sample residents (Resident 89). 2.Follow up and PASARR recommendation to obtain Level II evaluation for three of three sampled residents (Resident 11, 15 and 57). These deficient practices had the potential for Resident 89,11,15, and 57 not receiving the necessary and appropriate psychiatric (diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders) level of treatment and evaluation in the facility. Findings: 1. During a review of Resident 89's admission record, the admission Record indicated Resident 89 was initially admitted to the facility on [DATE] and was readmitted [DATE] with diagnoses schizoaffective disorder (mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Ensure availability and administration of Restasis ([Generic name cyclosporine] a medication used to treat dry eye disease) in accordance with physician orders or professional standards of practice for one of three sampled residents (Resident 60.) This deficient practice increased the risk for Residents 60 to suffer from eye complications including dry eyes. 2. Maintain accurate documentation of administered clonazepam (a medication used to treat panic disorder and seizure [a medical term used to describe sudden, uncontrolled burst of electrical activity in the brain] on controlled drug record (a document indicating perpetual inventory and administration of controlled substances [a term used for medications with high level of abuse and dependence]) for Resident 45 as per facility's policies and procedures (P&P) titled, Controlled Medications in one of three inspected medication carts (Medication Cart 1B.) This deficient practice had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 follow their policy on food handling and storage in the refrigerator by not dating prepared food stored in the refrigerator. This deficient practice had the potential to cause food borne (illness caused by food contaminated with germs or toxins) diseases among the facility residents who depend on facility prepared food for daily feeding, Findings: During a concurrent kitchen observation and interview with the Dietary Supervisor (DS) on 6/27/2024 at 12:06 p.m., observed snacks/nourishment stored in the refrigerator were not labeled with preparation date or expiration date. DS stated the snacks were just prepared and stored in the refrigerator to cool down for lunch service. The DS stated it was not labeled with the date of preparation. During a review of facility's policy and procedure (P&P) titled, Food receiving and storage, (undated) the P&P indicated all foods stored in the refrigerator or freezer must be covered labelled and dated.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to observe infection control measures on two of six sampled residents (Resident 48 and Resident 80) by failing to: a.Ensure doffing of (removal) personal protective equipment ([PPE] specialized clothing or equipment worn by an employee for protection against infectious materials) properly after rendering care to Resident 48. b.Practice infection prevention measures by placing medications in unclean and unsanitary conditions for one of three observed residents during medication administration (Resident 80). These failures had the potential to spread infection among residents, staff, and visitors. Findings: a.During a review of Resident 48's admission Record, the admission Record indicated Resident 48 was admitted to the facility on [DATE] to the facility with diagnoses that included dependence on renal dialysis (kidneys are no longer working adequately and depends on dialysis to detoxify the body), diabetes(high blood sugar), and gastrostomy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 antibiotic stewardship program (measures used by the facility to ensure antibiotics [drug to treat infection] are used only when necessary and appropriate) for three of seven sampled residents (Resident 12,47, and 111), by prescribing an antibiotic without meeting the criteria of their protocol (checklist or guide to initiate antibiotic). This deficient practice had the potential to put Resident 12,47, and 111 at risk for antibiotic resistance (not effective to treat infection) and inappropriate use of antibiotic. Findings: During a review of Resident 12's admission Order indicated Resident 12 was admitted to the facility on [DATE] with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body) following cerebral infarction (damage to the brain from interruption of its blood supply) , bipolar disorder (a serious mental illness that causes unusual shifts in mood), and chronic…

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

Based on interview and record review , the facility failed to track and update Covid 19 ( contagious and highly transmissible respiratory disease caused by a virus) immunizations among the staff and residents. This deficient practice had the potential to cause an outbreak of Covid among the staff members and residents in the facility. Findings: During an interview on 6/25/2024 at2:58 p.m. with Infection Preventionist Nurse (IPN), IPN stated the facility had no updated list of Covid vaccination status of residents and staff. IPN stated she took over as an IPN nurse last April 2024 and the last time it was updated was March 2024. IPN stated she did not have the current listing of staff and residents who are vaccinated and unvaccinated. IPN further added she did not have the information or in-services about educating staff about Covid vaccines. IPN stated as part of their Quality Improvement Activities the facility will offer a vaccine clinic for this coming July 2024. IPN stated staff and residents should be educated about the importance of Covid vaccinations to ensure residents…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to: 1.Eensure one of three sampled residents (Resident 3) provided privacy while sitting on a wheelchair wearing an incontinent brief (diaper). This deficient practice had the potential to affect Resident 3's self-worth and dignity. 2.Ensure one of eight sampled residents (Resident 61) who had limited range of motion [(ROM) full movement potential of a joint (where two bones meet)] and mobility (ability to move) was dressed in their own clothes and not in a hospital- type gowns. This failure had the potential to negatively impact Resident 61's psychosocial (social conditions related to mental health) well-being and prevented Resident 61 from receiving movement to the left arm during activities of daily living (ADLs, tasks related to personal care including bathing, dressing, hygiene, eating, and mobility). Findings: 1.During a review of Resident 3's admission Order, the admission Record indicated Resident 3 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 ensure one of ten residents (Resident 105) during Resident Council Meeting (organized group of residents who meet regularly to discuss and address concerns about their rights, quality of care and life) know how to file a grievance. This deficient practice had the potential to violate resident's rights to have his grievance heard and addressed. Findings: During a review of Resident 105's admission Record, the admission Record indicated Resident 105 was admitted to the facility on [DATE] with diagnoses including acute pyelonephritis (a bacterial infection causing inflammation of kidneys), benign prostatic hyperplasia (non-cancerous enlargement of prostate gland), and hemiplegia (paralysis of one side of the body) following cerebral infarction (damage to the brain from interruption of its blood supply) During a review of Resident 105's Minimum Data Set ([MDS] standardized assessment and care screening tool) dated 5/28/2024, the MDS indicated Resident 105…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 16 and 56) were free from unnecessary restraint (any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body) as evidenced by: 1. Resident 16 having a bolster mattress (mattress has a defined perimeter that helps to create a secure and stable edge around the bed) with no order, no assessment, and no consent (permission for something to happen). 2. Identify, and appropriately monitor the use of built-in bolster pads in Resident 56's bed. These deficient practices had the potential to place Resident 16 and Resident 56 at risk for unnecessary prolonged use of restraints, restricting movement and impaired circulation. Findings: 1. During a review of Resident 16's Face Sheet (admission record), the Face Sheet indicated Resident 16 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to obtain an orthopedic (branch of medicine dealing with the correction or prevention of deformities, disorders, or injuries of the bones and associated soft tissue) specialist appointment for one of eight residents (Resident 102) with limited range of motion [(ROM) full movement potential of a joint (where two bones meet)] and mobility (ability to move) in accordance with the physician's order, dated 6/25/2024. This deficient practice had the potential to prevent Resident 102 from receiving an assessment and possible intervention for Resident 102's left knee contracture (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness), which caused Resident 102 pain, limited mobility, and affected Resident 102's quality of life and psychological (related to the mental and emotion state of a person) wellbeing. Findings: During a review of Resident 102's admission Record, indicated the facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 perform a quarterly pain evaluation for one of eight sampled residents (Resident 102) with limited range of motion [ROM, full movement potential of a joint (where two bones meet)] and mobility (ability to move). This deficient practice had the potential to prevent Resident 102 from receiving adequate pain management and additional intervention for Resident 102's left knee contracture (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness). Findings: During a review of Resident 102's admission Record, indicated the facility admitted Resident 102 on 1/9/2024 with diagnoses including pain in the right elbow, psychosis (severe mental disorder in which thought, and emotions are so impaired that contact is lost with external reality), and depression. During a review of Resident 102's Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 five sampled residents (Resident 74) did not receive unnecessary psychotropic medications (medications which affect perception, mood, consciousness, and behavior). This deficient practice had the potential to place Resident 74 at risk for adverse consequences due to unnecessary prolonged use of psychotropic medication. Findings: During a review of Resident 74's admission Record , the admission Record indicated Resident 74 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and eventually the ability to carry out the simplest tasks), unspecified dementia (loss of cognitive functioning such as thinking, remembering and reasoning) , history of falling, and depression( mood disorder that causes a persistent feeling of sadness). During a review of Resident 74's Minimum Data Set([MDS] a standardized assessment and care screening tool) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than less than five percent (%) affecting three of three residents observed for medication administration (Residents 60, 80 and 106) by failing to: a. Ensure availability and administration of Restasis ([Generic name - cyclosporine] a medication used to treat dry eye disease) for Resident 60 in accordance with physician orders. b. Ensure proper administration of Advair Diskus ([Generic name - fluticasone-salmeterol] a combination medication delivered through a device in the form of inhalation powder to treat breathing problems) for Resident 80 by ensuring rinsing of mouth after use per prescriber instructions. c. Hold amlodipine (a medication used to treat high blood pressure) dose administration for Resident 106 per prescribed blood pressure parameters. These deficient practice resulted in an overall medication error rate of 11.59 % exceeding 5% threshold and placed Residents 60, 80 and 106 at…

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

Based on observation, interview, and record review, the facility failed to: 1. Ensure removal of expired calcium plus vitamin D3 ([D3 - cholecalciferol a form of vitamin D] a dietary supplement to treat calcium and vitamin D deficiency, and promote bone health), bisacodyl (a medication used to treat constipation and bowel irregularity), vitamin B12 (a vitamin used to treat anemia and prevent vitamin B12 deficiency), simethicone (a medication used to relieve bloating and discomfort of gastrointestinal [the organs through which food passes after swallowing and digestion] gas) and cranberry (a dietary supplement used to prevent urinary tract [a medical term used to describe drainage system for removing urine] infection) tablets, per manufacturer requirements, from one of one inspected medication room (Medication Room Station 1). 2. Ensure latanoprost (a medication in form of eye drops used to treat high pressure in the eyes) eye drops, Humulin R insulin (a medication used to treat high blood sugar) and gabapentin (a medication used to treat seizures [a medical term used to describe…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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) failed to provide documented evidence of the implementation of their Quality Assurance and Performance Improvement (QAPI-data driven approach to quality improvement) plan in reference to facility falls, weight management and wound management issues identified. This deficient practice had the potential to have reoccurring deficient practices that can impact the quality of care for the residents. Findings: During a review of the QAPI plan received, the active QAPI plan included falls, wounds, and weights. During a concurrent interview and record review of the QAPI plan on 6/28/2024 at 6:50 p.m., with the Assistant Director of Nursing (ADON), the ADON stated the QAPI plan for weight variance and wound management was initiated. The ADON stated cannot provide documented evidence QAPI plan was being implemented. The ADON also indicated they wish they had a map they can use to compare the different months for the weight variance. During a concurrent interview and record review of QAPI plan…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 pneumococcal (Pneumococcal vaccines are vaccines against the bacterium Streptococcus pneumoniae) vaccines on one of five sampled resident ( Resident 112). This deficient practice placed Resident 112 at a higher risk of acquiring and transmitting pneumonia to other residents of the facility. Findings: During a review of Resident 112's admission Record, the admission Record indicated the resident was admitted on [DATE] to the facility with diagnoses that included respiratory failure with hypoxia ( condition where the body does not have enough oxygen in the tissues due to tissue damage, fluid buildup or muscular spasms),personal history of nicotine dependence( addiction to tobacco products caused by drug nicotine) and chronic obstructive pulmonary disease([COPD] group of lung diseases causing restricted airflow and breathing problems). During a review of Resident 112's Minimum Data Set ([MDS] standardized screening tool) dated 6/6/2024, the MDS…

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

Based on observation, interview, and record review, the facility failed to ensure one of one adjustable height therapy mats located in the therapy gym had a flat surface instead of a slanted position. This deficient practice had the potential to cause a safety and fall hazard for resident requiring the mat for therapy intervention. Findings: During a concurrent observation and interview on 6/24/2024 at 9:00 a.m. with Occupational Therapist 1 (OT 1 profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) in the therapy gym, a grey-colored adjustable height therapy mat was located against the wall next to the door. The therapy mat appeared slanted with one side of the mat, closet to the door, lower than the opposite site of the mat. OT 1 raised the height of the mat using a remote and stated the therapy mat continued to have a slanted position. OT 1 stated residents used the therapy mat at the lowest position. During a concurrent observation and interview on 6/25/2024 at 1:50 p.m. with the Director 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 keep three out of five sampled residents' (Resident 3, Resident 4, and Resident 5) call lights within reach. This deficient practice had the potential to prevent residents from receiving timely assistance, and compromise the residents safety and health. a. During a review of Resident 4 ' s Face Sheet (admission record), the Face Sheet indicated Resident 4 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including Type II Diabetes Mellitus (DM: chronic condition that affects the way the body processes blood sugar) with hyperglycemia (high blood sugar), gastrostomy (opening into the stomach for nutritional support), contractures (conditioning of shortening and hardening) of muscle on multiple sites, dysphagia (difficulty swallowing), history of falling, chronic kidney disease stage 3 (CKD: mild to moderate damage to kidney and are less able to filter waste and fluid out of blood) , 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 staff failed to document the resident ' s wound care treatments for one of two sampled residents (Resident 1) to indicate the treatment was performed for a resident who has multiple skin complications. This deficient practice has the potential to negatively affect tracking the effectivness of the wound treatments and has potential for Resident 1's wounds to get worse. a. During a review of Resident 1 ' s Face Sheet (admission record), the Face Sheet indicated Resident 4 was initially admitted to the facility on [DATE] with diagnoses including acute osteomyelitis (infection of the bone) on left ankle and foot, Type II Diabetes Mellitus (DM: chronic condition that affects the way the body processes blood sugar), hemiplegia (complete paralysis of half of the body) and hemiparesis (weakness of one entire side of the body) following cerebrovascular disease (medical condition that affect the blood vessels of the brain and cerebral circulation) affecting left dominant…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 1), who had a history of striking another resident and a staff person was monitored for agitation to prevent further aggressive behavior toward staff and residents. This deficient practice resulted in Resident 1 becoming agitated and then left alone to enter the facility's dining room where he hit a resident (Resident 2) in the face. Findings: During a review of Resident 1's admission Record (Face Sheet), dated 11/28/2023, the Face Sheet indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder bipolar type (a mental illness that can affect your thoughts, mood, and behavior), and anxiety disorder (persistent and excessive worry). During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care planning tool), dated 9/22/2023, the MDS indicated Resident 1's cognitive skills for daily decision making were severely impaired. During…

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

Based on observation, interviews and record reviews the facility failed to ensure the dietary manager had a current unexpired certificate that reflected the dietary manager (DM 1) possessed the education and experience to competently perform the responsibilities of a dietary manager. This failure had the potential to result in the an improperly managed food and nutrition services that can pose detriment to the residents of the facility. Findings: During an interview on 10/13/2021 at 836 AM, the registered dietician (RD) stated that she worked part time hours in this facility. The DM 1 stated that he worked full time in this facility. During an interview and record review of an event registration for the DM 1 on 10/15/2021 at 8:26 AM, Per the dietary assistant (DS) the DM they were unable to provide a copy of the DM 1's certificate. The DS gave me a copy of the event registration form which indicated that DM 1 paid the registration to sit for the CDM and CFPP (Certified Dietary manager, Certified food protection professional) credentialing exam on 5/3/2014. The DM did not was unable…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Dietary Aide 3 (DA3) demonstrated the correct calibration technique (process of validating the thermometer was working properly) in accordance with its policy and procedure on How to Calibrate a Thermometer. This deficiency had the potential to result in food being held at unsafe temperature levels, thus potentially compromising food safety and contaminating foods that facility residents consume. Findings: a. During a concurrent observation and interview on 10/13/21 at 11:59 a.m., DA3 was testing beverage temperatures for resident lunch trays. DA3 stated in calibrating a thermometer it should read 20 degrees Fahrenheit. DA3 was observed calibrating a thermometer in a cup of ice water. DA 3 then proceeded to check the temperature of a carton of milk and then stated the temperature reading was 33 degrees Fahrenheit. DA3 then wiped the thermometer with a paper towel in between testing a carton of milk and a cup of orange juice. DA3 then tested a cup of orange juice, then stated the temperature reading was…

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

Based on observations, interviews and record reviews the facility failed to follow the facility's policy regarding storing food brought in by visitors to ensure three (3) of 3 residents' refrigerators (refrigerators in station 1, 2, and the yellow zone), used for storing residents' personal food from visitors, were safe and sanitary by ensuring: 1. Residents' Refrigerators were clean. 2. All items in the resident's refrigerator were labeled with date and residents name. 3. Temperature of the refrigerators were monitored on a daily basis and maintained at the recommended temperature range. 4. Any food items that have been stored for 7 days are discarded. 5. Foods were in a sealed container to prevent cross contamination. This deficient practice had the potential to result in contamination of residents' food items and food-borne illnesses (food poisoning). Food borne illness if contracted by the facility's' vulnerable population can cause symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea and fever and can lead to other serious medical complications,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 that maintained or enhanced a resident's dignity and respect in full recognition of resident's individuality for three (3) out of the 12 sampled residents (Resident 148, 196 and 93), by failing to: A. Ensure Resident 148's was attended to and not left in a wet and soiled diaper for a prolonged period. B. Ensure the Speech Therapist (ST) fed resident 196 at eye level. C. Ensure the Director of Staff Development (DSD) fed Resident 93 at eye level. These deficient practices had the potential to affect the residents' self-esteem and self-worth resulting in a decline in psychosocial well-being and a diminished quality of life. A. During a review of Resident 148's Face Sheet (admission record), dated 10/15/2021, the Face Sheet indicated the facility admitted Resident 148 on 10/11/2021 with diagnoses of dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two (2) of 29 sampled residents (Resident 82 and 69) had accurate assessments, by failing to: A. Ensure Resident 82's weight was not documented on the MDS when it was not obtained. B. Ensure Resident 69's upper extremities functional limitations were assessed and documented accurately on the MDS to reflect Resident 69's lack of functional limitations. This deficient practice had the potential to negatively affect Resident's 82 and 69 plans of care and delivery of necessary care and services. Findings: A. During a review of the admission record (AR), dated 10/15/2021, the AR indicated the facility originally admitted Resident 82 on 3/13/2019 and readmitted on [DATE], with diagnoses including unspecified protein-calorie malnutrition (lack of sufficient nutrients in the body), anemia in chronic kidney disease (low levels of red blood cells because of kidney disease), and hypertension (high blood pressure). During a review of Resident's 82 Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and/or implement an individualized plans of care with measurable objectives, timeframes, and interventions to meet the residents' needs for three (3) of 29 residents (Resident 94, 82, 7). The facility failed to ensure: A. Resident 94, who was assessed to have bilateral (both ears) hearing loss, had a careplan developed and implemented for hearling loss. B. Residents 82, who was at risk for significant weight loss, a care plan was implemented. C. Resident 7's careplan for mobility was properly implemented. These deficiencient practices had the potential to result in: A. Diminished quality of life due to ineffective communication interventions, for Resident 94. B. A risk for dehydration and further weight loss, for Resident 82. C. A higher risk for impaired mobility for Resident 7. Findings: A. A review of Resident 94's admission records indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE]. 2021…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 review, the facility failed to provide services that met professional standards of care for two residents (Residents 63 and 27) when: A. Licensed Vocational Nurse (LVN) 2 did not clarify with the physician that Resident 63's bubble pack (medications dispensed organized and filled in a 28 to 31-day cycle allowing users to take each dose according to the calendar by punching out each bubble) count was not the same as the medication administration record (MAR) and physician orders. B. LVN 5 did not to alert Resident 27's physician when Resident 27's bubble pack and over-the counter (OTC) label were not the same as the MAR and physicians order. These deficient practices resulted in Resident 63 not receiving the correct form (e.g. capsules chewable tablets, powders, liquid solutions) of medications that were ordered and had the potential for Resident 27 to receive incorrect dosages of medications which could have precipitated in unintended medical complications. Findings:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 (1) out of 29 sampled residents (Resident 85) received treatment and care in accordance with the physician`s order by failing to: 1. Ensure per the physicians order for Resident 85 to wear a wander Guard (monitoring device such as a Wander guard bracelet may be used to help ensure safety) bracelet was monitored every shift. This deficient practice had the potential for Resident 85 to elope from the facility. Findings: A review of Resident 85's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that included hyperlipidemia (an abnormally high concentration of fats or lipids in the blood), dysphagia (difficulty swallowing) and hypertension (a long-term medical condition in which the blood pressure in the arteries is persistently elevated). A review of Resident 85's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 09/28/2021, indicated that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure 2 of 2 sampled residents (Resident 22 and 7) received the Restorative nursing assistant (RNA) services ordered by the physician. This deficient practice placed Resident 22 and 7 at risk for a decrease of physical function and at risk for contractures. Findings: During a record review of Resident 7's (face sheet) admission record dated 10/15/2021, the face sheet indicated Resident 7 was readmitted to the facility on [DATE]. Resident 7's diagnoses including hemiparesis (weakness or inability to move one side of the body)following a cerebral infarction (a result of disrupted blood flow to the brain causing parts of the brain to die off) affecting the right dominant side, encephalopathy (damage in the brain) , aphasia (disorder that makes the individual unable to communicate), dysarthria (motor speech disorder), essential hypertension (high blood pressure that does not have a known secondary cause) , and dementia (general term for the…

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

Based on observation, interview, and record review, the facility failed to follow it's diet menu instructions for the mechanical soft texture (a diet that involved only foods that were physically soft, with the goal of reducing or eliminating the need to chew the food) for one of one resident reviewed for meal service (Resident 65) by not ensuring the parsley sprig was in a proper mechanical soft form. This deficiency inadvertently put Resident 65 at high risk for aspiration (condition in which food, liquids, saliva, or vomit is breathed into the airways)and could have further compromised Resident 65's medical status. Findings: During a record review of Resident 65's face sheet (admission record) dated 10/19/2021, the face sheet indicated the facility admit Resident 65 on 3/21/ 2018 with a diagnosis, including but not limited to, unspecified dementia (mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), osteoarthritis (disorder most commonly affects joints in hands, knees, hips and spine) , major depressive 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 observations, interviews, and record reviews, the facility failed to store and prepare food under sanitary conditions in one (1) of 1 kitchen, by failing to: A. Ensure six (6) of 6 residents (Residents 32, 94, 196, 12, 75, and 31) who were served and ate over-easy eggs (egg gets fried on both sides, but it's not cooked for very long on the second side, so the yolk remains runny and uncooked) were cooked from pasteurized eggs (eggs that have gone through pasteurization, a process that kills germs in foods and drinks) and that all eggs served were cooked to a minimum of 145 degrees Fahrenheit (temperature scale) for at least 15 seconds. B. Ensure 1 of 1 ice machine was clean. C. Ensure 1 of 1 dietary staff did not enter the kitchen with personal belongings. The deficient practice of serving undercooked, unpasteurized eggs to residents had the potential for the transmission of Salmonella (a germ that may cause diarrhea, fever, and stomach cramps, leading to hospitalization and death). The deficient…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure infection control practices were maintained as evidence by: a. Licensed Vocational Nurse (LVN) 1 failed to don (put on) complete personal protective equipment ([PPE] equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) and perform hand-hygiene prior to entering a transmission-based precaution room ([TBP] additional measures focused on the particular mode of transmission used in addition to standard precautions) room. b. Certified Nursing Assistant (CNA) 2 failed to perform hand-hygiene in between assisting multiple residents in the dining room. c. Not ensuring that one of 6 sampled residents (Resident 49), who was receiving nutrition by gastrostomy tube (GT - a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration), was provided service to prevent aspiration by failing to ensure the resident's head of the bed was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to update the inventory list for one of one sampled resident (Resident 33). This deficient practice resulted in the loss of Resident 33's important papers and prescription glasses with the potential for misappropriation of property. Findings: During an initial tour, Resident 33 stated he been missing a lot of important papers and my prescription glasses since Resident 33 came back from the hospital. Resident 33 stated he told the facility staff about the important papers and glasses when he During a review of the admission record, dated 10/18/21, the admission record indicated the facility admitted Resident 33 on 12/20/2018 and re-admitted on [DATE], with diagnoses including congestive heart failure (a condition in which the heart doesn't pump blood as efficiently as it should), atrial fibrillation (An irregular, often rapid heart rate that commonly causes poor blood flow), dementia (term for loss of memory, language, problem-solving and other thinking…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 (1) of 29 sampled resident (Resident 82) had an accurate weight loss assessment for 3 months. This deficient practice had the potential to result in the Resident not receiving proper nutrition and treatment. Findings: During a review of the admission record (AR), dated 10/15/2021, the AR indicated the facility originally admitted Resident 82 on 3/13/2019 and readmitted on [DATE], with diagnoses including unspecified protein-calorie malnutrition (lack of sufficient nutrients in the body), anemia in chronic kidney disease (low levels of red blood cells because of kidney disease), and hypertension (high blood pressure). During a review of Resident's 82 Minimum Data Set (MDS, a comprehensive assessment and care-screening tool), dated 9/23/2021, the MDS indicated Resident 82 had clear speech, usually understood others and was usually able to be understood. The MDS, section K, indicated Resident 82 had weight loss that was not prescribed by 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 3 sampled residents (Resident 148) was provided dependent care and services to maintain personal hygiene. This deficient practice resulted in Resident 148 being left unattended in bed with wet and soiled adult briefs for a prolonged period of time. Findings: A review of Resident 148's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses of dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning), abnormal posture, osteoarthritis (occurs when the protective cartilage that cushions the ends of the bones wears down over time), muscle wasting. A review of Resident 148's History and Physical (H/P) assessment dated [DATE], indicated that the resident had fluctuating capacity to make decisions of daily living. A review of Resident 148's Occupational Therapy and Physical Therapy (OT/PT) evaluation dated October…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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's staff failed to ensure a resident received the proper assistive devices to maintain hearing abilities by not assisting in arranging for an audiologist referral consultation for one of 6 sampled residents (Resident 94). This deficient practice resulted in a delay of services and Resident 94 not being able to hear adequately during a conversation. Findings: During a review of Resident 94's admission records indicated the resident was admitted to the skilled nursing facility on [DATE] and was re-admitted on [DATE] with diagnoses that included hypertensive (the pressure inside the blood vessels (called arteries) is too high, Myasthenia gravis without acute exacerbation (weakness and rapid fatigue of any of the muscles under voluntary control), abnormal gait and mobility and hearing loss bilateral (both sides). During a review of Resident 94's Minimum Data Set [(MDS, a standardized assessment and care planning tool)] dated October 4, 2021 indicated…

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

Based on observation, interview and record review, the facility failed to label one bottle of multi-dose ophthalmic medication (eye drops) for Resident 17. This deficient practice increased the risk that Resident 17 could have received medication that had become ineffective due to failure to label open date, possibly leading to health complications. Findings: On 10/13/21 at 3:34 p.m., during an inspection of Station 2's Medication Storage Cart #4 with Licensed Vocational Nurse (LVN 3), one multi-dose ophthalmic medication, Refresh Liqui-gel (lubricant eye gel used for the temporary relief of burning, irritation, and discomfort due to dryness of the eye), for Resident 17 was not discarded or labeled with an open date as required by the manufacturer's specifications. During a review of the manufacturer's product labeling for Refresh Liqui-gel, the medication should be discarded 90 days after opening. During an interview on 10/13/21 at 4:10 p.m. with LVN 3, LVN stated when a medication is opened, it is important to label the medication with the open date because the medication could 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.