Pacific Palms Healthcare

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of two resident's (Resident 20) Bilevel positive airway pressure ([BIPAP] type of noninvasive ventilation that helps you breathe) machine was maintained as indicated in facility policy and indicated in the BIPAP User Guide. The deficient practices had the potential to result in serious health risks such as bacterial growth and infection and potential damage to the device.Findings:During a review of Resident 20's admission Record, the admission Record indicated Resident 20 was readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease ([COPD]a chronic lung disease causing difficulty in breathing) and chronic respiratory failure (condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body).During a review of Resident 20's Minimum data Set ([MDS] a resident assessment tool), dated 9/26/2025, the MDS indicated Resident 20 had intact cognition…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one out of one sampled Certified Nursing Assistant (CNA) 3 was competent and knowledgeable with a pureed (foods that are blended, mashed, or whipped to a smooth, lump-free, pudding-like consistency, which is easier to swallow and does not require chewing) texture diet when passing the meal tray to Resident 13. This deficient practice had the potential for Resident 13 to aspirate (when something other than air gets into your airways) or for Resident 13 to lose weight because she was provided with a diet not consistent with her physician's orders. Findings: During a review of Resident 13's admission Record, the admission Record indicated Resident 13 was admitted to the facility on [DATE] with diagnoses of hemiplegia (unable to move one side of the body) and a contracture (a permanent tightening of muscles, tendons, or skin that causes joints to become stiff and short, restricting movement) of the left hand. 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.

Based on interview and record review, the facility failed to ensure [NAME] (CK) 1 was competent in preparing pureed (foods that are blended, mashed, or whipped to a smooth, lump-free, pudding-like consistency, which is easier to swallow and does not require chewing) scrambled eggs and oatmeal.As a result of this deficient practice 27 residents who were on a puree diet were placed at risk for receiving eggs and oatmeal that were not completely smooth and without lumps which could lead to aspiration (when something other than air gets into your airways). Findings:During a review of the facility's Recipe titled, Pureed Eggs by Healthcare Menus Direct, LLC.2025, the recipe indicated to prepare eggs per recipe for eggs) and then puree the eggs on low speed (food processor or blender) to a paste consistency before adding any liquid then gradually add warm milk. The finished puree item should be smooth and free of lumps, hold its shape, while not being too firm or sticky. During a review of the facility's Recipe titled, Pureed Hot Cereal (Hot Cereal of Choice i.e. Oatmeal) by Healthcare…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 serve food that was at the correct temperature to one of three sampled residents (Resident 131).This deficient practice had the potential to result in loss of appetite and cause unplanned weight loss.Findings:During a review of Resident 131's admission Record, the admission Record indicated Resident 131 was admitted to the facility on [DATE] with diagnoses including hypoglycemia (low blood sugar), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), gastroesophageal reflux disease (digestive disorder most often causes a burning and sometimes squeezing sensation in the mid-chest), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).During a review of Resident 131's Admit/Re-Admit Nursing Evaluation, dated 11/10/2025, the Evaluation indicated Resident 131 was alert and oriented. The Evaluation indicated Resident 131 needed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one out of six sampled residents (Resident 13) was provided with a puree diet as ordered by the physician. This deficient practice had the potential for Resident 13 to aspirate (when something other than air gets into your airways) or for Resident 13 to lose weight because she was provided with a diet consistent with her physician's orders. Findings:During a review of Resident 13's admission Record, the admission Record indicated Resident 13 was admitted to the facility on [DATE] with diagnoses of hemiplegia (unable to move one side of the body) and a contracture (a permanent tightening of muscles, tendons, or skin that causes joints to become stiff and short, restricting movement) of the left hand.During a review of Resident 13's Minimum Data Set (MDS, a resident assessment tool) dated 9/11/2025, the MDS indicated Resident 13 had severe cognitive impairment (a significant loss of mental ability, such as memory, thinking, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store and prepare food under safe and sanitary conditions in one of one kitchen, by failing to:a) Ensure no staff personal belongings were in the kitchen preparation area.b) Ensure the sanitizer bucket was not in the food preparation sink while food was being prepared. c) Ensure the pancake, breakfast meat, and waffles holding temperature (temperature at which food is kept) on the steam table (specifically made for holding prepared foods at a consistent temperature) were checked prior to meal service.d) Ensure the ice machine was clean.e) Ensure two of three residents' (Resident 101 and 112) refrigerated personal food items were dated on when it was opened or procured.These deficient practices had the potential to result in contamination of food items that placed residents in high risk for food borne illness (any illness resulting from eating contaminated/spoiled foods) that can lead to hospitalization and a decline in health.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 maintain accurate and complete medical records for three of nine sampled residents (Resident 13, Resident 101, and Resident 113) when:a. Restorative Nursing Aide (RNA 1) documented he provided RNA feeding program (staff provide feeding assistance) assistance to Resident 13 for two meals, when he did not. b. RNA 1 documented Resident 101 wore both knee splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) for two hours during Restorative Nursing Aide (RNA, nursing aide program that help residents to maintain their function and joint mobility) treatment on 11/18/2025 when Resident 101 wore both knee splints for 40 minutes to one hour.c. RNA weekly documentation did not accurately reflect Resident 113's ambulation distance from 8/3/2025 - 10/4/2025. These deficient practices resulted in inaccurate medical documentation for Resident 13, Resident 113, and Resident 101 and had the potential 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 staff failed to: a. Perform hand hygiene when entering and exiting Resident 5's room.b. Replace Resident 96's tube feeding line when it was found on the floor without a cap. c. Implement and document control measures per water management policy and procedure.d. Monitor, document, and implement contact isolation precautions (infection control measures used to prevent the spread of germs by direct contact) for Resident 131. These deficient practices had the potential to transmit infectious microorganisms (living organisms that are too small to be seen with the naked eye) and increase the risk of infection for the residents. Findings: a. During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was initially admitted to the facility on [DATE] with diagnoses including hemiplegia weakness to one side of the body) and hemiparesis (inability to move one side of the body) affecting right dominant side, gastrostomy (g-tube:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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. 1.Administer the coronavirus vaccination for one of five sampled residents (Resident 5). b. 2. Offer and educate coronavirus vaccinations for staff per facility's policy for three of five sampled employees. These failures had the potential to place all residents at risk for exposure to infection of coronavirus.Findings: 1. During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was initially admitted to the facility on [DATE] with a diagnosis of hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or paralysis on one side of the body) following cerebral infarction (stroke - loss of blood flow to a part of the brain). During a review of Resident 5's History and Physical (H&P), dated 3/18/2025, the H&P indicated Resident 5 did not have the capacity to understand and make decisions. During a review of Resident 5's Minimum Data Set (MDS - a resident assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to inform one of two sampled residents (Resident 11) of the risks associated with repeated subcutaneous (beneath the skin) insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) injections administered in the same anatomical site.This deficient practice had the potential to limit Resident 11's ability to make informed decisions regarding treatment.Findings:During a review of Resident 11's admission Record (Face sheet), the admission Record indicated the facility admitted the resident on 12/6/2023 and was readmitted on [DATE], with diagnoses including type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), 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), and cataract (clouding of the eye's natural lens).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 notify the physician when Resident 113's ambulation (walking or moving from one place to another) distance declined. This failure had the potential to result in a delay of care and further decline of ambulation. Findings: During a review of Resident 113's admission Record, the admission Record indicated Resident 113 was initially 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), difficulty in walking, and pressure induced deep tissue damage (discolored skin over a bony prominence caused by prolonged, unrelieved pressure) of the sacral (base of the spine) region. During a review of Resident 113's History and Physical (H&P), dated 6/19/2025, the H&P indicated Resident 113 had the capacity to understand and make decisions. During a review of Resident 113's Minimum Data Set (MDS - a resident assessment tool), dated 9/23/2025, the MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the use of mirtazapine (a medication used to treat mental illness) was used to treat a medical condition diagnosed and documented in the medical record between 7/7/25 and 11/9/25 for one of five residents sampled for unnecessary medications (Resident 9.)The deficient practice of using psychotropic medications (medications that affect brain activities associated with mental processes and behavior) to treat medical conditions without sufficient documentation of their diagnosis increased the risk that Resident 9 may have experienced adverse effects (unwanted or dangerous medication-related side effects) related to the use of mirtazapine.A review of Resident 9's admission Record, dated 11/20/25, indicated she was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses including anxiety disorder (a mental illness characterized by excessive worry, fear, or panic strong enough to interfere in everyday…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 Minimum Data Set (MDS - a resident assessment tool) assessment accurately reflected one of three sampled Residents (Resident 74). This failure had the potential to negatively affect Resident 74's plan of care and delivery of necessary care and services. Findings: During a review of Resident 74's admission Record, the admission Record indicated Resident 74 was initially admitted to the facility on [DATE] with diagnoses including major depressive disorder. During a review of Resident 74's MDS dated [DATE], the MDS indicated Resident 74 had moderate cognitive (ability to learn, reason, remember, understand, and make decisions) impairment, required setup assistance when eating, required moderate assistance (helper does more than half the effort) for oral hygiene and upper body dressing, and was dependent for toileting hygiene, bathing, and lower body dressing. During a concurrent interview and record review 11/21/2025 at 9:55 a.m., with the MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to revise a comprehensive care plan for one of two sampled residents (Resident 11), who preferred not to have subcutaneous (beneath the skin) insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) injection sites rotated, to include individualized goals and interventions addressing resident preference and associated risks.This deficient practice placed Resident 11 at risk for skin tissue damage and inconsistent insulin absorption due to unmet care needs related to the absence of a revised, individualized care plan.Findings:During a review of Resident 11's admission Record (Face sheet), the admission Record indicated the facility admitted the resident on 12/6/2023 and was readmitted on [DATE], with diagnoses including type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), dependence on renal dialysis (a treatment to cleanse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure one out of two sampled Residents (Resident 13) on the restorative nursing assistant (RNA) feeding program (staff provide feeding assistance) was supervised during two meals.This deficient practice had the potential for Resident 13 to aspirate (when something other than air gets into your airways) or for Resident 13 to lose weight if she was not encouraged to consume the meal. Findings:During a review of Resident 13's admission Record, the admission Record indicated Resident 13 was admitted to the facility on [DATE] with diagnoses of hemiplegia (unable to move one side of the body) and a contracture (a permanent tightening of muscles, tendons, or skin that causes joints to become stiff and short, restricting movement) of the left hand.During a review of Resident 13's Minimum Data Set (MDS, a resident assessment tool) dated 9/11/2025, the MDS indicated Resident 13 had severe cognitive impairment (a significant loss of mental ability,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to discontinue an intravenous (IV, in the vein) catheter (flexible tube inserted into a vein to deliver fluids and medications into the blood stream) for two of two sampled residents (Resident 15 and Resident 121) per the facility's policy and procedure (P&P) titled Removal of a Peripheral IV (Over the needle, Peripheral Short) Catheter.As a result of this deficient practice, Resident 15 and Resident 121 were placed at risk for discomfort and infection at the IV site. Findings: A. During a review of Resident 15's admission Record, the admission record indicated Resident 15 was admitted to the facility 9/22/2025 with diagnoses including history of malignant neoplasm (cancerous tumor) of the large intestine and type 2 diabetes (your body does not use insulin properly, leading to high blood sugar). During a review of Resident 15's Minimum Data Set (MDS, a resident assessment tool) dated 9/25/2025, the MDS indicated Resident 15 had moderate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 113) was assessed by a neurologist and wound doctor as ordered by the physician. This deficient practice had the potential to result in delay in the delivery of care and services. Findings: During a review of Resident 113's admission Record, the admission Record indicated Resident 113 was initially 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), difficulty in walking, and pressure induced deep tissue damage (discolored skin over a bony prominence caused by prolonged, unrelieved pressure) of sacral (base of the spine) region. During a review of Resident 113's History and Physical (H&P), dated 6/19/2025, the H&P indicated Resident 113 had the capacity to understand and make decisions. During a review of Resident 113's Minimum Data Set (MDS - a resident assessment tool), dated 9/23/2025,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to monitor the valproic acid level (a lab value used to determine the effectiveness of certain medications used to treat seizures) related to the use of Depakote (a medication used to treat seizure disorder) per the physician's order in one of five residents sampled for unnecessary medications (Resident 9.)The deficient practice of failing to monitor valproic acid levels for the use of Depakote according to the physician's instructions increased the risk that Resident 9 could have experienced seizures or adverse effects related to the use of Depakote possibly leading to medical complications resulting in hospitalization.A review of Resident 9's admission Record (a record containing diagnostic and demographic resident information), dated 11/20/25, indicated she was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses including anxiety disorder (a mental illness characterized by excessive worry, fear, or panic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 serve regular texture toast to one of three sampled residents (Resident 98).The deficient practice had the potential to result in loss of appetite and cause unplanned weight loss.Findings:During a review of Resident 98's admission Record, the admission Record indicated Resident 98 was readmitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), gastroesophageal reflux disease (digestive disorder most often causes a burning and sometimes squeezing sensation in the mid-chest), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).During a review of Resident 98's Minimum Data Set ([MDS] a resident assessment tool), dated 9/1/2025, the MDS indicated Resident 98 had intact cognition. The MDS indicated Resident 98 needed set-up assistance when eating.During a review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the binding arbitration agreement (a contract in which a person agrees to settle future disputes with the facility outside of court, through a private, neutral decision-maker instead of a judge or jury) was explained in a language that a resident could understand for two of three sampled residents (Resident 78 and Resident 82).This deficient practice had the potential to limit Resident 78 and Resident 82's understanding of the binding arbitration agreement and their legal rights.Findings:a. During a review of Resident 78's admission Record (Face sheet), the admission Record indicated the facility admitted the resident on 10/11/2023, with diagnoses including type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN-high blood pressure) and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body).During a review of Resident 78's History 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 six sampled residents (Resident 2) who was under hospice care (compassionate care for people who are near the end of life provided at the person's home or within a health care facility) was visited by hospice licensed nurses weekly per hospice care agreement.This failure had the potential to result in Resident 2 did not receiving hospice care as they agreed upon.Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted on [DATE] and was readmitted on [DATE] with diagnoses including respiratory failure (a condition in which the blood does not have enough oxygen or has too much carbon dioxide), dysphagia (difficulty swallowing), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and cerebral infarction (loss of blood flow to a part of the brain) affecting right side 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, interviews, and record reviews, the facility did not adequately provide pharmaceutical services to meet the needs of both sampled residents (Resident 1 and Resident 2) by failing to: a. Follow the order as prescribed when the physician discontinued a Hydrocodone-Acetaminophen (used to relieve pain severe enough to require opioid treatment and when other pain medicines did not work well enough or cannot be tolerated) 10-325miligram (mg-unit dose) and ordered 5-325mg dose for Resident 1. b. Follow the facility's policy requiring the controlled substances to be stored in the medication room in a locked container, separate from non-controlled medications. Instead, a bottle of Lorazepam Intensol (knowns as Ativan, is used to treat anxiety disorders) for Resident 2 was found stored unlocked in the refrigerator. c. Properly dispose of the discontinued narcotic medication from the refrigerator for Resident 2. These failures had the potential to result in unmet needs of residents, misuse, 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 implement Enhanced Barrier Precautions ([EBP] involve gown and glove use during high contact resident care activities for residents at risk for Multidrug-Resistant Organisms ([MDRO, bacteria that have become resistant to certain antibiotics]) for one of three sampled residents (Resident 1), who had a left thigh wound and required daily dressing (sterile pad or material placed directly on a wound to protect it from infection and to promote healing ) changes. The facility failed to: 1. Ensure the Treatment Nurse (TN) had the proper understanding of EBP and put on the appropriate personal protective equipment ([PPE] clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) prior to conducting Resident 1 ' s dressing change. 2. Ensure proper signage was placed outside Resident 1 ' s room indicating Resident 1 was on EBP. These deficient practices resulted in the TN not applying a gown…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents' medical records were up to date as per the facility's policy and procedure (P&P) regarding advance directives (a legal document indicating resident preference on end-of-life treatment decisions) for two of seven sampled residents (Residents 18 and 83). These deficient practices violated the residents' right to be fully informed of the option to formulate an Advance Directive and had the potential to cause conflict with the residents' wishes regarding health care in the event residents became incapacitated (unable to participate in a meaningful way in medical decisions) or unable to make medical decisions that would not be identified and/or carried out by the facility staff. Findings: A. During a review of Resident 18's admission Record, the admission Record indicated Resident 18 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of heart failure (a heart disorder which causes the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide accurate information in the Minimum Data Set ([MDS], a federally mandated resident assessment tool) assessment for two of three sampled residents (Resident 81, and Resident 83). This deficient practice had the potential to result in inaccurate care and services for the residents due to inappropriate MDS assessment and care screening tool practices. Findings: A. During a review of Resident 81's admission Record, the admission Record indicated Resident 81 was originally admitted on [DATE] with a re-admission date on 5/31/2023 with diagnoses of atrial fibrillation (a condition that causes irregular and fast heartbeat in the heart), congestive heart failure ([CHF], when the heart cannot pump enough blood to meet the body's needs), type 2 diabetes mellitus ([DM], a disorder characterized by difficulty in blood sugar control and poor wound healing) , depression (sad mood disorder), dementia (a gradual decline in cognitive abilities such as 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 observation, interview, and record review, the nursing staff failed to update and revise a fall risk care plan for two of three sampled residents (Resident 106 and 170). This deficient practice had the potential to place Residents 106 and 170 to be at risk for recurrent falls. Findings: a. During a review of Resident 106's admission record, the admission record indicated Resident 106 was initially admitted to the facility on [DATE] with a diagnoses of acquired absence of the right leg above the knee (amputation), Lack of coordination, and difficulty walking. During a review of Resident 106 's history and physical (H&P) dated 9/13/202 4, the H&P indicated resident 106 had the capacity to understand and make decisions. During a review of Resident 106's Minimum Data Set (MDS), a Federally mandated assessment tool, dated 7/31/2024, the MDS indicated Resident 106 required substantial /maximum assistance (helper lifts and hold the trunk or limbs, but provides less than half the effort) with upper and lower…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow through Registered Dietitian (RD-a health professional who has special training in diet and nutrition)'s recommendations in a timely manner and failed to assess, monitor, and evaluate interventions to prevent two of nine sampled residents (Resident 42 and 79) from further weight loss by: A. Failing to ensure to monitor and assess Resident 42's weekly weights and intake of supplements, and obtain an order for Megestrol Acetate (a medication to treat loss of appetite and weight loss) in a timely manner as recommended by the RD. B. Failing to ensure Resident 79 received the boost glucose control (a nutritional drink designed to help people with type 2 diabetes [uncontrolled blood sugar] increase their nutrient consumption while maintaining their blood sugar levels) as recommended by the RD due to a significant weight loss. This failure resulted in placing Resident 42 and 79 at risk for continued weight loss. Findings: A. During a…

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

Based on observation, interview and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency related to their duties when: 1.Dietary Aid (DA2) and Dishwasher (DW) did not know the concentration strength of the chlorine sanitizer used in the dish machine (chlorine sanitizer a product that is used to reduce or eliminate pathogenic agents on surfaces). 2. Cook1 did not follow standardized recipes when preparing pureed diet and did not prepare enough zesty meat sauce to meet facility residents need. These deficient practices had the potential to result in unsafe and unsanitary food production that could place 109 residents in the facility who received food at risk for foodborne illness and 16 residents who received lumpy pureed spaghetti at risk for choking and meal dissatisfaction in 12 residents who did not receive the spaghetti and meat sauce. Findings: 1.During an observation in the dishwashing area on 10/6/2024 at 9:45AM, Dishwasher (DW) was wearing gloves and rinsing the dirty dishes then loading them inside the dishwasher.…

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

Based on observation, interview and record review, the facility failed to ensure the standardized recipes for lunch menu was followed on 10/6/2024 when: 1.Facility failed to ensure 16 residents on puree diet (The pureed diet provides foods that do not require chewing and are easily swallowed. All foods should be smooth and pureed to the consistency of pudding.) received spaghetti texture in form that meet their needs when the texture of the puree spaghetti was lumpy, not smooth and had large pieces of pasta present requiring chewing before swallowing. 2.The facility failed to follow lunch menu and portion sizes as written for residents on pureed diet. 16 residents on pureed diet received ½ cup of pureed meat sauce instead of 2/3 of cup per the food portion and serving guide. Residents on pureed diet did not receive the pureed garlic bread per the menu. These deficient practices had the potential to result in meal dissatisfaction, decreased nutritional intake, wight loss and increased choking risk for 16 residents who were on puree diet. Findings: 1.During an observation of the tray…

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

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and preparation practices when: 1. There was no soap available in the handwashing sink. 2. One plastic bag of sliced raw meat, and two logs of ground beef thawing on the rack with no thaw date. One open container of cottage cheese and one container of juice with no open date and previously prepared house shake stored in a large one-gallon milk container. 3. Food brought to residents from outside of the facility, were stored in the resident food refrigerator with no use by date. There were four tv dinners with manufactures instruction to store frozen was stored in the refrigerator with no use by date. These deficiencies had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to food borne illness in 109 out of 111 residents who receive food from facility, including 28 residents who received house shake and residents who had food stored in the resident refrigerator. 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 interview and record review, the facility failed to implement the antibiotic stewardship program policy for four of five sampled residents (Resident 39,96, 37 and 42) when an antibiotic (a substance used to kill bacteria and to treat infections) did not meet McGeer Criteria (criteria used to determine appropriate use of antibiotics) for administration. This deficient practice had the potential to increase antibiotic resistance and provide antibiotics to the residents without justification. 1.During a review of Resident 39's admission record, the admission Record indicated Resident 39 was admitted to the facility on [DATE] with diagnoses including Parkinsonism (condition that affects movement), Bullous Pemphigoid (rare skin disorder that causes large fluid filled blisters on the skin), and Type II Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 39's Minimum Data Set [(MDS) a Federally mandated assessment tool], dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure following up with an optometrist (health care providers who examine, diagnose, treat, and manage diseases and disorders of the visual system, the eye and associated structures as well as diagnose related systemic conditions) visit in six months as recommended by the optometrist and referring to ophthalmologist (a specialist who can treat complex medical issues related to your eyes, and can perform corrective procedures or surgeries including cataracts [tissue that forms over the eye, causing vision loss) and glaucoma [built up pressure in the eye that causes gradual vision loss]) for one of six sampled residents (Resident 55). This failure had the potential to result in Resident 55 not receiving proper care to maintain and/or improve his vision. Findings: During a review of Resident 55's admission Record, the admission Record indicated, Resident 55 was initially admitted to the facility on [DATE] and last readmission was 4/2/2024…

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

Based on observation, interview, and record review, the facility failed to accurately account for one dose of a controlled medication (medications with a high potential for abuse) affecting Residents 10 in one of two inspected medication carts (West Station Cart 1.) This deficient practice increased the risk of diversion (any use other than that intended by the prescriber) of controlled mediations and the risk that Resident 10 could have received too much or too little medication due to lack of documentation possibly resulting in serious health complications requiring hospitalization. Findings: During an observation and concurrent interview of [NAME] Station Cart 1, on 10/7/24 at 1:12 PM, with the Licensed Vocational Nurse (LVN 1) the following discrepancies were found between the Narcotic and Hypnotic Record (a log signed by the nurse with the date and time each time a controlled substance is given to a resident) and the medication card (a bubble pack from the dispensing pharmacy labeled with the resident's information that contains the individual doses of the medication): 1.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the physician responded to the consultant pharmacist's recommendation from 8/3/24 to consider a gradual dose reduction (GDR - a periodic attempt to manage a resident's behavioral issues with a lower dose of medication) related to the use of Depakene solution (a medication used to treat mood swings) in one of five sampled residents (Resident 65.) The deficient practice of failing to ensure the physician evaluated and responded to medication irregularities (potential issues with a resident's medication regimen) identified by the consultant pharmacist during the Medication Regimen Review (MRR - a monthly report from the consultant pharmacist identifying any medication irregularities in a resident's current medication regimen) increased the risk that Resident 65 could have experienced adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to their medication therapy possibly leading to impairment or decline in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to discontinue hydroxyzine (a medication used to treat itching and allergies) per the physician's order due to non-use in one of five residents sampled for unnecessary medications (Resident 40.) The deficient practice of failing to discontinue the use of hydroxyzine when Resident 40 was simultaneously using another medication to treat itching effectively could have increased the risk that Resident 40 may have experienced adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to the use of hydroxyzine possible resulting in a decline in her quality of life. Findings: During a review of Resident 40's admission Record (a document containing diagnostic and demographic information), dated 10/8/24, indicated she was admitted to the facility on [DATE] with diagnoses including multiple sclerosis (a neurological condition causing muscle weakness.) During a review of Resident 40's History and Physical (H&P - a record of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to perform a gradual dose reduction (GDR - a periodic attempt to manage a resident's behavioral issues with a lower dose of medication) related to the use of Depakene solution (a medication used to treat mood swings) or document a clinical rationale as to why an attempt would be contraindicated in one of five sampled residents (Resident 65.) The deficient practice of failing to perform or consider an GDR increased the risk Resident 65 could have experienced adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to Depakene therapy possibly leading to impairment or decline in their mental or physical condition or functional or psychosocial status. Findings: During a review of Resident 65's admission Record (a document containing diagnostic and demographic information), dated 10/8/24, indicated she was admitted to the facility on [DATE] with diagnoses including bipolar disorder (a mental illness characterized by mood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to assess the mental capacity (ability to make decisions) of one of three sampled residents (Resident 65) to sign a legaly binding document before indicating the Arbitration agreement (a contract indicating any disputes would be resolved within the facility rather than in court) was signed by Resident 65. This failure had the potential to result in Resident 65 not fully understanding their rights, to limit opportunity to initiate judicial proceedings that challenge unfavorable decisions. During a review of Resident 65's admission Record, the admission Record indicated, Resident 65 was admitted to the facility on [DATE] with diagnoses including unspecified sequalae (condition resulting from a prior disease or injury) of cerebral infarction (a loss of blood flow to part of the brain), bipolar disorder (mental disorder that causes extreme shifts in mood, energy, and activity levels), anxiety disorder (uncontrollable feelings of fear and anxiety), 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 protect one of one resident (Resident 1) from misappropriation of property (deliberate misplacement exploitation, or wrongful, temporary, or permanent use of a resident ' s belongings or money without the resident ' s consent) when Housekeeper 1 (HK 1) was running several personal errands procuring personal items, bringing the items to Resident 1, and cashing personal checks from Resident 1. This deficient practice placed Resident 1 at risk for misappropriation of property. 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 end stage renal disease (kidney [organ that filters wastes and extra fluid from the body] failure), hemiplegia (paralysis of one side of the body), type 2 diabetes mellitus (a problem in the way the body regulates and uses sugar as a fuel) and heart failure (heart cannot pump as it should). 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: A. call light was functioning properly for one of five sampled residents (Resident 76). B. Call light was within reach for Resident 52 while up in Geriatric Chair(([Geri Chair]- a large, padded chair that is designed to help seniors with limited mobility) C. care was provided in a manner that maintain or enhanced a resident's dignity and respect for Resident 63. This deficient practice had the potential for Resident 76 and Resident 52 not receiving necessary assistance when needed, experience loss of dignity, and loss of self-esteem due to inability to summon help with call lights. This deficient practice has the potential to affect Resident's 63 sense of self-worth and self-esteem. Findings: A. During a record review of Resident 76's admission Record (Face Sheet), the Face Sheet indicated Resident 76 was admitted to the facility on [DATE] with diagnoses with fracture of right humerus (your upper arm bone is broken), dementia…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 appropriately assess and monitor one of one sampled resident (Resident 73) during the use of a pommel cushion (blue cushion placed on a wheelchair) to prevent the resident from sliding. This deficient practice had the potential to result in entrapment and injury. Findings: During a review of Resident 73's Face Sheet (admission record), the Face Sheet indicated Resident 73 was admitted to the facility on [DATE] with diagnosis including dementia with behavioral disturbance (impaired ability to think or make decisions accompanied by behaviors such as agitation and depression), Type II Diabetes Mellitus (high blood sugar) with diabetic chronic kidney disease (CKD: long term condition where the kidneys do not work as well), anxiety, repeated falls, hypertension (high blood pressure) and cognitive communication deficit. During a review of Resident 73's Minimum Data Set [(MDS) a standardized assessment and care screening tool], dated 9/8/2023,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 Preadmission Screening and Resident Review (PASRR is guided by federal regulations that require all individuals being considered for admission to a Medicaid-certified nursing facility (NF) be screened prior to admission, to determine if the person has, or is suspected of having, a mental illness) ) screening was completed for two of five sampled residents (Resident 14 and Resident 22) who were diagnosed with mental disorder (MD). This deficient practice had the potential for Resident 14 and 22, not receiving appropriate behavioral services Findings: During a record review of Resident 14's admission Record (Face Sheet), the Face Sheet indicated Resident 14 was admitted to the facility on [DATE] with diagnoses including anxiety (feeling of fear, and uneasiness) disorder, bipolar disorder (mental illness that cause unusual shifts in a person's mood, energy, activity levels, and concentration), and major depressive disorder (loss of pleasure 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 two of two sampled residents (Resident 14, and Resident 57) were provided with a communication board and language translating service were readily available. These deficient practices lead the potential Resident 14 and 57 not communicating her needs effectively with staff and delay in care and services being rendered for Resident 14 and 57. Findings: a. During a record review of Resident 14's admission Record (Face Sheet), the Face Sheet indicated Resident 14 was admitted to the facility on [DATE] with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body), aphasia (loss of ability to understand or express speech, caused by brain damage), and apraxia (loss of ability to carry out skilled movement and gestures). During a record review of Resident 14's History and Physical (H/P), dated 8/28/2023, the H/P indicated Resident 14 does not have the capacity to 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 observation, interview, and record review the facility failed to ensure five vials of pens of insulin (a type of medication used to treat high blood sugar) requiring refrigeration were stored according to the manufacturer's requirements affecting Residents 5, 14 and 17 in one of two inspected medication carts (West Station Cart 2.) The deficient practices of failing to store medications per the manufacturers' requirements increased the risk that Residents 5, 14 and 17 could have received medication that had become ineffective or toxic due to improper storage possibly leading to health complications resulting in hospitalization. Findings: During a concurrent observation and interview on [DATE] at 1:37 PM of [NAME] Station Cart 2 with the Licensed Vocational Nurse (LVN 2), the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as required by their respective manufacturer's specifications: 1. One…

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

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1.Cooked eggs, cooked bacon and ready to eat tofu were stored on the same shelf next to raw eggs and a carton of raw liquid eggs. Raw chicken was stored to thaw on shelf above raw marinated ground beef. This had the potential to cross contaminate food and result in food borne illness in 100 residents who received food from the kitchen. 2.Kitchen wash cloths/towel were stained and discolored, and dishware were chipped. Staff using discolored and stained wash cloths to clean food contact surfaces. 3.Cook1 did not wash hands after removing soiled gloved and returned to food prepare vegetables and rice. Dishwasher staff working in the dish machine area did not wash hands after changing gloves and when removing the clean and sanitized dishes from the dish machine. 4.Ice machine was not maintained in a sanitary manner and the inside compartment of ice machine was stained and dirty. 5. Food brought to residents from outside of…

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

Based on observation and interview, the facility failed to ensure the electric hi-low therapy mat (therapy mat, electric and adjustable padded mat table used for therapy treatments) was in safe, operating condition. This deficient practice had the potential to cause injury to any resident or staff member who used this equipment as part of therapy treatment. Findings: During an observation on 10/4/2023 at 2:55 pm, in the rehab gym, a padded therapy mat was observed against the window of the rehab gym. The button controls to adjust the therapy mat height up and down were centered and attached to the base of the therapy mat frame. During an observation and interview on 10/5/2023 at 10:00 am, in the rehab gym, the Director of Rehabilitation (DOR) who was also a Physical Therapist(PT- movement experts who improve quality of life through prescribed exercise, hands-on care, and patient education) confirmed the height of the therapy mat could not be adjusted because it was broken. The DOR stated the therapy mat was always left unplugged because the motor that controlled the height of the…

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

Based on interview and record review, the facility failed to ensure the facility's Certified Nursing Assistants (CNAs) were provided mandatory (required by law or rules) minimum 12 hours per year in-service training of Dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) Care and Abuse (treat a person with cruelty or violence, especially regularly or repeatedly). This failure had the potential to result in the residents being subject to abuse, and residents who had dementia improperly cared for. Findings: During a concurrent interview and record review on 10/6/2023, at 4:38 p.m., with Director of Staff Development (DSD), CNA 8's In-Service Attendance Log for Abuse and Dementia Care (IALAD), dated from 1/2022 to 10/2023 was reviewed. The IALAD indicated, there were four abuse in-service trainings done on 2/17/2022, 5/18/2022, 7/7/2022, 12/5/2022 and three dementia care in-service trainings done on 3/15/2022, 4/21/2022, 9/8/2022. The IALAD indicated, there were five abuse in-service trainings done 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 advance directives (written statement of a person's wishes regarding medical treatment made to sure those wishes are carried out should the person be unable to communicate) was discussed and written information was provided to the residents /or responsible parties for one of five sampled residents (Resident 22). This deficient practice violated the resident's right to be fully informed of the option to formulate their advance directives and had the potential to cause conflict with the residents' wishes regarding health care. Finding: During a record review of Resident 22's admission Record (Face Sheet), the Face Sheet indicated, Resident 22 was admitted to the facility on [DATE] with diagnoses including hemiplegia (one-sided paralysis) and hemiparesis (one-sided weakness), dementia (impaired ability to remember, think, or make decisions), hypertension (high blood pressure), and schizoaffective (mental health disorder affect mood, behavior, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 96) was reviewed for changes in Medicare (federal health insurance for people 65 or older) coverage were provided with the Notice of Medicare Non-Coverage (NOMNC) appeal process in a timely manner. This failure had the potential to result in Resident 96 and/or responsible party not being able to exercise their right to file an appeal. Findings: During a review of Resident 96's admission Record (Face sheet), the admission Record indicated Resident 96 was admitted to the facility on [DATE] with diagnoses including schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), hypertension (a condition in which the force of the blood against the artery walls is too high), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and anxiety (persistent worry and fear about everyday situations). During a record 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 observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 57) was reviewed for Preadmission Screening and Resident Review (PASARR) in a timely manner. This failure had the potential to result in the resident not receiving appropriate care or delay in treatment. Findings: During a review of Resident 57's admission Record (Face sheet) indicated Resident 57 was admitted to the facility on [DATE], with diagnoses including schizoaffective disorder (a mental health disorder including schizophrenia and mood disorder symptoms) encephalopathy (brain disease that alters brain function or structure) unspecified dementia (dementia without a specific diagnosis), and anxiety (persistent worry and fear about everyday situations). During a review of Resident 57 Minimum Data Set (MDS, a standardized comprehensive assessment and care-screening tool, dated 7/20/2023, indicated Resident 57 has schizoaffective disorder, encephalopathy, unspecified dementia, and anxiety.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to initiate a care plan for one of three sampled residents (Resident 13) who has decreased hearing. This deficient practice had the potential to negatively affect the delivery of necessary care and services. Findings: During a review of Resident 13's admission record (face sheet), the face sheet indicated resident 13 was initially admitted to the facility on [DATE] with a diagnosis of diabetes mellitus with other specified complications (high blood sugar ) , hypertension ( high blood pressure), bilateral osteoarthritis of the knee ( when the cartilage that lines your joints is worn down ). During a review of Resident 13's history and physical (H&P) report dated 6/3/2015, the H&P indicated Resident 13 had the capacity to understand and make decisions. During a review of Resident 13's Minimum Data Set ( MDS -a standardized assessment and care planning tool) dated 1/1/2023, the MDS indicated Resident 13 requires limited assistance ( 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 update and implement the comprehensive care plan for one of one sampled resident (Residents 73) who sustained a fall from his wheelchair. This failure resulted in Resident 73 sustaining an injury from the actual fall. Findings: During a review of Resident 73's Face Sheet (admission record), the Face Sheet indicated Resident 73 was admitted to the facility on [DATE] with diagnosis including dementia with behavioral disturbance (impaired ability to think or make decisions accompanied by behaviors such as agitation and depression), Type II Diabetes Mellitus (high blood sugar) with diabetic chronic kidney disease (CKD: long term condition where the kidneys do not work as well), anxiety, repeated falls and hypertension (high blood pressure) . During a review of Resident 73's Minimum Data Set [(MDS) a standardized assessment and care screening tool], dated 9/8/2023, the MDS indicated Resident 73's cognitive skills (the mental action or process of acquiring…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to obtain a physician's order for foot care for one of one sample resident (Resident 97). This deficient practice had the potential for placing the resident at risk for complications such as infection or bleeding of the feet. Finding: During a review of Resident 97's Face Sheet (admission record), the Face Sheet indicated Resident 97 was admitted to the facility on [DATE] with diagnosis including hemiplegia and hemiparesis (paralysis and partial weakness on one side of the body) following a cerebral infarction (impaired blood flow to the brain) affecting the left non-dominant side, atrial fibrillation (irregular heart rhythm), cerebral aneurysm (bulging of the vessel that supplied to the brain) nonruptered, muscle weakness, contracture on the left hand, abnormalities of gait and mobility, Type II Diabetes Mellitus (high blood sugar without complications), and anxiety. During a review of Resident 97's Minimum Data Set [(MDS) a standardized…

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

Based on observation, interview, and record review, the facility failed to accurately account for the use of one dose of a controlled substance (medications with a high potential for abuse) affecting Resident 17 in one of two inspected medication carts (West Station Cart 2). This deficient practice increased the risk that Resident 17 could have received too much or too little medication due to lack of documentation possibly resulting in serious health complications requiring hospitalization. Findings: During an observation and concurrent interview of [NAME] Station Cart 2, on 10/4/23 at 1:37 PM, with the Licensed Vocation Nurse (LVN 2), the following discrepancies were found between the Narcotic and Hypnotic Record (a log signed by the nurse with the date and time each time a controlled substance is given to a resident) and the medication card (a bubble pack from the dispensing pharmacy labeled with the resident's information that contains the individual doses of the medication): 1. Resident 17's Narcotic and Hypnotic Record for clonazepam (a medication used to treat mental illness)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 enter or clarify a prescriber's order to reduce the dose of Seroquel (a medication used to treat mental illness) between 9/20/23 and 10/5/23 for one of five sampled residents (Resident 52.) As a result of this deficient practice, Resident 52 received a higher than necessary dose of Seroquel between 9/20/23 and 10/5/23 which increased the risk that he could have experienced adverse effects (unwanted side effects of medication therapy like drowsiness or constipation) related to the use of Seroquel leading to a decline in his quality of life. Findings: A review of Resident 52's admission Record (a document containing a resident's demographic and diagnostic information), dated 10/5/23, indicated he was admitted to the facility on [DATE] with diagnoses including psychosis (a severe mental condition in which thoughts and emotions are so affected that contact is lost with external reality.) A review of Resident 52's Order Summary Report (a document…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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 Resident 55 was assisted and provided with additional nutritive packets to have a therapeutic diet (a prescribed meal plan that controls certain aspects of nutrients and/or foods as part of a treatment plan) as ordered by the physician during Restorative Nurse Assistant (RNA) feeding program (a feeding assistant program to restore residents to a former capacity or to improve their level of independence and thereby promote improved nutrition status) for one of three sampled residents (Resident 55). This failure had the potential to result in preventing Resident 55 from receiving benefit of a therapeutic diet. Findings: During a review of Resident 55's admission record, the admission record indicated Resident 52 was admitted to the facility on [DATE]. Resident 55's diagnosis included atrial fibrillation (an irregular and often very rapid heart rhythm), dysphagia (difficulty swallowing), protein-calorie malnutrition (a nutritional…

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

Based on observation, interview, and record review, the facility failed to provide proper adaptive eating utensils (AE, eating equipment such as forks, knives, and spoons that are modified to increase independence with eating) for one of seven sampled residents (Resident 69) by failing to: 1. Follow physician's orders for AE. 2. Perform an assessment to determine the AE provided to Resident 69 was suitable and effective. These deficient practices resulted in Resident 69 being issued built-up utensils (eating utensils with large handles made from hard plastic or soft foam to allow a person with limited grasp or hand strength to hold utensils with more ease) instead of weighted utensils (eating utensils with large handles with weights inside that help reduce tremors and improve control while eating) per physician's order for meals and had the potential to cause weight loss, decreased independence with self-feeding, and decreased quality of life. Findings: A review of Resident 69's admission Record indicated the facility admitted Resident 69 on 7/20/2021. Resident 69's diagnoses…

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