Pacific Villa, INC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide effective pain management for one of four sampled residents (Resident 9). The facility failed to:1. Ensure Resident 9 was provided with pain medicine based on his assessed pain level.This failure had the potential to result in Resident 9 having unrelieved pain or overmedication (receiving too much medication and taking excessively high doses). Findings:During an observation on 2/24/2026 at 10:14 a.m. with Resident 9, observed Resident 9's right arm was on a sling (a supportive device typically a strap or cloth used to immobilize, support, and protect an injured arm, shoulder or wrist).During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. The admission Record indicated Resident 9 diagnoses including autistic disorder ( a condition related to brain development ), unspecified dislocation of right shoulder joint (…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 staff competency in cardiopulmonary resuscitation (CPR- emergency lifesaving procedure that is performed when someone's stopped breathing or heartbeat has stopped) for one of three reviewed staff members (CNA 2). The facility failed to:1.Ensure CNA 2 demonstrates the knowledge and skills necessary to perform CPR by obtaining Basic Life Support (BLS-verifies training in essential, life-saving techniques for healthcare professionals and first responders focusing on CPR ) certification that includes an online training and in-person skills demonstrations.The failure to ensure CNA 2 completed the required hands on CPR skills competency had the potential to result in CNA 2 performing CPR ineffectively during life threatening emergencies (dangerous or serious that it could kill or pose a very high risk of death if not handled or treated immediately) in the facility.Findings:During a concurrent interview and record review on [DATE] at 10:13 a.m. with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement their protocol for Antibiotic Stewardship (the effort to measure and improve how antibiotics are prescribed by clinicians and used by patients) for one of five sampled residents (Resident 48) who was prescribed an antibiotic drug without meeting the McGeers Criteria (a set of clinical definitions used for surveillance to define the resident symptoms and other clinical criteria that are used to meet infection surveillance definitions).This failure had the potential to result in Resident 48 developing antibiotic resistance (when bacteria develop defenses against the antibiotics designed to kill them) from unnecessary or inappropriate antibiotic use. Findings:During a review of Resident 48's admission Record, the admission Record indicated Resident 48 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 48's diagnoses included hypertensive heart disease (heart damage leading to high blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Activity Assistant accurately documented on Activity Attendance Record provided for one of five sampled residents (Residents 63) in 2/12/2026,2/13/2026,2/14/2026 and 2/2/24/2026.This deficient practice had the potential for confusion in the care and services provided to Resident 63 and placed the resident at risk of not receiving appropriate care due to inaccurate and incomplete medical information.Findings:During review of Resident 63's admission Records, the admission Record indicated Resident 63 was admitted to the facility on [DATE] with diagnoses including anxiety (conditions that cause excessive and persistent feelings of fear or worry that can interfere with daily life), major depression ( mood disorder that causes a persistent feeling of sadness and loss of interest) and muscle weakness (loss of muscle strength).During a review of Resident 63's Minimum Data Set (MDS- resident assessment tool) dated 02/22/2026, 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 Antibiotic Stewardship Program ( process for improving how antibiotics [medication used to treat infection] are prescribed and used by residents) was implemented for one of three residents (Resident 90). The facility failed to monitor antibiotic use and review the appropriateness of the prescribed antibiotic.This failure had the potential to put Resident 90 at risk for antibiotic resistance (ability of bacteria and other microorganisms to withstand the effects of antibiotics, rendering them ineffective) or inappropriate use of antibiotic.Findings:During a review of Resident 90's admission Record, the admission Record indicated Resident 90 was initially admitted to the facility on 1/13/2023 and was readmitted on [DATE]. The admission Record indicated Resident 90 diagnoses including urinary tract infection (UTI- an infection in the bladder/urinary tract), anxiety disorder(persistent, excessive fear or worry that interferes with life), diabetes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure that the attending physician was notified of a change in condition ([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive (ability to think, understand, learn, and remember) behavioral, or functional status which without immediate intervention, may result in complications or death ) for one of three sampled residents (Resident 1), after Resident 1 reported being struck and expressed fear, indicating a psychosocial change ( shifts in a person's thoughts, feelings, behaviors, and relationships) in condition. This failure had the potential to delay or prevent medical and mental health evaluation, resulting in unaddressed psychosocial distress, continued fear, lack of appropriate interventions, and increased risk to resident safety and well-being.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure the comprehensive care plan (a personalized, written guide detailing a patient's health status, specific needs, goals, and the nursing actions [interventions]) was developed and implemented for one of three sampled residents (Resident 1) following a change in condition ([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive (ability to think, understand, learn, and remember) behavioral, or functional status which without immediate intervention, may result in complications or death), when Resident 1 reported being struck and expressed fear, indicating a psychosocial change ( shifts in a person's thoughts, feelings, behaviors, and relationships) in condition. This deficient practice had the potential to result in staff being unaware of the residents' psychosocial and safety needs leading to inconsistent care, lack of protective interventions, continued fear, unaddressed psychosocial distress, and increased…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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) was not subject to abuse when Resident 2, who has history of schizophrenia (a mental illness that is characterized by disturbances in thought), and sudden mood changes threw water on Resident 1. This deficient practice resulted in Resident 1 feeling like she was drowning when the water that Resident 2 threw on her, covered her face, went into her mouth and down her throat.Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of hypertensive heart disease (a condition where the heart has been damaged by years of high blood pressure). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 9/10/2025, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) 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 report an allegation of abuse for one of two sample residents (Resident 1), when Resident 1 told Certified Nursing Assistant (CNA) 1, that Resident 2 threw water on her (Resident 1). This deficit practice resulted in the inability of the California Department of Public Health (CDPH) to conduct a timely investigation and had the potential for information to be lost and/or forgotten. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of hypertensive heart disease (a condition where the heart has been damaged by years of high blood pressure). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 9/10/2025, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact and Resident 1 was dependent 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 follow enhanced barrier precautions ([EBP] an infection control intervention designed to reduce transmission of multidrug- resistant organisms that employs targeted gown and gloves use during high contact resident care activities) for one sampled resident (Resident 4) when Treatment Nurse (TN) 1 did not wear a gown while providing care to Resident 4's wound. This deficient practice resulted in an increased risk for Resident 4's wound to become infected. 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 a diagnosis of chronic (constantly recurring) osteomyelitis (inflammation of bone or bone marrow, usually due to infection) of the right ankle and foot and peripheral vascular disease ([PVD] a slow progressive narrowing of the blood flow to the arms and legs. During a review of Resident 4's Minimum Data Set ([MDS] a resident assessment…

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

Based on observation, interview, and record review, the facility failed to ensure that window blinds were intact and provided adequate visual privacy for 5 of 18 sampled residents. This deficient practice resulted in residents' exposure to the parking lot and sunlight and a potential violation of residents' rights to visual privacy in five resident rooms.Findings: During a concurrent observation and interview on 11/19/2025 at 09:30 a.m. with Resident 1, Resident 1 room window blinds were missing slats, allowing sunlight and visibility from the parking lot. Resident 1 stated, I turn to the opposite side and cover my head when the sun rises. During a concurrent observation and interview on 11/19/2025 at 10:06 a.m., with Resident 4 in Resident 4's room, observed missing pieces of the window blinds. Resident 4 was exposed to the parking lot and sunlight was penetrating in the room on Resident 4 face. Resident 4 stated that the blinds had been broken for a long time and no one had come to fix them. During an interview on 11/19/25 at 2: 13 p.m. with the Director of Nursing (DON), 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 observation, interview, and record review, the facility failed to maintain a clean, sanitary, and homelike environment for one of three sampled residents (Resident 1). This deficient practice had the potential to expose residents to unsanitary conditions and increase the risk of transmission of disease-causing organisms. Findings: During review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), hyperlipidemia ( a condition where both cholesterol and triglycerides are elevated in the blood) , and lack of coordination (refers to jerky, uncoordinated movements and balance problems caused by an issue with the part of the brain that controls muscle coordination). During a review of Resident 1's Minimum Data Set (MDS -resident assessment tool), dated 09/19/2025, the MDS indicated Resident 1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an injury of unknown origin (an injury whose source was not observed by any person or cannot be explained by the individual) to the State Department per the facility ' s policy and procedure (P/P) titled Abuse, Neglect and Exploitation for one of three sampled residents (Resident 1) when Resident 1 who was complaining of right hip pain and was experiencing decreased range of motion (ROM, the extent or limit to which a part of the body can be moved around a joint or a fixed point), was found to have right hip fracture (broken bone). As a result of this deficient practice, Resident 1 had the potential for delay in care and investigation into the cause of Resident 1 ' s fractured right hip. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was originally admitted to the facility 1/31/2019 and was readmitted [DATE] with diagnoses of encounter for orthopedic (a branch of medicine dealing with 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 investigate an injury of unknown origin (an injury whose source was not observed by any person or cannot be explained by the individual) for one of three sampled residents (Resident 1) when Resident 1 was found to have right hip fracture (broken bone). As a result of this deficient practice, Resident 1 had the potential for delay in care and investigation into the cause of Resident 1 ' s injury. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was originally admitted to the facility 1/31/2019 and was readmitted [DATE] with diagnoses of encounter for orthopedic (a branch of medicine dealing with the correction or prevention of deformities, disorders, or injuries of the skeleton and structures (as tendons and ligaments) closely associated with it) aftercare, epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 1 was competent and reported a Change of Condition (COC) for one out of three sampled residents (Resident 1) who experienced new right hip pain and decreased right hip range of motion (ROM, the extent or limit to which a part of the body can be moved around a joint or a fixed point) to the director of nursing (DON) for further assessment. As a result of this deficient practice, Resident 1 had the potential for delays in care and on 5/4/2025 Resident 1 was found to have a right hip fracture (broken bone). Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses of encounter for orthopedic (a branch of medicine dealing with the correction or prevention of deformities, disorders, or injuries of the skeleton and structures (as tendons and ligaments) closely associated with it)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 resident for signs and symptoms of neurological decline (brain and nervous system are not working correctly which can lead to problems with thinking, memory, movement or change in level of consciousness[loc-person ' s awareness and responsiveness to their surroundings]) for one of three sampled residents (Resident 4) after being struck on the face by Resident 5. This deficient practice had the potential to lead to serious life-threatening effect that could go unnoticed without a neurological assessment (assessment of a patient ' s mental status , level of consciousness, changes in pupil size and reaction to external stimulus , motor strength, sensation and movement of arms and legs). Findings: During a review of Resident 4 ' s admission Record, the admission Record indicated Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including human immunodeficiency virus disease (HIV- virus that attacks…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Assurance (Q A)/ Quality Assurance and Performance Improvement (QAPI) (a data driven proactive approach to improvement used to ensure services are meeting quality standards) committee failed to address , maintain, and develop an effective plan to correct identified problems after the deficient practices were identified related to abuse and accident on 4/28/2025 during an investigation of a facility reported incident (FRI- process by which a healthcare facility documents and reports an event that occurred within the facility and potentially affected the safety of residents, staff or the facility itself). This failure resulted into a repeated deficient practice about abuse and supervision which could affect the health and safety of the residents. Findings: During an interview on 6/6/2025, at 11:50 a.m. with the Director of Nursing (DON), the DON stated she did not address the identified problems related to abuse and smoking supervision in their QAPI/QA Committee agenda. The DON stated it did not dawn on me to do it and did…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observe infection control practice by failing to ensure four of ten sampled staff members wear a mask when the facility was in a Covid outbreak( two or more linked cases of the same illness caused by Covid 19 virus[infectious and contagious disease caused by coronavirus]). This failure had the potential to spread and transmit infection to the residents and other staff. Findings: During a concurrent observation and interview on 6/5/2025, at 8:00 a.m. and subsequent interview on6/6/2025, at 9:00 a.m. with Certified Nursing Assistant (CNA 2) who was the screener for Covid 19 signs and symptoms was not wearing a mask. Observed a housekeeper (HSK 1) vacuuming the carpet at the lobby of the facility not wearing a mask. CNA 2 stated there were residents who were positive for Covid 19 in the facility. CNA 2 stated she did not wear a mask because she thought it was not mandatory to wear mask even there was a Covid 19 outbreak. During an initial tour observation of the facility on 6/5/2025, at 8:20 a.m., observed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 three of three outside grey garbage dumpsters were covered. This deficient practice had a potential to harbor and attract flies, insects, mice, rats, and other animals to the garbage containers. This deficient practice also had the potential for those pests to enter the facility which could lead to the spread of infectious diseases to the residents, staff, and visitors. Findings: During a concurrent observation and interview on 3/14/2025 at 2:26 p.m., with the Director of Nursing (DON), three outside grey garbage dumpsters were observed uncovered. The DON confirmed the dumpsters were uncovered and without their lids. The DON stated that the lids to the dumpsters should be on when not in use because it may attract unwanted animals and/or pests. During an interview on 3/14/2025 at 3 p.m. with the Administrator (ADM), the ADM stated the dumpster lids should be on when not in use and that the facility staff are aware to keep the dumpsters completely covered with lids to avoid attracting unwanted animals. During a review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 sample residents (Resident 1) was not physically assaulted by another resident while under the facility ' s care. This deficient practice resulted in Resident 1 being assaulted by her roommate (Resident 2) when during an unprovoked attack, Resident 2 hit Resident 1 with her fist then her shoe. Resident 1 sustained a contusion (a bruise) to her left upper and lower eyelid. Resident 1 was transferred to a General Acute Care Hospital (GACH) on 2/4/2025 for evaluation and treatment where an ice pack was applied. 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] and readmitted on [DATE] with unspecified dementia (loss of cognitive [thinking process] functioning, remembering, and reasoning to such an extent that it interferes with a person ' s daily life and activities) and schizophrenia (a mental illness which can affect a person ' s…

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

Based on observation, interview, and record review the facility failed to ensure the food in the refrigerator are not outdated when: a. chicken stored in the refrigerator in a clear plastic container with a cracked lid dated 10/13/2024, b. seasoned hash brown potatoes stored in the refrigerator with an expiration date of 11/26/2024, c. potato salad stored in the refrigerator with an expiration date of 12/9/2024, d. macaroni salad stored in the refrigerator with an expiration date of 12/14/2024, e. tomatoes stored in the refrigerator a plastic container covered with plastic wrap dated 12/14/2024, f. bread stored in the refrigerator in a plastic container covered with foil dated 12/16/2024, g. lettuce stored in the refrigerator in a plastic container covered with plastic wrap dated 12/16/2024 and h. freezer burned meat stored in the freezer were discarded. These failures have the potential to result in residents being exposed to food borne illnesses, any illness resulting from food spoilage or contaminated food and eating compromised quality of meat due to dryness and altered texture.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 an advance directive (a legal document indicating resident preference on end-of-life treatment decisions) for five of seven residents (Residents 5, 21, 36, 65, and 68). These failures had the potential to result in causing a conflict with Resident 5, 21, 36, 65, and 68's wishes regarding their health care. Findings: During a review of Resident 5's admission Record, Resident 5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of dementia (a progressive state of decline in mental abilities) and chronic obstructive pulmonary disease ({COPD}- a chronic lung disease causing difficulty in breathing). During a review of Resident 5's Minimum Data Set ({MDS}- resident assessment tool), the MDS indicated Resident 5 had moderate cognitive impairment (a noticeable decline in thinking abilities, problem-solving, and judgement). The MDS indicated required substantial/maximal assistance (helper does more than half the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a preadmission screening and annual resident review (PASARR) was accurately documented for five of eight residents (Resident 19, 21, 45, 65, and 84). This deficient practice had the potential to result in an inappropriate placement and delay of needed services for Resident's 19, 21, 45, 65, and 84. Findings: During a review of Resident 19's admission Record, Resident 19's admission Record indicated Resident 19 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of schizophrenia (a mental illness that is characterized by disturbances in thought) and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 19's Minimum Data Set (MDS- a resident assessment tool), dated 10/7/2024, the MDS indicated Resident 19 was cognitively intact. The MDS indicated Resident 19 had delusions (having false or unrealistic behaviors). During a review of Resident 19's care plan initiated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide services to three of nine residents (Resident 5, 20, and 68) with limited range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) by failing to: 1. Provide Resident 5 with passive range of motion ([PROM] movement of joint through the ROM from an external force with no effort from the person) to both arms from 12/1/2024 to 12/19/2024 in accordance with the physician's order and care plan. 2. Provide PROM to Resident 5's ankles on 12/19/2024 in accordance with the physician's order and care plan. 3. Provide PROM to Resident 20's elbows, wrists, hands, knees, and ankles in accordance with the physician's order and care plan. 4. Provide PROM to Resident 20's hands and ankles prior to applying rolled hand towels (rolled towel placed in the palm) and ankle splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 infection control practices for four of six sampled residents (Resident 20, 27, 54, and 73) by failing to: 1) Ensure the humidifier was changed for Resident 73. 2) Ensure staff wore appropriate Personal Protective Equipment ([PPE] clothing and equipment that is worn or used to provide protection against hazardous substances and/or environment) while providing passive range of motion ([PROM] movement of joint through the ROM from an external force with no effort from the person) exercises and applying splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) to Resident 20, who had Enhanced Barrier Precautions ([EBP] an approach of targeted gown and glove use during high contact care activities to reduce transmission of infections). 3) Ensure facility staff implemented infection prevention and hand hygiene precautions before administering eye drops to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident's call light was within reach for one of 20 random sampled residents (Resident 42). This deficient practice had a potential for the resident not able to call for assistant as needed. Findings: During review of Resident 42's admission record, indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hypertension (high blood pressure), type 2 diabetes mellitus (a group of diseases that result in too much sugar in the blood), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest During a review of Resident 42's Minimum Data Set (MDS - a resident assessment tool), dated 10/08/2024, indicated Resident 42's cognitive skills for daily decision-making were intact. The MDS indicated Resident 42's required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure Resident 81 bed was not broken for 1 out of 3 Residents. This deficient practice had the potential to put Resident 81 at risk for accidents while in bed. Findings: During a review of Resident 81's admission Record dated 12/19/24, indicated Resident 81 was admitted on [DATE] and readmitted on [DATE] with diagnoses of hypertensive heart, psychosis (loss of contact with reality), glaucoma (a group of eye diseases that cause blindness), muscle weakness. During a review of Resident 81's History and Physical (H&P), dated 6/12/24 indicated, Resident 81 does have the capacity to understand and make decisions. During a review of Resident 81's Minimum Data Set (MDS- a resident assessment tool) dated 11/22/24 the MDS indicated Resident 81 has moderate cognitive impairment. The MDS also indicated Resident 81 needed partial/moderate assist with activities of daily living (ADL's- activities such as bathing, dressing, and toileting a person…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 a comprehensive person focused care plan for two of three sampled residents (Resident 6 and 339) by failing to: 1. develop a comprehensive care plan that will address Resident 339's fabrication (making something up) of stories. 2. develop and implement care plan for skin redness and swelling of the right eye and right cheek for Resident 6. These failures placed Resident 6 and Resident 339 at risk for a delay of care and treatment. Findings: 1.During a review of Resident 339's admission Record, the admission Record Resident 339 was admitted to the facility 10/9/2020 with diagnoses including bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional highs) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 339's Minimum Data Set ({MDS}- resident assessment tool), dated 10/9/2024, the MDS indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Resident was provided care and services to maintain good grooming and personal hygiene by failing to clean and cut Resident 29 fingernail for one of three sampled residents (Resident 29). This deficient practice resulted in Resident 29 not receiving fingernail care and can potentially impact Resident 29's self-esteem Findings: During a review of Resident 29's admission Record, the admission Record indicated Resident 29 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest),bipolar disorder (; mood swings that range from the lows of depression to elevated periods of emotional highs) During a review of Resident 29's Minimum Data Set ([MDS], a resident assessment tool) dated 10/23/2024, the MDS indicated Resident 29…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 6 who had redness on the right side of the cheek was monitored and received treatment for one of 22 sampled residents. This failure had the potential for Resident 6 not receiving necessary care and treatment. Findings: During a review of Resident 6's admission Record (face Sheet) , the Face Sheet indicated Resident 6 was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses of but not limited to schizophrenia (a mental illness that is characterized by disturbances in thought), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), gastro-esophageal reflux disease (a digestive condition where stomach contents flow back up into the esophagus, the tube connecting the mouth to the stomach) and hypertensive heart disease (a condition that occurs when the heart is damaged by long-term high blood pressure). 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 observation, interview, and record review, the facility failed to ensure the facility's Restorative Nursing Aide ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) staff were competent to provide range of motion ([ROM] full movement potential of a joint [where two bones meet]) exercises and apply splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) to three of nine residents (Resident 5, 20, and 68) with limited ROM and mobility (ability to move) in accordance with the facility's undated job description titled, Restorative Aide. This failure had the potential for Resident 5, 20, and 68 to develop further ROM limitations. Findings: 1. During a review of Resident 5's admission Record, the facility admitted Resident 5 on 5/7/2024 with diagnoses including muscle wasting and atrophy (thinning or loss of muscle tissue) and dementia (a progressive state of decline in mental abilities). During a review of Resident 5's physician orders, 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: 1. Administer risperidone (a medication used to treat schizophrenia (a mental illness that is characterized by disturbances in thought) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), calcium (a supplement used to treat low level of calcium) and vitamin D (a vitamin used to treat low level of vitamin D) in accordance with physician's orders affecting one of four sampled residents during medication administration (Resident 54). 2. Clarify dose and frequency of physician's order for docusate sodium (a medication used to relieve constipation) affecting one of four sampled residents (Resident 440). 3. Accurately account for the administration of Vimpat (generic name - lacosamide, a controlled substance [a medication with a high potential for abuse] used to treat seizure [a sudden, uncontrolled electrical disturbance in the brain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to monitor one of three sampled resident's (Resident 439) behaviors while prescribed with psychotropic medications (medications can alter brain chemistry, impact body functions, and modify a person's thoughts, moods, feelings, awareness, and perceptions). This failure had the potential to result in unnecessary medications. Findings: During a review of Resident 439's admission Record, Resident 439's admission Record indicated Resident 439 was admitted on [DATE] and readmitted to the facility on [DATE] with a diagnosis of Atrial fibrillation (rapid heart rate), presence of a pacemaker, psychosis (loss of contact with reality) During a review of Resident 439's History and Physical (H&P), dated 11/8/24 indicated, Resident 439 does not have the capacity to understand and make decisions. During a review of Resident 439's Minimum Data Set ({MDS}- a resident assessment tool) dated 11/16/24 the MDS indicated Resident 439 has severe cognitive impairment. 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 maintain a medication error rate of less than 5% (percent) during medication pass for one of four sampled residents (Resident 54) by failing to provide risperidone (a medication used to treat schizophrenia (a mental illness that is characterized by disturbances in thought) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), calcium (a supplement used to treat low level of calcium) and vitamin D (a vitamin used to treat low level of vitamin D) in accordance with physician's orders. This deficient practice of medication administration error rate of 7.14% exceeded the five (5) percent threshold. Findings: During a review of Resident 54's admission Record (a document containing demographic and diagnostic information), dated 12/18/2024, the facility originally admitted Resident 54 on 3/24/2022 and readmitted Resident 54 on 9/18/2024 with diagnoses including, but not limited to, hypertensive (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.

Based on observation, interview, and record review, the facility failed to: 1. Ensure storage and/or labeling of brimonidine tartrate ophthalmic solution (a medication in form of eye drops used to treat high intraocular pressure [a term used to describe fluid pressure inside the eye]), bisacodyl (a medication used to treat constipation) suppositories (a medication designed to be inserted into the anus), and removal of expired Lantus ([generic name - insulin glargine] a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) Solostar Pen from medication refrigerator, in accordance with manufacturer requirements affecting at least two residents (Resident 34 and 51) in one of two inspected medication rooms (Medication Room). 2. Ensure removal of expired zinc sulfate (a mineral supplement used for wound healing and treat low level of zinc), vitamin D3 (a vitamin used to treat low level of vitamin D) and hydrogen peroxide (a product used as an antiseptic and for wound cleaning) from one of two inspected medication rooms (Central…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Restorative Nursing Aide ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) treatment records for one of nine sample residents (Resident 12) with limited range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) was complete for the month of 10/2024. This failure resulted in incomplete RNA records for the provision of passive range of motion ([PROM] movement of joint through the ROM from an external force with no effort from the person) for Resident 12. Findings: During a review of Resident 12's admission Record, the facility admitted Resident 12 on 8/22/2024 with diagnoses including dementia (a progressive state of decline in mental abilities), bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional highs), anxiety disorder (mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one'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 one of three sampled residents (Resident 1), who was transferred to a General Acute Care Hospital (GACH) on 9/5/2024 for evaluation and treatment related to abnormal laboratory (labs) results, was refused readmission to the facility after Resident 1 was treated and stabilized at the GACH on 10/1/2024. This deficient practice resulted in Resident 1 remaining at the GACH for 11 days after Resident 1 was deemed appropriate for transfer back to the facility but was denied readmission by the facility. Resident 1 was subsequently transferred to a different facility (10/1102024), placing the resident at risk for confusion, disorientation related to displacement from a place that was considered Resident 1's home. Findings: During a review of Resident 1's admission Record (Face Sheet) the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including bipolar disorder (mania and depression combination), and extrapyramidal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report a resident-to-resident altercation not later than two hours to the Ombudsman (public advocate who tries to resolve complaints) and the California Department of Public Health (CDPH) after the abuse allegation was made according to mandatory reporting requirements for two of four sampled residents (Resident 1 and 2). This deficient practice had the potential to impede the safety of the residents and place the residents at risk for elder abuse. 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 diagnosis including diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves) and low back pain. During a review of Resident 1's Minimum Data Set (MDS, a standardized resident assessment and care-screening tool), dated 01/24/20024, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its abuse policy and procedure by failing to submit a five-day investigative report for one of three sampled resident ' s (Resident 1). This deficient practice resulted in an incomplete investigation and incomplete conclusion of the alleged abuse in the facility. 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] and readmitted [DATE] with a diagnosis of schizophrenia, unspecified ( a serious mental health condition that affects the a person thinks and communicate the way a person thinks and communicates with the outside world ), Bipolar disorder, unspecified ( significant, abnormal mood elevations ), and Anemia , unspecified ( a condition in which the blood doesn ' t have enough healthy red blood cells). During a review of Resident 1 ' s history and physical (H&P) dated 11/30/2023, the H&P indicated Resident 1 has fluctuating capacity to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement resident-centered care plan for one of three sampled residents (Resident1). This deficient practice had the potential to result in a delaying delivery of care and services. 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] and readmitted [DATE] with a diagnosis of schizophrenia, unspecified ( a serious mental health condition that affects 0a person thinks and communicate the way a person thinks and communicates with the outside world ), Bipolar disorder, unspecified ( significant, abnormal mood elevations ), and Anemia , unspecified ( a condition in which the blood doesn ' t have enough healthy red blood cells). During a review of Resident 1 ' s history and physical (H&P) dated 11/30/2023, the H&P indicated Resident 1 has fluctuating capacity to understand and make decisions. During a review of the Resident 1 ' s…

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

Based on observation, interview and record review, the facility failed to follow proper sanitation and food handling practices for 88of 88 residents according to the facility's policy and procedure and manufacture' s instructions by failing to: 1.Ensure stored foods were labeled with an open date. 2.Ensure monitoring and documentation for sanitization bucket log. 3.Ensure oasis multi-quat sanitizer strips (to sanitize hard, non-porous food contact surfaces such as tables, counters, utensils and food processing equipment) and sanitation range testing kit (ensures the sanitizer agents are of the correct pH, strength and temperature to ensure equipment is sanitized effectively) were available. These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (caused by consuming contaminated foods or beverages illness with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea and fever) and can lead to other serious medical complications and hospitalization. Findings: 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 Cross referenced to F600 Based on observation, interview and record review, the facility failed to implement its abuse policies and procedure for three of four sample residents (Resident 27, Resident 70 and Resident 74 by failing to: 1.Intervene, report, and investigate resident to resident altercation between Resident 27 and 70. 2.Report and investigate Resident 70'[s verbal and mental abuse after reporting it to CNA 1 and after request of room change to Director of Social Service Findings: 1.During a review of Resident 27's admission Record (Face Sheet), the Face Sheet indicated Resident 27 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including bipolar disorder (mental disorder that causes unusual shifts in person's mood, energy, activity levels and concentration which make it difficult to carry out day-to-day tasks. and human immunodeficiency virus ([HIV] virus that attacks the body's immune system). During a review of Resident 27's Minimum Data Set ([MDS] a standardized…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to implement policies and procedures for ensuring the reporting of an allegation of abuse were reported to Department of Public Health (DPH) no later than 24 hours for three out of 19 sampled residents (Resident 27,70 and 74). This failure had the potential to delay the investigation by the State agency and had the potential to place Resident 27, 74 and 70 at risk for further occurrence of abuse. Findings: During a review of Resident 27's admission Record (Face Sheet), the Face Sheet indicated Resident 27 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including bipolar disorder (mental disorder that causes unusual shifts in person's mood, energy, activity levels and concentration which make it difficult to carry out day-to-day tasks. and human immunodeficiency virus ([HIV] virus that attacks the body's immune system). During a review of Resident 27's Minimum Data Set ([MDS] a standardized assessment and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its abuse policy and procedure by failing to investigate and separate Resident 70 from Resident 9 to prevent further potential verbal and mental abuse. These failures resulted in Resident 70 being verbally and mentally abused by Resident 7 for four months and felt depressed (a mood disorder that causes a persistent feeling of sadness and loss of interest) and stressed. Findings: During a review of Resident 70's admission Record (Face Sheet), the Face Sheet indicated Resident 70 was admitted to the facility on [DATE], with diagnoses including major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), epilepsy (sudden, uncontrolled electrical activity in the brain that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness), and neuropathy (nerve damage leads to pain,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure three of 19 sampled residents ( Resident 74, 21 and 68) received Restorative Nursing Aide (RNA- assist the resident in performing task that restore or maintain physical function) services as ordered by the physician by failing to: 1.Provide active range of motion exercises ([AROM] occurs when a person use their muscles to help move their body) to upper and lower extremities (limbs) five days a week as ordered by the physician to Resident 74. 2.Resident 21 has hand rolls on both hands as ordered by the physician. 3.Resident 68 received Restorative Nursing Aide as ordered by the physician. These failures had the potential to result in Resident 74, 21 and 68 developing contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) and decreased mobility. Findings: During a review of Resident 74's admission Record (Face Sheet), the Face Sheet indicated the resident 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 provide supervision and monitor residents who are on smoking list for three of 19 sampled residents (Resident 15, Resident 72 and Resident 11). This deficient practice resulted to superficial right middle fingers burn to Resident 15, and Resident 11 and Resident 72 at risk for accidental burn due to unsupervised smoking. Findings: A. During a review of Resident 15's admission Record (Face Sheet), the admission Record indicated Resident 15's was initially admitted to the facility on [DATE] and re-admitted back to the facility on 8/07/2023, with diagnoses including chronic obstructive pulmonary disease ([COPD] a common lung disease causing restricted airflow and breathing problems]), hypertensive heart disease with heart failure (heart problems that occur because of high blood pressure that is present over a long time), and hyperlipidemia (elevated cholesterol level in the blood). During a review of Resident 15's Minimum Data Set (MDS-a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to: 1.Follow physician written orders and instructions regarding oxygen therapy (the administration of oxygen at concentrations greater than that in ambient air with the intent of treating or preventing the symptoms and manifestations of low oxygen) for one of 19 sampled residents (Resident 39). This failure resulted in Resident 39 receiving too much oxygen and potentially leading to complications such as headaches, lethargy (state of sleepiness or deep unresponsiveness), drowsiness, confusion, coma, and death. 2.Replace empty oxygen humidifier for Resident 15. This deficient practice had the potential for respiratory infections for Resident 15. Findings: During a review of Resident 39's admission Record (Face Sheet), the Face Sheet indicated Resident 39 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic obstructive inflammatory lung…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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.Account for four doses of controlled medication ([CM]- medications which have a potential for abuse and may also lead to physical or psychological dependence) for four out of four sampled residents (Resident 31, 44, 58 and 60) in one of two inspected medication carts (Medication Cart South). 2.Document four doses of CM in the January 2024 Medication Administration Record ([MAR] - a record of mediations administered to residents) for Resident 31, 44, 58 and 60 in one of two inspected medication carts (Medication Cart South.) These failures increased the opportunity for CM diversion (the transfer of a controlled substance or other medication from a lawful to an unlawful channel of distribution or use) and increased the risk that Residents 31, 44, 58 and 60 could have delayed medication treatment and continuity of care due to lack of availability of the CM, and accidental exposure to harmful medications, possibly leading to physical 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 it was free of not greater than five (5) percent (%) or below medication error rate, as evidenced by two medication errors out of 29 opportunities for error, which yield a 6.9 % medication error rate. The medication errors were as follows: 1.Resident 38 received a dose of artificial tears (eye drops used to moisturize dry eyes) different from the one ordered by Resident 38's physician. 2.Resident 182 did not receive vitamin D3 (medication used as a dietary supplement to promote bone health) as ordered by Resident 182's physician. These failures had the potential to result in Resident 38 and 182 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) and the potential to result in Residents 38's and 182's health and well-being to be negatively impacted. Findings: During a review of Resident 38's admission Record (Face Sheet) indicated Resident 38 was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure: 1.Twenty-five Licensed Vocational Nurses (LVNs) and one Registered Nurse Supervisor (RNS) did not administer expired insulin (a medication used to regular blood sugar levels) to one of seven sampled residents observed (Resident 10.) 2.Five LVNs and one RNS did not administer lorazepam oral concentrate (a medication used to treat anxiety and restlessness) stored at room temperature to one of seven sampled residents observed (Resident 232.) These failures resulted in Residents 10 received a total of one hundred-one doses (units) of expired insulin and Resident 232 received a total of twenty-one doses of inappropriately stored Lorazepam. These failures had the potential to cause Residents 10 to experience serious health complications due to uncontrolled blood sugar levels and Resident 232 unrelieved anxiety and continued behaviors, possibly resulting in hospitalization or death. Findings: During an observation on 1/3/2024 at 12:12…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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.Removed and discard one expired insulin (medication used to regulate blood sugar levels) Novolog (fast-acting insulin) vial for Resident 10, in accordance with manufacturer's requirements in one of two inspected medication carts (Medication Cart South.) 2.Store two insulin Basaglar (long-acting insulin) Kwikpens (type of insulin injection devise) for Resident 10, two insulin Humulin R (short-acting insulin) vials for Resident 58 and 74 at room temperature, in accordance with manufacturer's requirements in one of two inspected medication carts (Medication Cart South.) 3.Store one lorazepam (a medication used to treat anxiety and restlessness) oral concentrate (a solution with increased strength) bottle in the refrigerator for Resident 232 in accordance with the manufacturer's requirements in one of two inspected medication carts (Medication Cart South.) 4.Remove and discard seventeen expired acetaminophen (medication used to treat pain or fever) suppositories (form of medication used for rectal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to follow up necessary dental services for two of 19 sampled residents (Resident 15 and Resident 74). This failure had the potential to put Resident 15 and Resident 74 at risk for development of tooth decay and weight loss. Findings: During a review of Resident 15's admission Order (Face Sheet), the admission Record indicated Resident 15's was initially admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses including chronic obstructive pulmonary disease ([COPD] a common lung disease causing restricted airflow and breathing problems]), hypertensive heart disease with heart failure (heart problems that occur because of high blood pressure that is present over a long time), and hyperlipidemia (elevated cholesterol level in the blood). During a review of Resident 15's MDS dated [DATE] indicated Resident 15 had no cognitive impairment and requires partial assistance for oral hygiene, toileting, and dressing. During a review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 the physician when one of 19 sampled residents (Resident 232) was complaining of painful urination (feel pain or a burning sensation when urinating). This failure resulted in a delay of treatment and had the potential to put Resident 232 for unrelieved bladder discomfort. Findings: During a review of Resident 232's admission Record (Face Sheet ), the Face Sheet indicated Resident 232 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease ( occurs when nerve cells of the brain don't make enough of a body chemical which can affect mood and movement ), dysphagia(difficulty of swallowing), cachexia(condition that leads to extreme weight loss and muscle wasting due to the underlying illness)and chronic pain syndrome( pain remained long after an illness or injury had healed). During a review of Resident 232's Minimum Data Set ([MDS] standardized assessment and care screening tool) dated 11/3/2023, 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 protect residents right to be free from verbal and mental abuse including racial slurs (words or phrases that refer to members of racial and ethnic groups in a derogatory manner ), calling him names (insult someone verbally) and being yelled at for one of 19 sampled residents (Resident 70). The facility failed to: 1.Ensure Resident 9 did not continue to use racial slurs, yell and called Resident 70 names after Certified Nursing Assistant (CNA) 1 witnessed the incident and Resident 70 informed CNA 1 in December. 2.Report Resident 70 verbal and mental abuse after reporting it to CNA 1 and after request of room change to Director of Social Service 3.Investigate Resident 70 verbal and mental abuse from Resident 9 for the four months. 4.The facility failed to prevent further abuse and mistreatment from Resident 9 to Resident 70 by allowing Resident 9 to continue to be on the same room with Resident 70. These failures resulted in Resident 70 being verbally…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 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 19 residents (Resident 68) received the proper assistive devices to maintain vision abilities by not assisting in providing of reading glasses. Resident 68 was recommended eyeglasses on 10/2/2023 and by 1/2/2024, the Director of Social Services (DSS) had not followed up in the delay of the reading glasses. This failure resulted in Resident 68 not having his reading glasses and being unable to read or see small objects for three months. Findings: During a review of Resident 68's admission Record (Face Sheet), the Face Sheet indicated, Resident 68 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hypertension (high blood pressure), hemiplegia (weakness on one entire side of the body), encephalopathy (damage or disease that affects the brain), and acute kidney failure (the kidneys become unable to filter waste products from the blood). During a review of Resident 68's History and Physical (H&P), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide necessary care and services to one of 19 sampled residents (Resident 10) to prevent complications of enteral feedings (method of supplying nutrients directly into the gastrointestinal tract) via gastrostomy tube ([G-tube] an artificial opening into the stomach to deliver medication, nutrition, and hydration) by failing to change the tube feed (liquid form of food that is carried through your body through a flexible tube called G-tube) and administration set (tubing used to deliver the enteral feeding) per facility's policy and procedure. This failure had the potential to result in administering expired enteral formula which could lead to diarrhea, intolerance, dehydration, and weight loss to Resident 10. Findings: During a review of Resident 10's admission Record (Face Sheet), the Face Sheet indicated Resident 10 was initially admitted on [DATE] and was readmitted on [DATE] to the facility with diagnoses including diabetes(…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow its policy and procedure regarding Trauma Informed Care (an intervention and organizational approach that focuses on how trauma may affect an individual's life and his or response to behavioral health) for one of five sampled residents (Resident 60) by failing to screen Resident 60 for history of trauma on admission. This failure had the potential to place Resident 60 at risk for not receiving adequate care and implement trigger specific interventions to meet Resident 60's psychosocial needs. Findings: During a review of Resident 60's admission Record (Face Sheet) , the Face Sheet indicated Resident 60 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including epilepsy( brain disorder characterized by repeated seizures), schizophrenia ( mental illness that affects how a person, thinks, feels and behaves), and major depressive disorder (mental disorder characterized by persistent feeling of sadness,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 31) did not receive Ativan (a psychotropic medication [drug that affects brain activities associated with mental processes and behavior] used for anxiety, and categorized as a controlled medication {CM-medications which have a potential for abuse and may also lead to physical or psychological dependence}) without a physician order to renew after 14 days of initial order on 11/16/23 and medication bubble pack (a medication packaging system that contains individual doses of medication per bubble) of Ativan was removed from the medication cart (Medication Cart South.) These failures resulted in Resident 31 to received Ativan beyond the date prescribed by Resident 31's physician and had the potential for increased risk for Residents 31 to experienced serious adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) of psychotropic medication therapy leading to an overall negative…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to offer the pneumococcal vaccine (vaccine that helps prevent pneumonia (an infection that inflames the air sacs in one or both lungs) to one of 19 sampled residents. This failure had the potential to result in Resident 19 acquiring and transmitting pneumonia to other residents, staff, and visitors. Findings: During a review of Resident 19's admission Record (Face Sheet), the Face Sheet indicated Resident 19 was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses to but not limited to chronic obstructive pulmonary disease (COPD-a chronic obstructive inflammatory lung disease that causes obstructed airflow from the lungs), hypertensive heart (a heart condition caused by high blood pressure over a long time), and chronic kidney disease (a gradual loss of kidney function). During a review of Resident 19's Physician admission Orders, dated 12/2/2023, the Physician admission Orders Indicated, resident 19 had an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure one of 19 sampled residents (Resident 68) had a functioning call light. This failure resulted in Resident 68 not being able to use his call light to get help or call for assistance from the nursing staff. Findings: During a review of Resident 68's admission Record (Face Sheet), the Face Sheet indicated, Resident 68 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of but not limited to hypertension (high blood pressure), hemiplegia (weakness on one entire side of the body), encephalopathy (damage or disease that affects the brain), and acute kidney failure (the kidneys become unable to filter waste products from the blood). During a review of Resident 68's History and Physical (H&P), dated 2/15/2023, the H&P indicated, Resident 68 had fluctuating (rising and falling irregularly in number or amount) capacity (the maximum amount that something can contain) to understand and make decisions. During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident (Resident 1) who had an appointed conservator ([CON] appointment of a guardian or a protector by a judge to manage the personal or financial affairs of another person who is incapable of fully managing their own affairs due to age or physical or mental limitations) 1 was informed in advance, of the risks and benefits of psychoactive medications (a medication which changes brain function and results in alterations in perception, mood, consciousness or behavior) for one of three sampled residents (Resident 1). This deficient practice violated the conservator ' s (CON 1) right to make an informed decision regarding the use of psychoactive medications for Resident 1 and placed Resident 1 at risk for making health care decisions she was not able to understand. Findings: A review of Resident 1 ' s admission Record (Face Sheet), indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including hypertensive heart disease…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed ensure a resident (Resident 1) who had an appointed conservator ([CON] appointment of a guardian or a protector by a judge to manage the personal or financial affairs of another person who is incapable of fully managing their own affairs due to age or physical or mental limitations) request to change psychiatrist (a medical doctor [MD] who specializes in mental health [emotional, psychological, and social well-being]) was honored for one of three sampled residents (Resident 1). This deficient practice resulted in the request for change in MD not being granted per the CON 1 ' s request and violated CON 1 ' s rights to change Resident 1 ' s MD. Findings: A review of Resident 1 ' s admission Record (Face Sheet), indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including hypertensive heart disease (heart problems which occur because of high blood pressure which is present over a long time), diabetes mellitus (DM) type 2 [a 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 provide a copy of medical records upon written request from an authorized conservator ([CON] appointment of a guardian or a protector by a judge to manage the personal or financial affairs of another person who is incapable of fully managing their own affairs due to age or physical or mental limitations) for one of three sampled residents (Resident 1) within two working days per the facility ' s policy and procedure (P/P) titled, Release of Medical Records. This deficient practice violated Resident 1 and the conservator ' s (CON 1) rights to obtain a copy of the resident ' s medical record. Findings: During a review of Resident 1 ' s admission Record (Face Sheet), indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including hypertensive heart disease (heart problems which occur because of high blood pressure which is present over a long time), diabetes mellitus (DM) type 2 [a chronic disease characterized by elevated levels of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident, who had a diagnosis of diabetes mellitus (DM) type 2 [a chronic disease characterized by elevated levels of blood glucose (or blood sugar) in a bloodstream], who was receiving Insulin (a hormone which lowers the level of glucose [a type of sugar in the blood]) every morning at 9 a.m., and blood glucose monitoring before meals and at bedtime, primary care doctor (MD 1) and appointed conservator ([CON] appointment of a guardian or a protector by a judge to manage the personal or financial affairs of another person who is incapable of fully managing their own affairs due to age or physical or mental limitations) was informed immediately after Resident 1 ' s refusal of medication on 1/5/2023 and 1/6/2023 and refusal of blood glucose monitoring on 1/5/2023 at 11:30 a.m. and on 1/6/2023 at 6 a.m. This deficient practice resulted in the licensed nurse ' s inability to determine what Resident 1 ' s blood glucose level was on 1/5/2023 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.

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 had an authorized conservator ([CON] appointment of a guardian or a protector by a judge to manage the personal or financial affairs of another person who is incapable of fully managing their own affairs due to age or physical or mental limitations) and had fluctuating capacity to understand and make decisions, a notice of discharge was provided to the CON 1. This deficient practice resulted in Resident 1 being discharged to an assisted living facility ([ALF] housing facility for people with disabilities or for adults who cannot or choose not to live independently) and CON 1 being unaware of Resident 1 ' s discharge status and whereabouts. This deficient practice also denied Resident 1 ' s protection from being inappropriately discharged and had the potential to result in an unsafe discharge. Findings: During a review of Resident 1 ' s admission Record (Face Sheet), indicated Resident 1 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 During an interview and record review the facility failed to ensure a resident (Resident 1) who had an appointed conservator ([CON] appointment of a guardian or a protector by a judge to manage the personal or financial affairs of another person who is incapable of fully managing their own affairs due to age or physical or mental limitations) was invited to participate in Resident 1 ' s care planning meetings upon admission and quarterly for one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1 ' s CON not attending the care planning meetings, and unable to participate in Resident 1 ' s care and treatment plans. Findings: During a review of Resident 1 ' s admission Record (Face Sheet), indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including hypertensive heart disease (heart problems which occur because of high blood pressure which is present over a long time), diabetes mellitus (DM) type 2 [a chronic disease characterized by elevated levels 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.